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311

Justice and Courage: A Blueprint

for San Francisco's Response to Domestic Violence

The San Francisco Commission and Department on the Status of Women were stunned by the murder of Claire Joyce Tempongko by her ex-boyfriend, Tari Ramirez, in front of her two young children in October 2000. We were sadly reminded of a similar murder that occurred in 1990 when there was no citywide response to domestic violence. At that time, the Commission and Department conducted an investigation into the murder of Veena Charan by her estranged husband, from which a coordinated intervention system was created. Although a citywide response to domestic violence was then developed, Claire's death demonstrates that significant problems still exist within the system. Because of the Commission and the Department's twenty-five years of experience working to stop violence against women, we knew we would once again take on the responsibility of reviewing the city's response to domestic and family violence.

The Commission and Department received full support from San Francisco Mayor Willie L. Brown, Jr. and the Board of Supervisors, particularly Supervisor Gavin Newsom and former Supervisor Michael Yaki. We would like to thank Mayor Brown for his quick response in addressing some of the immediate problems that were brought to his attention after Claire's death and to his long-term commitment to implementing this report's recommendations. A special thanks goes to Treasurer Susan Leal for her continued support and involvement.

This report represents hundreds of hours of work that could not have been completed without the efforts of many people. The Commission and the Department formed the Review Panel, made up of leaders from the domestic violence community, which oversaw the investigation of Claire's murder and reviewed and made recommendations regarding the city's domestic violence policies and procedures. I wish to express my gratitude to the members of the Review Panel, particularly Ken Theisen for his commitment to this work; to Supervisor Gavin Newsom who secured funding for the investigation, the public hearing, and the production and dissemination of this report; to my fellow Commissioners for their support; and to the Department on the Status of Women staff, particularly Rosario Navarrette, the Department's Interim Executive Director, for her leadership. I would like to recognize members of the City Attorney's Office for their outstanding efforts in handling the investigation: Louise Renne, former City Attorney, who was committed to the integrity of the process; Blanche Blachman, for conducting a thorough investigation; and Deputy City Attorney Amy Ackerman for writing a comprehensive report. I am also appreciative of all of the city departments who participated in the investigation.

The Commission and Department on the Status of Women believe that this report portrays a complete picture of where gaps exist in San Francisco's response to domestic violence and that the implementation of the outlined recommendations is essential to ensure that these gaps are closed in order to prevent future deaths. Our most critical recommendation is to promote public accountability by creating an oversight body that would include community members and city departments addressing domestic violence.

Finally, I would like to commend Claire's mother, Clara, and her family for their courage, in a time of deep loss and pain, in advocating for all women and their families who have experienced domestic violence.

Dorka Keehn
Chair, Review Panel
Vice President, Commission on the Status of Women


CONTENTS

Acknowledgements

Executive Summary

Background and History of Domestic Violence: Intervention Systems in San Francisco

Summary of the Murder of Claire Joyce Tempongko
The City and County of San Francisco's Response
Community Response

Recommendations
Interagency Recommendations
San Francisco Police Department
Emergency Communications Department
District Attorney's Office
Adult Probation Department
San Francisco Superior Court - Criminal Division
San Francisco Superior Court - Family Division
San Francisco Sheriff's Department
Medical Examiner
Department of Human Services - Child Protective Services
Community-Based Services

Conclusion


Acknowledgements

The Commission and Department on the Status of Women wish to thank Mayor Willie L. Brown, Jr. for his commitment and leadership ensuring that the city works to protect battered women and their children through a coordinated domestic violence response system. Mayor Brown is clearly dedicated to developing San Francisco as a model for effective domestic violence intervention. His continued support is essential to the successful implementation of the critical recommendations contained in this report.

The Review Panel donated many hours toward the completion of this report. The Review Panel was deeply committed to establishing accountability for effective domestic violence intervention systems and carried a vision of creating cutting edge programs and services in San Francisco. We would like to especially thank Ken Theisen, Bay Area Legal Aid, for his tenacity and dedication to systemic changes that will save lives. A special thanks to the other members of the Review Panel: Ricardo Carrillo, Ph.D.; Donna Diamond, formerly of San Francisco Domestic Violence Consortium and Partners Ending Domestic Abuse; Terry Person, Community United Against Violence; and Rebecca Rolfe, formerly of San Francisco Women Against Rape.

We thank the City Attorney's Office, particularly former City Attorney Louise Renne for being responsive to the Department on the Status of Women and agreeing to conduct the investigation. Her efforts to create an internal mechanism allowing staff assigned to this investigation to work independently from other staff that may be involved in legal actions regarding the Tempongko case resulted in an effective and thorough investigation. Additionally, we wish to acknowledge the leadership demonstrated by the City Attorney in taking the risk of not only conducting the investigation, but also providing additional questions and recommendations to the Commission and Department in an effort to improve the citywide response to domestic violence. We thank the current City Attorney, Dennis J. Herrera, for continuing to provide the necessary leadership in this effort to prevent domestic violence homicides and to protect our most vulnerable residents.

A very special thanks goes to Amy Ackerman, Deputy City Attorney, and to Blanche Blachman, Investigator for the City Attorney's Office. Ms. Ackerman gave many hours of her time to provide an investigative report that was factual, concise, and well written despite the number of challenges presented in organizing an investigation of this scope and depth. Ms. Ackerman's hard work and leadership in this effort is truly appreciated. Ms. Blachman reviewed hundreds of documents and interviewed many representatives of city departments, law enforcement, and community-based organizations in order to piece together the puzzle of the events that led to the murder of Claire Joyce Tempongko. We acknowledge the difficult task that Ms. Blachman took on in trying to portray an accurate picture of the city's response to Ms. Tempongko and her family and how this tragedy came to be. Ms. Ackerman's and Ms. Blachman's work and efforts form the heart of this report, laying a foundation for all of us to be held accountable for ensuring the safety and well-being of domestic violence survivors in our community.

We appreciate Susan Leal, San Francisco Treasurer, for her recognition of the impact domestic violence has on the city and for her work to increase the reward for information on Tari Ramirez from $10,000 to $25,000. Additionally, her support of the investigation and the implementation of the recommendations has been critical to this process.

We applaud the courage of Clara Tempongko and her family who took a very tragic personal loss and became an active living voice for victims and their families. Ms. Tempongko's participation in forming the Justice for Claire Joyce Tempongko Campaign helped raise awareness of the devastation domestic violence leaves in its wake and has had a significant impact in San Francisco. Ms. Tempongko calls us all to action, motivating many people in the community and the government to work together with a common goal and vision. We thank the Family Violence Prevention Fund for its model approaches, programs and work on a national, state, and local level to end domestic violence and for helping the Tempongko family through this tragedy to advocacy.

We thank the Commission on the Status of Women members for their support and leadership in bringing the truth to light on behalf of those who no longer can speak for themselves. A very special thanks goes to Dorka Keehn, Commission Vice President and Chair of the Review Panel, for her leadership in ensuring that community involvement and input was a part of this process.

Finally, a very special thanks to the Department on the Status of Women staff whose team spirit resulted in this report, particularly Holly Friel and Carol Sacco, for their invaluable assistance in this project. We give another very special thanks to Rebecca Rolfe for her hard work and dedication in keeping us focused in this process and in writing this report.


Executive Summary

In October of 2000, Claire Joyce Tempongko was murdered, allegedly by her estranged boyfriend, Tari Ramirez. Ms. Tempongko was stabbed to death in front of her two children, aged five and ten. Mr. Ramirez, who was seen fleeing the scene, is still at large and is believed to have left the country.

This murder shocked and angered the community and everyone who works to stop violence against women. We are angry that another woman was murdered by someone who professed to love her. We are angry that two children witnessed their mother being stabbed to death. We are angry because Claire Joyce Tempongko made repeated attempts to stop the violence in her life and because ultimately all of the services and systems designed to protect her failed to do so.

The murder of Ms. Tempongko is painfully reminiscent of the 1990 murder of Veena

Charan. Both women where murdered by their intimate partners, both where murdered in front of their children, and both attempted to access the criminal justice system and services to stop the violence they were experiencing.

