This article is from the Kentucky Center for Investigative Reporting.
In late January, Louisville Metro Police Department officers went to a house with blue steps in the Parkland neighborhood looking for a woman named Amanda Berry. Family members had reported her missing; neighbors would later say they’d heard her boyfriend beating her and yelling at her.
Police found her body in a storage container in the basement of the house. She had been dead for “quite a long time,” police said. Her boyfriend, William Sloss, was arrested and charged with murder and abuse of a corpse.
If this had happened anywhere else in Kentucky, that’s where the case would end. But because Berry died in Louisville in an apparent case of domestic violence homicide, there was one more step: Her case would be examined by the city’s Domestic Violence Fatality Review Committee.
Stakeholders from across the city would gather to look at every single place Berry and Sloss might have touched the system and figure out if there was a way her death might have been prevented — and whether that lesson might save someone else’s life in the future.
An LMPD official preparing for that committee meeting discovered something in their files: Two officers had been called out to that house with the blue steps just a month before Berry’s body was found.
The day after Christmas, Berry told the officers that Sloss had hit her, held her in the house, chased her down the street and took away her phone.
The officers did not fill out a report. They did not arrest Sloss. They failed to “use all reasonable means to provide assistance,” according to police documents. Instead, they left the scene — and left Berry alone with the man she had just called the cops on. A month later, she was found dead.
On May 22, LMPD charged the officers, Kierstin Holman and Cody Luckett, with failure of law enforcement to provide assistance to Berry. Neither LMPD nor a lawyer for the officers responded to a request for comment. LMPD also denied several open records requests about the case, saying they would not turn over records while it’s still being prosecuted.
Long-time domestic violence advocates believe this is the first time since the fatality review committee was created that LMPD decided to bring criminal charges based on information generated by the review.
Despite regularly reviewing fatalities for more than 25 years, Louisville’s domestic violence response remains imperfect. The reviews often raise the same issues, again and again: the need for more funding, more cooperation, more understanding of the complex issues that lead to domestic violence deaths.
But members of the fatality review team say it has helped breed accountability among agencies. They point to the Berry case as a prime example of the value of these sorts of reviews.
But despite several efforts over the years, Louisville is currently the only city in Kentucky that reviews domestic violence deaths. Efforts to create a statewide review system have repeatedly failed.
A Shocking Murder Prompted Reviews
Louisville officials began reviewing fatalities after a high-profile domestic violence murder in January 1991.
Bob Fortney shot and killed his estranged wife, Pam, in the middle of the day in the Highlands neighborhood before turning the gun on himself. Both were well-liked high school teachers in the Jefferson County Public Schools system, and the horrific, public nature of the murder outraged the city.
“A day of tragedy,” declared the Courier Journal over a full-page spread. News coverage that followed outlined how Pam Fortney had tried repeatedly to seek help from the police, the courts and what was then called the Spouse Abuse Center.
“Her efforts were to no avail,” an article in the Courier Journal said. That same week, Marcia Roth started her job as the director of the county’s brand new Office for Women. Her original mandate was to improve opportunities for women in the area.
But the Fortney case put those plans on hold. “I said to my boss, if we can’t keep women safe and alive, forget about improving their status,” she recalled in a recent interview.
So Roth set out to talk to everyone Pam and Bob Fortney interacted with — the police, the county attorney, the shelter, the judges, lawyers, hospital workers — to see how something like this had happened.
This was, essentially, Louisville’s first domestic violence fatality review. Roth found that every agency felt that they had done everything right; every agency thought someone else had dropped the ball.
She planned to produce a report about how this could have been prevented, and then move on to other issues. “I never moved on to other issues,” Roth said.
Instead, she started what would eventually be known as the Domestic Violence Prevention Coordinating Council, which Roth still serves on today. The council has representatives from across the community: judges, prosecutors, police, corrections, schools, medical professionals, legislators and citizens.
The council created the Fatality Review Committee in 1996 to begin formally doing what Roth had undertaken herself: put each fatality under a microscope to see what lessons could be gleaned.
At this time, domestic violence coordinating councils and fatality review teams were popping up across the country. This was the beginning of a slow — and still incomplete — shift from seeing domestic violence as an individual failing to a systemic issue that should be addressed by the whole community.
