Fatality review team urges protocol, data and follow-up changes after near-fatal domestic assault

The Phoenix Domestic Violence Fatality Review Team (DVFRT) presented its 2024 report to the Public Safety and Justice Subcommittee on Wednesday, identifying gaps in response and follow-up after a near-fatal domestic assault and issuing six recommendations to improve coordination among police, fire, medical providers and victim services.

Assistant Chief Ed De Castro told the subcommittee that Phoenix police handled 33,756 domestic violence calls for service in 2023, with 8,533 arrests that year and "just over 2,700 calls for service" that involved aggravated assault. The DVFRT selected a fully adjudicated near-fatality involving a married couple in which the night in question included a knife assault, strangulation and near-drowning; the victim and a witness were available for interview.

Kevin Mattingly, deputy director for Human Services, said the review produced six recommendations focused on: establishing protocols for when Crisis Response Teams (CRT) are deployed or canceled; aligning CRT protocols with Behavioral Health Team (BHT) responses where appropriate; requiring medical follow-up after forensic examinations; adding strangulation as a trackable data element; improving case-management timelines and follow-up; and updating training for emergency medical personnel to recognize and treat impeded breathing and strangulation.

"We arrived at six recommendations," Mattingly said, adding that police and fire representatives on the team "expect to have procedures established by June of this year" for some items. Staff said the Family Advocacy Center and contracted forensic examiners are already considering a medical follow-up program and that the Maricopa County Attorney's Office currently funds the forensic nurse examiners at the Family Advocacy Center.

Council members asked for better prosecution tracking and clearer data about case outcomes. Councilwoman O'Brien said the city should know how many arrests are prosecuted and how cases ultimately resolve. Assistant Chief De Castro said the departments can determine when cases are sent to the county attorney but that the city's current systems do not automatically track county outcomes; staff said they are working with a new vendor (Premier1) to add fields to the records system later this year.

The report also identified a missed opportunity when a CRT response was canceled at the scene, and staff acknowledged the cancellation was logged but did not show a reason in the reports. Deputy Director Mattingly said that lack of a documented reason is a gap the recommendations seek to address.

What follows: Staff committed to follow up with a status update on recommendation implementation by June 2025 and to form the 2024-25 DVFRT to review progress and close the loop on prior recommendations. The subcommittee requested that the city prosecutor's office include an explanation of how domestic violence cases move through charging and sentencing in the next meeting packet.