Ten years ago, Veena Charan's murder sparked an extensive review of the criminal justice system's response to domestic violence. The San Francisco Domestic Violence Consortium (DVC), a citywide coalition of service providers assisting battered women and their children, initiated the investigation. They asked the Commission on the Status of Women (COSW) to review the circumstances leading to Ms. Charan's death, specifically the way the criminal justice system responded to her attempts to seek help. The COSW formed a committee to conduct an investigation and review the responses to domestic violence by the Police Department, the District Attorney's Office, the Adult Probation Department, the courts, and the Department of Social Services (now called the Department of Human Services). The resulting investigation was published in a document titled San Francisco's Response to Domestic Violence: The Charan Investigation, the first report in the nation to examine the systemic response to a domestic violence homicide.

A major finding of the Charan investigation was that many domestic violence homicides are preventable. The Charan report identified problems within the city's response to domestic violence, specifically the lack of consistency and coordination between the various agencies, which hinders the system's ability to successfully intervene in situations of escalating violence. The Charan report made over one hundred recommendations for changes to the civil and criminal justice and social service systems. Among the areas covered by the recommendations were: interagency/department communication and coordination, data collection, access to services, training, and the creation of an interdisciplinary task force.

The 1991 Charan report provided the city with an opportunity to create a model citywide response to domestic violence. By 2000, many of the recommendations in the Charan report had been implemented, including some significant changes in the criminal justice and social service systems. The Police Department, the District Attorney's Office, and the Adult Probation Department created specialized domestic violence units within each department. The courts instituted a Domestic Violence Court specifically to hear domestic violence related misdemeanor cases. Training programs were created for law enforcement, bringing together community members and law enforcement personnel in interdisciplinary training teams. Many new programs were developed between 1990 and 2000 including programs designed to address the treatment of violent offenders, more culturally accessible and community specific services, and increased capacity for existing programs.

The murder of Ms. Tempongko ten years later confirms that, while many positive changes have been made, much remains to be done. Some of the recommendations from the Charan report were never implemented including a recommendation to create an oversight body to coordinate the work of individual departments and programs. Without an oversight body, or a formal structure to take its place, communication and coordination between the components of the criminal justice system continued to be a serious problem. Other recommendations were implemented but follow-through became inconsistent over time. There was no formal mechanism to evaluate how the recommendations were implemented or to review whether implementation of the recommendations was effective in achieving an improved systemic response.

By April of 1999, when Ms. Tempongko first sought assistance from the criminal justice and social service system, many services and programs were in place. The fact that the system ultimately failed her points to serious problems and failures in what needs to be a seamless system.

Ms. Tempongko contacted the police at least six times from April of 1999, when she filed the first police report regarding Mr. Ramirez's violence, to October of 2000, when Mr. Ramirez allegedly killed her. In addition to filing police reports, Ms. Tempongko actively participated in police investigations, obtained a Stay Away Order, sought assistance through the Victim/Witness Compensation Program, and initiated contact with programs providing counseling and assistance to victim/survivors of domestic violence. At the time that he allegedly killed her, Tari Ramirez was on probation for domestic violence crimes and had participated in treatment programs for domestic violence offenders.

After Ms. Tempongko's murder, the City and County of San Francisco and community members mobilized to address the apparent problems in the city's domestic violence intervention services-focusing on the criminal justice system. The Family Violence Prevention Fund provided leadership to community members and domestic violence agencies in creating the Justice for Claire Joyce Tempongko Committee. Treasurer Susan Leal worked with community members to increase the reward offered for information leading to the arrest of Tari Ramirez and worked to ensure funding for the JUSTIS system, a computer system designed to coordinate information sharing between the components of the criminal justice system. Mayor Willie L. Brown, Jr. pledged his support for improving domestic violence services provided by the city including full staffing for the specialized Domestic Violence Response Unit in the Police Department, culturally sensitive training on domestic violence, and the completion of the JUSTIS system.

Supervisor Michael Yaki asked the Commission and Department on the Status of Women (Commission and Department) to investigate the criminal justice and social service systems' response to domestic violence in general and Ms. Tempongko in particular. Supervisor Gavin Newsom led the effort to secure funding for the Department to take on this work.

In February of 2001, the Commission and Department convened a Review Panel to assist in the investigation. Community experts on violence against women were asked to participate on the Review Panel, which was charged with assisting the Department in evaluating the criminal justice and social service systems' response to domestic violence, identifying gaps in services and barriers to people accessing available services, and developing recommendations to remove those barriers and gaps.

In addition to convening the Review Panel, the Department asked City Attorney Louise Renne to conduct an investigation into the criminal justice system's response to, and interactions with, Ms. Tempongko and Mr. Ramirez. Ms. Renne fully supported the investigation, providing a senior investigator, Blanche Blachman, and a deputy city attorney, Amy Ackerman, to conduct the investigation and to prepare the report. Ms. Renne ensured the integrity of the investigative process by creating formal separations between the staff assigned to conduct the investigation and staff who may be called upon to represent San Francisco in any legal matters pertaining to Ms. Tempongko's murder.

Although all city departments pledged their initial support and participation in the investigation, the Police Department and the District Attorney's Office did not fully participate. These departments cited the ongoing criminal investigation and prosecution (since Tari Ramirez is still at large), legal restrictions on when peace officers can be compelled to answer questions, and a pending civil suit against the City and County of San Francisco filed by Ms. Tempongko's family as factors in their decision to limit their participation in the City Attorney's inquiry.

The Review Panel met with Ms. Blachman at the beginning of the investigation to provide general background information and expertise in domestic violence. Ms. Blachman conducted extensive interviews with staff from the participating departments and met with representatives of the Police Department and the District Attorney's Office. She reviewed thousands of pages of documents provided by the departments including public records regarding the Police Department's and the District Attorney's handling of Mr. Ramirez's cases.

The investigation is summarized in the City Attorney's report, which is provided in the appendix to the full Justice and Courage report. The report provides a comprehensive and detailed outline of the history of Ms. Tempongko's and Mr. Ramirez's interactions with the criminal justice system. It clearly outlines the system's response to Ms. Tempongko and her family, the protocols that were in place, and the degree to which actual practices deviated from the established protocols. Most importantly, the City Attorney's Report clearly demonstrates that there are serious flaws and problems in our domestic violence intervention and service delivery system.

In addition to the investigation conducted by the City Attorney's Office, the Review Panel assisted the Commission and Department in conducting a press conference and public hearing on domestic violence on May 15, 2001. The hearing provided members of the public with an opportunity to testify about their experiences with city departments and community-based organizations regarding domestic violence services. The issues raised at the public hearing centered around several areas including the need for coordination and communication between the different criminal justice departments; review of existing policies and protocols; methods to ensure that existing policies and protocols are followed consistently; training, particularly on cultural awareness and victim sensitivity; and the clear and consistent need for more services, particularly for marginalized communities and children. Overall, participants in the hearing expressed a strong need for leadership in the criminal justice and social service systems to make violence against women a priority issue.

The Commission and Department worked with the Review Panel to synthesize the information from the City Attorney's report, the public testimony at the hearing, and best practices models into a series of recommendations for changes in the criminal justice and social service systems' response to domestic violence. The full Justice and Courage report includes one hundred recommendations including general interagency recommendations as well as recommendations specific to the Adult Probation Department, the Department of Human Services - Child Protective Services, the District Attorney's Office, the Emergency Communications Department, the Medical Examiner, the San Francisco Police Department, the San Francisco Sheriff's Department, the San Francisco Superior Court - Criminal Division, the San Francisco Superior Court - Family Division, and community-based services.

The recommendations define a blueprint for a model response to domestic violence. Successful implementation requires the active participation of community-based service providers and the full support of city departments. Implementation of the recommendations may require additional costs or reallocation of existing resources; however, they will ultimately result in an overall reduction of expenses by making the domestic violence intervention systems more effective and reducing the number of domestic violence cases brought to the criminal justice system.

The recommendations in the report focus on five primary areas: 1) development of an oversight body, 2) communication and coordination between departments and programs, 3) protocols and policies, 4) resources including personnel and training, and 4) data collection and management.