In Louisville, every member brings all the information their agency has on that case to the table. They’ll watch court hearings, review police files and see whether the victim ever reached out to the Center for Women and Families or a hospital. If there are kids involved, they’ll see if the family interacted with Child Protective Services, or the school district.
The participants sign a confidentiality agreement at the outset of each meeting, and they’re closed to the public. But the group puts out a biannual report with their findings; each report is dedicated to the lives lost to domestic violence in Jefferson County.
Louisville’s fatality review committee has met consistently since it was founded in 1996. It’s unique in that it reviews open cases; most cities wait until the case is closed. This means they can review cases and issue recommendations without waiting years for a case to make its way through the criminal justice system.
The approach is not to “shame and blame” any one agency, Roth said, but rather to identify holes in the system that everyone can work together to fix.
When the committee first started, it was populated by the heads of agencies — the commonwealth’s attorney, the police chief, the coroner, people who had the power to institute changes and act decisively.
And Roth said they were addressing serious, obvious issues: cultures of victim-blaming, lack of trust and communication between agencies, and misunderstandings about domestic violence.
It has not been 25 years of uninterrupted progress, Roth said. There have been times when lower-level agency representatives populated the group, and momentum seemed to lull, and many times when the same issues seemed to surface again and again.
“I think like anything, if you start resting on your laurels, it goes backwards,” Roth said. “You have to just keep impressing upon everybody all the time, ‘This is good, but we can do better.’ Because until we have no domestic violence murders, we’re not doing enough.”
Does It Work?
That is the main criticism of domestic violence fatality review teams: They surface the same issues year after year, and little change happens once everyone leaves the conference room.
Experts say fatality review is only useful as one piece of a robust domestic violence response system, and its value cannot necessarily be measured in hard numbers.
Heather Storer, an assistant professor at the Kent School of Social Work at the University of Louisville who has researched domestic violence fatality review teams, said there’s no one solution to prevent these issues.
“We can’t expect one intervention to have momentous change,” she said. “[Domestic violence fatality review] is just one brick in a large sea change that is happening.”
She sees the presence of a fatality review team as a sign that a community may be willing to consider systemic reforms to its domestic violence response. And it means, at the very least, different entities are talking to each other more than they normally would. But the best work should happen after the committee adjourns.
“We’re really good at identifying needs, but what do we do when we identify these needs?” she said. “Agencies are doing everything they can but they still are dealing with chronic underfunding. They’re really challenged with resources. Law enforcement is being asked to do a lot more with a lot less.”
Elizabeth Wessels-Martin runs the Center for Women and Families, and sits on Louisville’s fatality review committee. She said the committee does a great job of having frank, difficult conversations about ways they may have erred.
“But I don’t know how much work is done outside of there,” she said. “Once we identify the gaps, now what? What are we doing to close them?”
To that end, Louisville commissioned a report last year that looked deeply at those gaps across all of the city’s domestic violence systems. Despite having a coordinating council for nearly 30 years, a fatality review committee for more than 25, and adding an interagency work group in recent years, the report found 86 areas for improvement.
Many of them were specific — expand funding for existing programs, restructure victim advocacy services throughout the criminal justice system, create more training opportunities, reform and enforce gun laws.
But the overarching theme connecting the recommendations was simple: Agencies are too siloed, and to improve victim response, they need to work better together.
That’s exactly what a domestic violence fatality review team is supposed to do, but it’s not a silver bullet, experts say. It’s a mechanism of gradual change, that, hopefully, over time, will change attitudes and practices.
That’s part of why Roth was “thrilled” to see the news that LMPD had charged two officers with misdemeanors out of the Amanda Berry case.
She said that’s a good example of how this should work: It’s not the committee’s job to tell LMPD how to deal with officers who mishandled a case. But in preparing to present on the case, or in the collective review that follows, an agency may find something they want to take their own action on.
“Let’s go back to [discussions of] police accountability recently,” Roth said. “Isn’t it wonderful that one of their own called them on it? That is very encouraging to me.”
Statewide, Efforts Have Floundered
Though Louisville is the only city in the commonwealth that’s currently reviewing domestic violence deaths, they were not alone in developing a coordinating council and a fatality review committee. In fact, they weren’t even the first in Kentucky.