One of the most critical ingredients for successful implementation will be the full commitment of each program and department to collaboration, accountability, and evaluation. San Francisco has been successful at creating specialized units and programs addressing domestic violence, however gaps in services and lack of communication between departments have created serious problems. In some cases, protocols exist but are not followed consistently and few mechanisms have been developed to evaluate their effectiveness or to analyze how they are being utilized. Additionally, while individual agencies and departments may have a commitment to evaluating the effectiveness of their own programs, there has been no overall system of evaluation or public accountability.

To address the need for collaboration and accountability, we recommend the development of a multidisciplinary oversight committee. The oversight committee would have responsibility for overseeing the implementation of these recommendations, and for ensuring that the recommended changes occur in a collaborative context. To be effective, these changes must take place within a context of cross-disciplinary input, open communication, and public accountability. Law enforcement, prosecution, the courts, and victim service providers must all actively participate in making changes to San Francisco's domestic violence services delivery system.

The full report lists recommendations in the following areas.

Oversight Committee: A multi-disciplinary oversight committee under the authority of the Commission and Department with responsibility for implementing the recommendations in this report and for evaluating and analyzing the impact of the implementation. The committee's work would culminate in a final evaluation of the implementation of these recommendations and a reassessment of violence against women service delivery, crisis intervention, and criminal justice response systems in San Francisco.

Interdepartmental Communication and Coordination: Agencies and departments working on domestic violence issues need to develop consistent and timely methods to share information between and across departments. These methods should ensure that information regarding changes within each department's policies and procedures can be shared with other departments, support a collaborative interdepartmental approach to service delivery, and allow for the members of the service delivery systems to identify and respond to trends and problems as they arise.

Resources: Departments and programs need to evaluate the staffing necessary to adequately meet domestic violence caseloads. Additionally, departments and programs with specialized units need to fully staff their units with active duty employees able to commit their time and expertise fully to domestic violence cases. Domestic violence training curricula for all departments need to be evaluated to ensure that trainings minimally include an overview of domestic violence, victim sensitivity, cultural awareness, information relevant to the specific role the department staff play in addressing domestic violence, relevant policies and protocols, and cross training on the role of other service providers or criminal justice agencies. Training curricula should be developed for initial training/orientation of new staff or officers, ongoing training for existing staff or officers, and specialized advanced training for staff or officers assigned to work with a large number of domestic violence cases.

Protocols: Existing protocols need to be reviewed to ensure that they adequately address the effective investigation, prosecution, and other forms of intervention for domestic violence. Protocols should be written wherever possible and all appropriate staff should be adequately trained on their purpose and application. Protocols should be reviewed internally as well as in an interdepartmental context to ensure that they meet the needs of the specific department and support effective work in other related departments. Evaluation mechanisms should be developed to ensure that actual practices in each department meet the criteria established in the protocols.

Data Collection: The criminal justice departments need to coordinate their data collection and information management systems to ensure interdepartmental access to current, accurate, and complete information on criminal cases pending or active within the system. Additionally, data should be collected to allow for accurate analysis and evaluation of the effectiveness of existing service delivery systems.


Background and History of Domestic Violence: Intervention Systems in San Francisco

In January of 1990, Veena Charan was murdered by her estranged husband, Joseph Charan. What made this domestic violence murder stand out from the many other domestic violence murders in San Francisco were the circumstances. Ms. Charan had actively sought the assistance of the criminal justice system, the family court, and social services. She had been successful in separating from her husband, who had been physically violent to her. She was granted custody of their nine-year-old son, obtained a restraining order, and pursued the options available to ensure her own safety and the safety of her son. In spite of her efforts, Joseph Charan continued to demonstrate an escalating pattern of violence that ended with his murder of her in the schoolyard of their son's school, in front of their son, other school children, and teachers. After murdering her, he committed suicide. Part of the tragedy of Ms. Charan's murder is that, had it not been for the extraordinary setting of her homicide, we might never have heard about it. She would have been lost in the nameless and faceless statistics of the 3.9 million women who are battered, stalked, and/or killed by their intimate partners each year.

Because of its extenuating circumstances, Ms. Charan's murder was one of the few domestic violence stories that made the headlines. The media coverage of the murder helped to focus public scrutiny on the fragmentation and problems in the civil and criminal justice systems' responses to domestic violence. Members of the San Francisco Domestic Violence Consortium, a citywide coalition of service providers assisting battered women and their children, asked the Commission on the Status of Women (Commission) to investigate the circumstances leading to Ms. Charan's death, specifically the criminal justice system's response to the violence in her life.

The Charan investigation was the first in the nation to look into the systemic response to domestic violence in direct relation to a domestic violence homicide. The Commission formed a committee to conduct the investigation and review the responses of the Police Department, the District Attorney's Office, the Adult Probation Department, the courts, and the Department of Social Services (now called the Department of Human Services) to domestic violence. The Family Court, the civil branch of the courts, did not participate in the investigation, citing confidentiality requirements, however the Criminal Courts did participate. The result of the investigation was The Charan investigation report (Charan report) published in 1991 (see appendix for the Charan report executive summary).

Perhaps the most significant finding in the report was that many domestic violence homicides are preventable. Joseph Charan clearly demonstrated a pattern of abuse and violence. Ms. Charan actively sought intervention from the civil and criminal justice and social service systems, creating multiple opportunities for effective intervention. These opportunities were never realized due to significant problems in the systems' fragmented response. The Charan report identified many of these problems, detailing over one hundred recommendations for change in the civil and criminal justice and social service delivery systems.

These recommendations covered five primary areas: 1) interagency/department communication and coordination, 2) data collection, 3) access to services, 4) training, and 5) creation of an interdisciplinary task force. The following details the general recommendations in each of these areas.

Communication and Coordination: Agencies and departments need to share information regarding their work on domestic violence; to coordinate their efforts so that domestic violence victim/survivors are given accurate, timely and consistent information; to cooperate with each other in investigation, prosecution, provision of social services and probation supervision of domestic violence related cases; and provide cross-training across departments and issues.

Data Collection: There is a lack of accurate and timely data collection or sharing of information between different components of the criminal justice system. These data collection problems negatively impact individual criminal justice cases as well as the ability to analyze patterns and trends in domestic violence overall.

Access to services: More culturally accessible services are needed within the civil and criminal justice and social service systems, particularly around cultural differences, language barriers, and sexual orientation.

Training: Domestic violence advocates should be involved in developing and implementing training for law enforcement on topics such as cultural sensitivity, dynamics and effects of domestic violence, training on specific department protocols, and language translation of civil and criminal justice materials and proceedings.

Oversight Committee: There is a need for an Oversight Committee with the authority to evaluate whether the systems are effective at protecting battered women and their children, and to oversee changes and improvements to the domestic violence services provided by the city.

Following the Charan investigation, the Commission requested that the Family Violence Project of the District Attorney's Office conduct a study of all domestic and family violence related homicides. They found that of all of the categories of homicides, domestic violence was the largest category accounting for 64% of total homicide cases. This study affirmed that Ms. Charan's murder was not an aberration, but that she was one of many women murdered by their partners every year. It also documented that domestic and family related homicides are preventable. One or more violent incidents are usually reported prior to a domestic violence related homicide. These early incidents provide opportunities for intervention, which could prevent further violence, including murder. These findings made the need for systemic changes in law enforcement's response all the more critical.

The 1991 Charan report provided the city with the opportunity to create a model response to domestic violence that was a coordinated and collaborative effort. All of the departments that participated in the Charan investigation acknowledged the need to create a citywide response to domestic violence. Community-based programs and advocates stood prepared to assist San Francisco in improving the response to domestic violence in order to prevent further domestic and family violence related homicides.

City departments had varied reactions to the Charan report, with most of the departments citing funding as a major barrier to implementing some of the recommendations outlined in the report. From 1992 to1996 changes that did not require additional funding were implemented. These efforts were conducted in partnership with law enforcement and community advocates. During the same period, the Commission on the Status of Women stabilized its existence by becoming chartered in 1994 and establishing the Department on the Status of Women (DOSW). The Department served as a critical link between city departments and the domestic violence community in the implementation of the Charan report recommendations.

By 2000, many of the Charan report recommendations had been implemented including some significant changes in the criminal justice and social service systems. The Police Department, the District Attorney's Office, and the Adult Probation Department created specialized domestic violence units within each department. The courts instituted a Domestic Violence Court specifically to hear domestic violence related misdemeanor charges. Training programs were created for law enforcement, bringing together community members and law enforcement personnel in interdisciplinary training teams.

Many new programs were developed during the past ten years. Programs designed to address treatment of violent offenders were instituted including Resolve to Stop the Violence Project (RSVP), a domestic violence program of the Sheriff's Department for offenders in custody. Culturally accessible services were developed or expanded to address the needs of victim/survivors of domestic violence including the Asian Women's Shelter, Mujeres Unidas y Activas, and same sex domestic violence programs at Community United Against Violence. These services and others moved toward addressing the issues of language accessibility, cultural accessibility, and community specific services. Existing service providers were able to increase their capacity as a result of increases in funding created by the federal Violence Against Women Act. In addition, the City and County of San Francisco increased funds for violence against women services. Increasingly, service providers began focusing on the effects of domestic violence on the whole family by addressing the needs of children who witness violence and the larger impact domestic violence has on the larger community.

California State Senator Hilda Solis introduced legislation in 1995 authorizing California counties to establish Domestic Violence Death Review Teams (DVDRT). The role of the DVDRTs was and is to investigate specific cases of domestic violence related deaths, including an in-depth analysis of the possible causes, and to review systemic responses. The California Attorney General's Office was given responsibility for overseeing the implementation of the DVDRT in the counties, which included the developing of guidelines and protocols, collecting data, and providing counties with technical assistance in the establishment of their DVDRT. With the establishment of their DVDRT, Santa Clara County became the model for other counties to follow.

The efforts to institute these reforms was helped by a significant increase in public awareness of domestic violence due to media coverage of high profile domestic violence homicides, including that of Nicole Brown Simpson, and the O.J. Simpson trial in the mid 1990s. The public attention created by media coverage of these cases raised the profile of domestic violence, generated wider support for domestic violence programs, and led to a significant increase in state funding for domestic violence shelter and intervention programs.

One of the major recommendations in the Charan report was the creation of a citywide oversight committee on domestic violence. Although several citywide, interagency bodies were started, including the Family Violence Council and the Domestic Violence Death Review Team, they did not fulfill the role of an oversight committee. The lack of an oversight committee has been one of the most significant obstacles to the implementation of an effective, coordinated citywide response to domestic violence. Without an oversight committee, each department implemented specific recommendations without a coordinated vision for developing departmental protocols and practices. Interdepartmental communication systems were never institutionalized, leading to a lack of effective information sharing between the many components of the civil and criminal justice systems. Without the oversight committee there was limited ability to review the implementation of new policies and protocols that were created. There was no assurance that recommendations were being followed and the ability to evaluate their effectiveness was lost. While trainings were developed collaboratively, each department was left on its own to implement, evaluate, and follow through on them. As a result, many training programs became inconsistent after a few years.

The efforts of individuals and departments to implement the recommendations in the Charan report should be applauded. Much change has been affected and the systems in place today are clearly an improvement upon the systems that were in place in 1990. Unfortunately, much work still remains to be done.

The murder of Claire Joyce Tempongko in October of 2000 is eerily reminiscent of the murder of Veena Charan ten years earlier. As with Veena Charan, Claire Joyce Tempongko's death is not an isolated incident, but it does demonstrate that there are still major gaps within San Francisco's citywide response to domestic violence.


Summary of the Murder of Claire Joyce Tempongko

On Sunday, October 22, 2000, Claire Joyce Tempongko was stabbed to death in front of her two children, ages five and ten. Neighbors heard Ms. Tempongko's screams and called the police. Responding police officers found her dead in her apartment.

Witnesses saw 28-year-old Tari Ramirez running down the street with a bloody kitchen knife, which was later recovered by police. Three days after the murder, the police issued an arrest warrant for Tari Ramirez, who is the primary suspect in Ms. Tempongko's murder. Mr. Ramirez is still at large and is suspected to have fled to Mexico.

Prior to her murder, Ms. Tempongko contacted the police regarding Mr. Ramirez's violence towards her on at least six occasions, beginning on April 28, 1999. In her early communications with the police, Ms. Tempongko told the police that Mr. Ramirez had hit her eighteen times in the first six months of their relationship, which began sometime in late 1998. In addition to filing police reports, Ms. Tempongko actively participated in police investigations, obtained emergency protective orders and a Stay Away Order, sought assistance through the Victim/Witness Compensation Program, and participated in programs providing counseling and assistance to victim/survivors of domestic violence.

Over the following eighteen months, Ms. Tempongko contacted the police at least five more times to report additional incidents of violence by Mr. Ramirez including hitting, attempting strangulation, violating a restraining order, and making threats against her and her children. The last incident she reported to the police occurred on September 7, 2000-just six weeks before her murder. It appears that Ms. Tempongko's children witnessed most of the reported incidents and that adult witnesses, including Ms. Tempongko's parents, her brother, and a friend, were present for at least three of the reported incidents.

In addition to the reports Ms. Tempongko filed, Tari Ramirez had at least one other encounter with law enforcement. On October 16, 1999, he was arrested for loitering at a public toilet with intent to engage in lewd conduct, a charge unrelated to Ms. Tempongko.

The City Attorney's report, which is included in the appendix of this report, contains a full chronology of the events that Ms. Tempongko reported to the police as well as a detailed report on the interactions Ms. Tempongko and Mr. Ramirez had with the criminal justice system. The following description of the events leading to Ms. Tempongko's death summarizes this information.

Ms. Tempongko first contacted the police on April 28, 1999. She reported that she had refused Tari Ramirez entry to her home because he was under the influence of drugs. He had broken a window attempting to gain entry. Fearing that the neighbors would be disturbed, she allowed him into the house and told him that she did not want him to live with her anymore. Without warning he grabbed her by the hair, dragged her into to the hallway, knocked her down, and left the scene. After leaving her home, Mr. Ramirez was involved in an automobile accident and arrested for driving under the influence.

On May 18, 1999, Ms. Tempongko again reported to the police that Mr. Ramirez had attacked her. She reported that he hit her head, threatened her with a broken beer bottle, pulled her by her hair and threatened to burn down her house.

On July 12, 1999, the Superior Court sentenced Mr. Ramirez to three years of probation for one count of felony spouse abuse as a result of the May 18 incident of violence. As a condition of his probation, the court ordered him to participate in a batterer treatment program and alcohol treatment program. The District Attorney's Office had previously dropped the battery charge relating to the April 28 incident. The District Attorney's Office also dismissed the charges relating to a May 24, 1999 violation of a Stay Away Order. The court sentenced Mr. Ramirez to time already served in exchange for a guilty plea on the driving under the influence charge.

On February 2, 2000, the court modified Mr. Ramirez's probation as a result of another battery incident that had occurred on November 18, 1999. On November 18, Mr. Ramirez grabbed Ms. Tempongko's hair and pulled her head back. Fearing for her safety, Ms. Tempongko left to go to her mother's house. She returned with her mother and stepfather after calling police from a pay phone. Upon her return, Mr. Ramirez forced her into the bedroom and refused to let her leave until the police arrived. The court modified probation to require Mr. Ramirez to serve six months of jail time and to continue participation in a batterer treatment program.

While in jail, Mr. Ramirez participated in the Resolve to Stop the Violence Project (RSVP). Both prior to his incarceration and upon his release in March 2000, he was enrolled in community-based batterer treatment programs. His evaluations from the batterer treatment programs are mixed, with some evaluating him as an ideal participant passionate about the work they were doing, while others evaluated him as extremely quiet or non-responsive. His participation in these programs was a condition of his probation and on at least one occasion Mr. Ramirez's probation officer advocated that he be readmitted to a program from which he had been discharged due to absences from mandatory sessions.

Mr. Ramirez was never prosecuted for the remaining two incidents that Ms. Tempongko reported to the police. On September 1, 2000, police responded to Ms. Tempongko's home and found her crying uncontrollably with blood spilling from her mouth. She reported that Mr. Ramirez had attempted to strangle her to the point that she had difficulty breathing. In a follow-up interview with the police, Ms. Tempongko added that Mr. Ramirez had stolen her purse and items in her purse at the time of the assault on September 1.