In 1987, Lexington started the Domestic Violence Prevention Board, which tackled domestic violence cases as well as child abuse and issues facing the elderly and disabled communities.
“I felt like the greatest dishonor we could do to a victim who didn’t survive would be to let whatever happened — if we could have prevented it — happen to someone else,” said Teri Faragher, who until 2015 was the director of the board. Faragher and the board created Lexington’s fatality review committee in 1996, the same year as Louisville’s.
It suspended operations in 2002 for what was supposed to be a brief interlude. Advocates and state officials planned to launch a statewide fatality review project and help local communities create their own boards. Lexington’s board wanted to ensure their methods and data collection were consistent with the state plan.
Five years later, none of the state’s plans had materialized, so Lexington began reviewing cases again. They continued until 2018. After Faragher retired, the group paused fatality reviews to reassess their approach. Her successor, Stephanie Theakston, said they hope to resume in the future.
The idea of a statewide domestic violence fatality review committee was revived once more in 2011. Then-Attorney General Jack Conway convened the first Statewide Summit on Domestic Violence Fatalities, aimed at identifying areas for reform to reduce the number of deaths.
The goals, according to a report from the time, were four-fold:
—establish a statewide fatality review program;
—develop a plan to collect and analyze domestic violence fatalities;
—develop local fatality review teams;
—and develop model policies and procedures to guide those local teams.
But the first summit was also the last. Nearly a decade later, there is no statewide fatality review, Kentucky still does not track domestic violence fatalities, and there are actually fewer local fatality review teams than there were before the summit.
The summit did lead to a one-off report on domestic violence fatalities in Kentucky, led by T.K. Logan, a domestic violence researcher and professor in the Department of Behavioral Science at the University of Kentucky.
“That report was pretty superficial,” Logan said. “It was just sort of, here’s some data: Here’s how many women killed men; here’s how many men killed women. Here’s the sentencing trends.”
But even that level of data collection doesn’t exist today. The key to using that data, Logan said, would be to continue to collect it and look at trends year-over-year. People involved with the summit said it was a good idea; there just wasn’t enough political support, or funding, at the time to keep it moving.
With Berry Case, Missed Opportunities
There is some precedent for statewide reviews of deaths. Under Kentucky law, deaths suspected to be caused by child abuse must be investigated by the Child Fatality and Near Fatality External Review Panel, a 20-member interdisciplinary group that reviews all deaths suspected to be a result of child abuse and neglect.
That panel publishes general notes on each case, as well as an annual report with statewide recommendations. There are no similar requirements for Kentuckians killed by domestic violence; in fact, the state does not even keep track of how many people die by domestic violence each year.
That would be a good starting point, Logan said. She’s lukewarm on the value of fatality review: Just dropping a fatality review committee into every city is not enough to substantially change attitudes and practices. But done well, she said, it can be a very powerful tool.
As it stands now, only one city in Kentucky regularly reviews domestic violence fatalities. The Berry case has cast new attention on the otherwise quiet work of Louisville’s fatality review committee.
At a recent meeting of the Domestic Violence Prevention Coordinating Council, Major Shannon Lauder said it was “really disheartening” to see how the officers had responded to Berry.
Advocates say LMPD has invested time and resources into improving its domestic violence response in recent years. They’ve added training, advocated for statewide changes and created programs specifically intended to catch these highest-risk cases — like the Lethality Assessment Program, through which an officer could have asked Berry a few questions intended to assess how likely she was to be killed within the next 24 hours.
If she’d tested high enough, they would have put her on the phone with the Center for Women and Families right there at the scene; the Center keeps a number of shelter beds open specifically for these highest-risk cases.
But the officers didn’t even take a report. Instead, they left, and the next time LMPD was called to the house, it was to find her dead.
“Those officers never could have anticipated the outcome of that case when they didn’t take a report,” Lauder said. “It really opened everyone’s eyes to see how serious our decisions that we make every day are.”
It seems to be having an impact: Even though domestic violence calls have decreased compared to last year, Lauder said the number of domestic violence reports officers filed has increased by 7% compared to this same time last year.
“I think that case is part of the reason why that number is up, if I’m being totally honest,” she said. “So there has been some good outcome from that being made public.”
Contact Eleanor Klibanoff at email@example.com.