Ms. Tempongko called the police again on September 7, 2000 to report that Mr. Ramirez was making threats against her. Mr. Ramirez, who remained on the scene until the police arrived, smelled strongly of alcohol. The police arrested him for drunk and disorderly conduct and false representation of identity to a police officer and served him with an Emergency Protective Order issued as a result of the September 1 incident.

At the time of Ms. Tempongko's murder, Mr. Ramirez was on probation for a domestic violence felony conviction and was enrolled in a community-based batterer treatment program. Although Mr. Ramirez clearly demonstrated a history of violence, he had not been reassigned to a new probation officer after June 30, 2000 when his probation officer left the Adult Probation Department. Mr. Ramirez continued without a probation officer until November 15, 2000, three weeks after the murder of Claire Joyce Tempongko, when the Adult Probation Department filed a Motion to Revoke Probation.

Following Ms. Tempongko's murder, which was witnessed by her children, her family expressed concern for the safety and well-being of her children. The police report of her homicide made no mention of her children other than as witnesses to the homicide. Among the family's concerns was that on the night of Ms. Tempongko's murder the police left her children in the care of neighbors for many hours before they attempted to locate a family member. Additionally, the family expressed concern that it took months for the police to contact the children's school to develop a safety plan with the teachers and security personnel in case Tari Ramirez attempted to contact or harm the children.

At the time of her murder, Claire Joyce Tempongko was a 28-year-old Filipina woman, and a mother of two young children who had what should have been a long life ahead of her. Her mother describes her as being a good mother, daughter, sister, and friend. She had her own apartment, a new job, and a network of family and friends in the Bay Area who cared for her. She had a vision for her own future and the future of her children including dreams of her son becoming a medical doctor and her daughter becoming an administrator. She was working hard to make this future a reality. In her communications with law enforcement and social service providers, she expressed her fear of Tari Ramirez and her concern for her own safety and the safety of her children. She knew she was in trouble, but everything she tried to do to stop the violence failed to work.

Unfortunately she is not alone. An estimated 3.9 million women are physically abused each year-about one every eight seconds-and an estimated 683,000 women are sexually assaulted each year-about one every forty-six seconds. On average, more than three women are murdered by their domestic partners in the United States every day. Domestic violence affects thousands of women in San Francisco each year, resulting in between eight and nine thousand calls to the police on domestic and family violence related complaints.

While it is too late to save Ms. Tempongko's life, it is not too late to end the violence in the lives of other victims of domestic violence. The investigation into Ms. Tempongko's death and the criminal justice system's handling of her numerous police reports clearly shows a need for major improvements in the civil and criminal justice and social service systems' response to domestic violence.

The City and County of San Francisco's Response

After the murder of Claire Joyce Tempongko in October of 2000, Supervisor Michael Yaki requested that the Commission and Department on the Status of Women (Commission and Department) conduct an investigation into the citywide response to domestic violence, similar to the 1991 Charan investigation. In order to make the investigation possible, Supervisor Gavin Newsom secured additional short-term funding for the Department on the Status of Women. To assist in the investigation, the Commission and Department convened community leaders in the field of violence against women on a committee it called the Review Panel.

The goals of the Review Panel were to evaluate the criminal justice and social service systems' response to domestic violence, to identify gaps in services and barriers to people accessing available services, and to make recommendations to remove those barriers and gaps. The Commission and Department requested that the City Attorney's Office conduct the initial investigation. Louise Renne, then City Attorney, assigned an investigator whose work included information gathering and interviews with the city departments that had interacted with Ms. Tempongko and with Ms. Tempongko's surviving family. Ms. Renne went to great lengths to protect the integrity of the investigation by creating formal separations between the staff working on the investigation and staff who might be involved in representing San Francisco in any legal proceedings related to Ms. Tempongko's death. The City Attorney's Office submitted a report to the Commission on the Status of Women in January of 2002 containing the results of the investigation as well as their analysis and recommendations. The City Attorney's report to the Commission is included in the appendix of this report.

The Review Panel was created with representatives from community-based organizations and staff from the Department on the Status of Women, and was chaired by Dorka Keehn, a member of the Commission on the Status of Women. The Review Panel developed questions for all of the parties involved (law enforcement, community-based service agencies, etc.) to help guide the City Attorney's investigator in the inquiry process. The Review Panel also planned and implemented a public hearing and established recommendations for corrective action to be included in the final report.

The Commission and Department on the Status of Women held a press conference and public hearing on May 15, 2001. At the press conference, Mayor Willie L. Brown, Jr. affirmed his commitment to improving domestic violence services including ensuring full staffing in the Police Department Domestic Violence Response Unit, supporting culturally sensitive training on domestic violence issues for the criminal justice system, and supporting a computer database to track domestic violence cases. The public hearing gave consumers, community members, and service providers an opportunity to provide testimony about their experiences with city departments and community-based services. Media clippings from the press conference and the Executive Summary of the public hearing can be found in the appendix.

The primary areas of concern raised at the public hearing were the need for the following:

1) coordination and communication between the different criminal justice departments; 2) review of existing policies and protocols; 3) methods to ensure that existing policies and protocols are being followed consistently; 4) training, particularly on cultural awareness and victim sensitivity; and 5) more services, particularly for marginalized communities and children. Perhaps the strongest overall theme expressed during the public hearing was the need for leaders in the criminal justice and social service systems to make violence against women a priority.

At the public hearing, members of Claire Joyce Tempongko's family provided powerful testimony about the criminal justice system's response to the violence in Ms. Tempongko's life and the system's apparent lack of concern for the safety and well-being of her children. Her family spoke about the number of times Ms. Tempongko asked for help, the seriousness of the violence at each incident, the burden placed on her to follow-up on the felony crimes committed against her, and the impact of the ongoing violence and murder on her children. Additionally, the family denounced the insensitivity of the police department's response to Ms. Tempongko's children on the night of her death and the apparent lack of security for them following her death. The family feels that the children, who witnessed their mother's murder, were at risk of further violence from the suspect, Tari Ramirez, who is still at large and had previously threatened to hurt the children.

It was clear from public testimony at the hearing that law enforcement, including representatives from the Police Department, the District Attorney's Office and the Adult Probation Department, are not consistent in implementing department protocols. The issues raised at the hearing were not only relevant in Ms. Tempongko's homicide but they also have much broader implications for the City and County of San Francisco. Battered women testified that the Police Department and the District Attorney's Office consistently failed in their responsibilities to victims of domestic violence related crimes. One woman testified that there was a total of six significant errors made by police officers and assistant district attorneys in investigating and prosecuting her abusive partner. The errors were committed by many different individuals within each of the departments, which demonstrated to her that these are systemic issues for the departments as a whole and not just the responsibility of the individuals involved in her case.

An example of systemic issues that need to be changed is that battered women who attempted to become independent of their batterers continued to have to deal with their former partners regarding issues related to shared child(ren) and other legal and familial commitments. Rather than supporting women in their efforts to end the violence, the civil and criminal courts often undermined these efforts. Rose Cassidy submitted written statements to the Department (included in the appendix) that demonstrate this experience. After leaving her husband, who had been physically abusive to her, Ms. Cassidy found that her husband became abusive to their daughter. Additionally, their son, who grew up witnessing his father's violence, physically assaulted Ms. Cassidy. Ms. Cassidy's experience with the police and courts was that they minimized the violence she and other family members experienced, thus participating in the victim blaming that has traditionally served to invalidate the experience of battered women and their children.

Testimony from members of the public, along with written statements submitted to the Department on the Status of Women, were incorporated into the recommendations of this report.

The City Attorney's investigation reveals law enforcement's response (Police Department, District Attorney's Office, Adult Probation Department, and the courts) to Ms. Tempongko and her family, the protocols that were in place, and the degree to which actual practices deviated from the established protocols.

Initially, city departments pledged their support for the investigation, however full participation was negatively affected by several factors. Since Tari Ramirez, the prime suspect, is still at large, the criminal investigation and prosecution of Ms. Tempongko's homicide is still open. After the investigation began, Ms. Tempongko's family filed a civil suit against the City and County of San Francisco. Finally, the Public Safety Officers Procedural Bill of Rights Act provides significant restrictions on when peace officers can be compelled to answer questions. As a result, the Police Department and the District Attorney's Office declined to allow interviews with staff members regarding this specific case and denied access to some files and documents related to the investigation and prosecution of criminal cases involving Mr. Ramirez. Although the Police Department and the District Attorney did not fully participate in the City Attorney's investigation, both were responsive to the Commission and Department in our preparation of this report and have expressed their full support for improving the criminal justice system's response to domestic violence.

During the investigation, full interviews were conducted with representatives of the Superior Court, the Adult Probation Department, the Sheriff's Department, men's batterer treatment programs and domestic violence victim service providers. The investigator also met briefly with representatives of the San Francisco Police Department and the District Attorney's Office. The City Attorney's Office reviewed thousands of pages of documents provided by the participating agencies including public records related to the investigation and prosecution of the complaints filed against Mr. Ramirez and information that the Police Department and the District Attorney's Office agreed to make available.

The City Attorney's report creates a comprehensive and detailed outline of the history of Ms. Tempongko's and Mr. Ramirez's contacts with the criminal justice system. The report also outlines the system's and agencies' responses to Ms. Tempongko's and Mr. Ramirez's actions. In spite of the limited participation from the Police Department and the District Attorney's Office, the City Attorney's report provides a clear and comprehensive picture of the criminal justice system's response to domestic violence and reveals substantial gaps and problems.

Community Response

The community reacted strongly to news about Ms. Tempongko's murder. Domestic violence victim service providers and advocates, community members, and activists joined together in outrage. The Family Violence Prevention Fund (FVPF) took the lead in establishing the Committee for Justice for Claire Joyce Tempongko, organizing members of the Filipino-American community, and convening vigils in Ms. Tempongko's memory.

Initially a reward of $10,000 was created for information leading to the arrest of Tari Ramirez. Treasurer Susan Leal and the FVPF, with the support of Mayor Willie L. Brown, Jr., worked to increase the reward to $25,000 in February of 2001.

In response to Ms. Tempongko's death, the FVPF organized the Not in My Home, Not in My Town campaign against domestic violence. The campaign seeks to prevent domestic violence and improve the city's response to domestic violence through advocacy and public education. As a measure of the very personal nature of domestic violence, the campaign asks San Franciscans to sign a pledge promising to stop domestic violence: Not in My Home, Not in My Town. The campaign reached out at public events throughout San Francisco and thousands of people signed pledge cards committing them to ending domestic violence. As an outgrowth of this campaign, the FVPF sponsored bringing V-Day, Eve Ensler's annual awareness event to stop violence against women and girls, to San Francisco in February of 2002.

The FVPF also convened a series of discussions with community leaders on domestic violence issues. Community leaders involved included funders, service providers, and people in key policy and/or decision-making roles.

To achieve the successful and full implementation of the recommendations in this report, we will need the continued active participation and support of all the community members as well as the Mayor, the Board of Supervisors and city departments involved in responding to domestic and family violence. We have the opportunity for San Francisco to become a national leader in our response to domestic and family violence. Our mission must be to create a system that effectively protects women and children from continued domestic violence and ends the violence in our families long before it escalates to a life-or-death situation.


Recommendations

San Francisco has demonstrated a historic commitment to building an effective response to domestic violence. While many important gains have been made, much remains to be done.

We now have an opportunity to create a national model of cutting-edge services and effective interventions for domestic violence.

These recommendations define a model domestic violence response, which will require individual city departments and agencies to commit to internal reviews and change as well as necessitate broad-based, collaborative interdepartmental revisions to service delivery systems. A model response will require government agencies and community-based service providers working together to implement recommendations and to ensure that the implementation meets established goals. We believe that it is within our power to create a model that will significantly increase the safety, health, and well-being of victim/survivors of domestic violence. Our goal is to save lives and to effectively intervene in situations of domestic and family violence long before violence escalates to murder.

While some of the recommendations will require a considerable reallocation of existing resources, implementation of these recommendations will save money in the long run. The criminal justice system is the most costly of all domestic violence interventions and in most domestic violence situations numerous incidents of violence are reported to the police. If we can successfully resolve domestic violence cases earlier, we can substantially decrease the need to involve the criminal justice system, thus saving money over the long term.

Of all of the recommendations provided here, two stand out as the most critical. The first is a commitment to evaluation, accountability, and collaboration. In the past ten years we have seen major expansion of the programs and services available for domestic violence survivors. In spite of these improvements, gaps in services and lack of communication between departments and programs have created serious problems. In many cases, protocols exist but are not being followed consistently and few mechanisms have been developed to evaluate their effectiveness or to analyze how they are being utilized. Additionally, while individual agencies and departments may have commitments to evaluating the effectiveness of their individual programs, there has been no overall system of evaluation or accountability. The City Attorney's report clearly speaks to this issue in its recommendations. While the work of the Death Review Team is important in reviewing specific domestic violence cases, it lacks enforcement to mandate change within individual departments and has not led to public accountability or to widespread change in service delivery systems. The City Attorney's report clearly demonstrates the fact that a series of seemingly small failures can significantly undermine the effectiveness of the criminal justice system, in this case leading to the system's failure to stop the clear pattern of violence demonstrated by Tari Ramirez against Claire Joyce Tempongko.

To address the need for collaboration and accountability, our second critical recommendation is the development of a multi-disciplinary oversight committee. The San Francisco Charter mandates that the Commission and Department on the Status of Women develop and recommend policies and practices for San Francisco regarding domestic violence and other forms of violence against women. In carrying out this mandate, the Commission and Department have a twenty-five-year history of active involvement in recommending policy changes on violence against women and of working in partnership with city departments and community-based agencies to implement recommended policy changes. Both the City Charter's mandate and the Commission and Department's long history and demonstrated leadership on this issue support the need for the Commission and Department to continue to have a strong leadership role in creating and implementing this oversight committee. The Commission has adopted a resolution that would create an oversight body under the direction of the Commission and Department and staffed by the Department in order to continue this vital work.

The oversight body would have responsibility for overseeing the implementation of the recommendations contained in this report, ensuring that the recommended changes occur in a collaborative context. To be effective, these changes must take place within a context of cross-disciplinary input, open communication, and public accountability. The components of the criminal justice system are so closely interlinked that changes in one department will require the active support and cooperation of other departments. Victim services agencies must be included in all of the implementation to ensure that the perspectives and experiences of victim/survivors and those who assist them, are represented and that services provided directly to victim/survivors are appropriately linked to the criminal justice system.

The oversight committee will ensure public accountability for the implementation of these changes. For this reason, the committee must have strong leadership and active participation from a broad range of city departments and community-based agencies involved in domestic violence services. The committee will hold the individual agencies and programs responsible for implementation of departmental recommendations as well as support overall systemic change.

The recommendations presented in this report were compiled from the City Attorney's report, the public hearing, the Review Panel, and best practices identified by the Review Panel. The Commission and Department want to thank the City Attorney's Office for their report and recommendations. Additional information regarding specific implementation of the City Attorney's recommendations can be found in their report.

All of these recommendations must be implemented within the constitutional rights accorded to both victims and defendants. They also must be carried out within the boundaries of the California Penal Code and all other laws defining criminal investigation and prosecution and the civil rights of United States citizens and residents. Any conflict between these recommendations and civil rights accorded by law must be conceded to civil rights.

These recommendations focus primarily on domestic violence between adults-individuals aged eighteen and over. While we recognize that dating violence is a serious issue for teens and strongly support an analysis of service and intervention strategies for teens, we were unable to undertake that issue within the scope of this report.

Interagency Recommendations

1. Create a multi-disciplinary oversight committee under the authority of the Commission and Department with responsibility for implementing the recommendations in this report and for evaluating and analyzing the impact of the implementation. The committee should include representatives from the Mayor's Office, the Board of Supervisors, the Commission on the Status of Women, city departments including the Police Department, the District Attorney's Office, the Adult Probation Department, the Sheriff's Department, the courts, the Department of Public Health, and representatives from community-based programs including violence against women intervention and advocacy service providers, shelters, men's programs, and violence against women prevention programs. The committee's work will culminate in a final evaluation of the implementation of these recommendations and a reassessment of the violence against women service delivery, crisis intervention, and criminal justice response systems in San Francisco.

2. Establish written protocols for regular and effective communication between the Police Department, the District Attorney's Office, the Adult and Juvenile Probation Departments, the Sheriff's Department and the courts (civil, criminal and juvenile divisions). At a minimum, these protocols should provide a mechanism for interdepartmental tracking of cases and criminal history of defendants and regular communication between the heads of the specialized domestic violence units to share information regarding changes to processes and protocols of each department.

3. Establish written protocols for agreements between the Police Department, the District Attorney's Office and the Adult Probation Department regarding how each department will address probationers who are involved in new offenses or violations of probation. At a minimum protocols should provide:

a) a mechanism for sharing of information,

b) an outline of each department's role in responding to these situations,

c) timelines for sharing information and action to be taken,

d) guidelines that address both prosecution for new offenses and revocation of probation or parole,

e) a tracking system to document interdepartmental communication, and

f) the resolution of each case.

This documentation should be reviewed regularly to ensure that the protocols are adequate to affect a timely and effective response and that cases are resolved satisfactorily.

1. Develop collaborate agreements between the components of the criminal justice system (Police Department, District Attorney's Office, Adult Probation Department, and Superior Court) and social service and victim service programs. These agreements should establish effective referral processes and coordinate communication to victim/survivors of domestic violence. At a minimum, this referral process should specify how victim/survivors will be informed of their full options and legal rights, how victim/survivors will be referred to existing support services, what types of follow-up contacts will be made, and how referral and communication with victim/survivors will be documented.

2. Establish an evaluation process to monitor the implementation of individual agency and interdepartmental protocols regarding domestic violence and regularly evaluate the effectiveness of existing policies and service delivery systems. Evaluation procedures may include auditing individual agency performance, evaluation of individual cases, spot checks, or other methods.

3. Establish departmental complaint procedures for each component of the criminal justice and social service systems that victim/survivors can use to address instances in which they feel that they have not received adequate response to a domestic violence situation. Departments should develop internal databases to track complaints and resolution of complaints. Complaints should be reviewed regularly within the individual departments to assess for breakdowns in the policies and procedures and/or for individual performance issues and between departments to assess the service delivery systems overall.

4. Cooperate in the development and implementation of a compatible computer system(s), such as the Justice Information System (JUSTIS), to ensure that effective tracking of current and accurate data can be shared between the Police Department, the District Attorney's Office, the Adult Probation Department, the Sheriff's Department, and the courts (civil and criminal divisions). This system should allow for access to information regarding criminal activity within the City and County of San Francisco as well as jurisdictions outside of San Francisco. This system should provide instant notification to the appropriate departments when a probationer or parolee is involved in any reported crime.

5. Review existing policies, and where needed, establish new policies for the Police Department, the District Attorney's Office, the courts and social services related to child witnesses of family violence. Training should be provided to all staff in all departments on the effect of exposure to domestic violence on children. Where possible and appropriate, departments and programs should work collaboratively with SafeStart and the Greenbook Project as well as other child welfare programs.

6. Review and enforce employee policies on domestic violence and violence in the workplace to ensure that employees who are victim/survivors of domestic violence are accorded their full legal rights. Ensure that every legal effort is made to hold employees who are domestic violence offenders accountable in their workplace.

7. Review domestic violence training for staff in all components of the civil and criminal justice and social service systems. Advocates who work against domestic violence must be included in the review of existing trainings, in developing new or revised training protocols, and in providing trainings. Funding should be made available to ensure that advocates and domestic violence experts are able to participate fully in developing and implementing trainings. All trainings must include:

a) victim sensitivity,

b) cultural diversity,

c) dynamics of domestic violence,

d) the connections between domestic violence and substance abuse, and

e) cross-training on the role of other services and/or systems which victim/survivors of violence encounter.

1. Develop programs to reduce the burn-out and secondary trauma of staff assigned to domestic violence units. Work on issues of domestic violence is extremely challenging, personally and professionally. Staff of any criminal justice agency, social service agency, or community-based program who deal with domestic violence issues on a regular basis should have access to stress reduction programs, counseling, and other programs or services which address or reduce the impact of secondary trauma. In addition, staff assigned to work in specialized units or programs should be given the opportunity to rotate assignments frequently and/or other accommodations should be made available to reduce burnout and vicarious trauma.

2. Establish clear protocols within each agency having direct contact with domestic violence victim/survivors supporting the right of all victim/survivors to seek assistance regardless of citizenship status, residency status, or country of origin. These policies should be well publicized and efforts made to ensure that victim/survivors who are immigrants or refugees are aware of their legal right to seek services without having to provide immigration documents or endanger their immigration status.

3. Increase resources for community based domestic violence agencies. A recent study completed by the Department on the Status of Women titled Violence Against Women and Girls in San Francisco: Meeting the Needs of Survivors documents a need to invest more resources in San Francisco violence against women service delivery systems. The report clearly documents barriers that survivors of domestic violence face when seeking support and the need for additional programs and funding to reduce or eliminate these barriers.

4. Evaluate civil and criminal justice and social service systems regarding their accessibility to people who do not speak and/or read English. Develop and implement a plan to improve access to services for non-English speakers and/or readers.

5. Establish clear protocols and tools for components of the criminal justice system, social service system, victim services programs, and batterer treatment programs to assess for the primary aggressor. Review criminal justice statistics regarding mutual arrests to evaluate for systemic problems related to the determination of primary aggressor and/or situations erroneously defined as mutual battery/combat. Evaluate protocols and tools regularly, including feedback from victim service programs and offender treatment programs.

6. Evaluate civil and criminal justice and social service systems regarding their accessibility to people with physical and mental disabilities. Develop and implement plans to improve access to services for people with disabilities.

San Francisco Police Department

1. The Police Department should develop protocols to assess all police reports for the relationship between the defendant and the victim. The Domestic Violence Response Unit (DVRU) should receive information on all cases involving a domestic relationship (marital, partner, or dating) between the defendant and the victim regardless of the type of crime. Protocols should address communication and cooperation between the DVRU and any other units that may also receive domestic violence related cases.

2. All domestic violence cases should be assigned to a DVRU inspector within 48 hours after the alleged commission of a crime or the reporting of a crime. Protocols for the assignment of cases to the DVRU should allow for expedient and effective communication regarding the reporting of the crime to the DVRU.

3. Written protocols for communication of reports and information regarding incidents of violation of parole or probation for domestic violence probationers must be developed. These protocols should specify that information on any reported incident be sent to the appropriate parties, even if the incident represents a seemingly minor infraction or misdemeanor.

4. New protocols should be developed and/or existing protocols enhanced to specify procedures for DVRU inspectors to follow-up with victims of domestic violence. Follow-up should happen as soon as possible after an alleged crime is reported and inspectors should actively follow-up with all victims of domestic violence crimes. Protocols should clearly indicate that follow-up contact is the responsibility of the Police Department and the burden should not be placed on the victim to follow-up on police reports.

5. Protocols regarding the investigation of domestic violence crimes should be reviewed and investigation questions standardized. All victims reporting domestic violence related crimes should be asked for complete information regarding the current alleged crime, any prior history of reported or unreported crimes, and any questions or concerns the victim may have regarding the domestic violence situation. Referrals should be provided based on any issues raised by the victim. These questions and the victims' responses should be fully documented.

6. All domestic violence crimes assigned to the DVRU should be assigned using a model of vertical investigation so that only one inspector is assigned to investigate each new report of a domestic violence violation related to an alleged perpetrator.

7. Protocols for the temporary placement of a child(ren) should be reviewed and, where appropriate, revised to address situations when parents are not able to care for a child(ren) due to homicide, injury, arrest, or other circumstances related to domestic violence.

8. All victims of domestic violence crimes should be provided with a referral card in a language that she or he is able to read. If the officer determines that the victim may not be able to read, referrals should be provided verbally as well as in written form.

9. Referral cards should be updated regularly and new languages should be added based on an evaluation of significant populations living and/or working in San Francisco.

10. The Domestic Violence Response Unit should be staffed fully with active duty inspectors who actually work in the unit full-time as opposed to with inspectors who are assigned to the unit but are temporarily working in another area or are on leave. Review the current allocation of twenty inspectors to the unit to ensure this capacity adequately supports the caseload.

11. Staff evaluation tools specific to the investigation of domestic violence should be developed. All staff of the DVRU should have regular performance reviews that use standard evaluation tools as well as specialized domestic violence evaluation tools.

12. The need for more victim advocates in the DVRU should be assessed. These advocates should be part of a collaborative effort between the criminal justice system and victim service programs. The Police Department should actively participate in the collaboration. Advocates should work directly out of the DVRU but should be employed by victim service providers and/or community-based agencies. The collaborative partners should assess the number of advocates needed. An initial recommendation would be no less than five advocates working in the unit full time.

13. Existing training on domestic violence should be reviewed and evaluated. Trainings should be evaluated by the Police Department and the oversight body, and, if needed, revised for:

a) the Police Academy (recommend 16 hours minimum on domestic violence),

b) advanced Officer trainings (recommend eight hours of domestic violence training annually), and

c) inspectors assigned to the DVRU (recommend 40 hours of specialized domestic violence training at the time they are assigned to the unit).

Training should address the legal and social aspects of domestic violence, strangulation and stalking crimes, effective responses to domestic violence, the impact of substance abuse on domestic violence, and victim sensitivity.

14. The Police Department should conduct regular department-wide trainings on stalking and Emergency Protective Orders as appropriate and necessary to ensure that all officers understand these important domestic violence issues and criminal justice tools.

15. The Police Department should review data collection procedures and, where necessary, expand data collection to include documentation of the number of:

a) domestic violence calls to the police,

b) domestic violence police reports,

c) domestic violence related arrests,

d) misdemeanor domestic violence charges,

e) felony domestic violence charges,

f) Emergency Protective Orders (EPOs) requested,

g) EPOs granted,

h) domestic violence reports investigated by the DVRU, and

i) domestic violence cases presented to the District Attorney's Office regardless of outcome.

16. Procedures should be established to regularly and systematically review police reports to ensure that responding officers write accurate and complete incident reports.

17. Evaluation tools should be developed to review and evaluate violence against women cases to ensure that all protocols are followed and cases are handled properly.

Emergency Communications Department

1. All emergency and non-emergency police dispatchers should receive domestic violence training.

2. The Emergency Communications Department should review data collection procedures and, where necessary, expand data collection to include documentation of all domestic violence related 911 calls.

District Attorney's Office

1. Review and enhance existing policies and procedures leading to effective prosecution including vertical prosecution, clear "no-drop" policies, policies to avoid unnecessary continuances, and other policies to ensure timely and effective prosecution. Establish evaluation mechanisms to ensure that these policies are followed consistently.

2. Create a system to track the assignment of cases to ensure that all domestic violence related cases are assigned to an attorney in one of the domestic violence vertical prosecution units.

3. Develop protocols regarding use of stalking charges and enhanced penalties for repeat offenders. Develop or enhance existing protocols to ensure that each domestic violence case is reviewed for all possible options including prosecution for new offenses committed by defendants on parole or probation; stalking charges; and request for additional penalties and state prison sentences due to prior offenses.

4. Review policies to support the active prosecution of cases in which probationers are charged with new offenses without relying on the Adult Probation Department to file for revocation of probation. In these cases, close communication and coordination should be supported between the Adult Probation Department and the District Attorney's Office.

5. Develop guidelines for determining the action to be taken regarding child abduction charges in cases where domestic violence is involved, particularly where the abused parent may be attempting to protect themselves and/or their child(ren).

6. Develop or enhance existing protocols so that prior to any court appearance, including consideration of bail, any assistant district attorney working on a domestic violence case has all current, accurate and complete information relevant to the charges including but not limited to:

a) prior criminal history,

b) the existence of restraining orders,

c) any failure to appear in court when ordered,

d) probation status in San Francisco or any other jurisdiction,

e) family court rulings, and

f) any pertinent civil cases including lawsuits and restraining orders.

1. Develop protocols to evaluate whether assistant district attorneys are bringing all relevant and permissible materials to the attention of the court at each stage of the prosecution and sentencing.

2. Develop or enhance existing protocols to ensure that victim/survivors are informed through verbal and written communication of their right to address the court regarding sentencing. Victim/survivors should be offered assistance in preparing any written or verbal statements to the court regarding sentencing.

3. Review services provided through the criminal justice victim assistance programs including an evaluation of services available to children who witness or are exposed to domestic violence and accessibility of services regarding cultural competency, language capacity, and access for people with physical disabilities. Develop and implement a plan to address any problem areas and ensure greater utilization of victim assistance services.

4. Review and evaluate existing training on domestic violence. Mandatory initial trainings (recommend 40 hours) and annual advanced trainings (recommend eight hours) should be provided for all prosecutors, investigators and advocates assigned to domestic violence misdemeanor and felony cases. In addition to these trainings, the District Attorney should make funds available for staff assigned to domestic violence cases to attend specialized and advanced trainings provided by organizations and trainers outside the department.

5. Develop staff evaluation tools specific to the prosecution of domestic violence cases. All staff working on domestic violence cases should have regular performance evaluations, that utilize general department evaluation mechanisms and specialized domestic violence evaluation tools.

6. Review data collection procedures used by the District Attorney and, where necessary, expand data collection to include documentation of the following domestic violence statistics:

a) arrests;

b) re-bookings;

c) cases dropped and justification;

d) cases not charged and justification;

e) cases dismissed by the court;

f) misdemeanor convictions;

g) felony convictions;

h) sentencing including county jail, state prison, or probation;

i) fines assessed and the amount of each fine;

j) cases not pursued where probation was revoked; and

k) cases pursued where probation was also revoked.

7. Establish evaluation tools, including spot checks, to review and evaluate violence against women cases to ensure that all protocols are followed and cases are handled properly.

Adult Probation Department

1. Develop written standards of supervision for domestic violence cases including minimum standards that should be fulfilled on a monthly basis. The Adult Probation Department should develop these standards with input from the courts, other criminal justice experts, and community advocates.

2. Improve communication between the Adult Probation Department and social service agencies including batterer treatment programs. This communication must allow for the timely sharing of information regarding specific probationers as well as better communication on protocols, policies, and program review and evaluation.

3. Create an incident receipt log and tracking system to document when the Adult Probation Department receives reports from other departments and to track internal routing of all reports through the department.

4. Develop or enhance existing protocols to ensure that no domestic violence probationer is unsupervised at any time. The department should develop a risk assessment tool specific to domestic violence using the best available research on batterer characteristics and/or consultation with experts in batterer intervention. The risk assessment tool should be used along with other appropriate factors to determine the minimum level of supervision for each probationer. No domestic violence probationer should be unsupervised and domestic violence cases should not be "banked" or otherwise left without direct, active supervision.

5. Establish a system for probation officers to routinely and regularly run a criminal history check of all assigned probationers. Probation officers should be able to access current, complete, and accurate criminal histories including relevant civil records such as restraining orders. Ideally criminal history checks would occur prior to each scheduled contact with a probationer. Criminal history checks should be done before any court appearance.

6. Review and enforce protocols regarding revocation of probation for domestic violence offenses where probation has been violated due to any offences, not just domestic violence related offences. Revocations must be timely in order to ensure that probationers do not repeatedly violate probation.

7. Develop policies to support revocation of probation in cases in which probationers are charged with new offenses without relying on the District Attorney's Office to pursue prosecution of the new offenses. In these cases, close communication and coordination should be supported between the Adult Probation Department and the District Attorney's Office.

8. Revise existing protocols regarding probation officers' communication with domestic violence victim/survivors to ensure that the following areas are addressed: ways victim/survivors can report violations of probation and/or re-offenses, options for victim/survivors to contact the probation officer responsible for the case of their abuser, and ways to access services or programs available for victim/survivors. Develop written materials to be distributed to victim/survivors regarding the resources and remedies available to them as victim/survivors of a domestic violence crime. Develop a tracking system to see whether probation officers provide this and all other information and materials specified in department policies.

9. Screen all probationers for histories of domestic and sexual violence regardless of their conviction. Develop adequate services and referrals for probationers who have been victimized by sexual assault or violence within their family. Probationers who disclose that they have been violent in the past should be referred to appropriate services even when participation in those services is not mandated in the terms of their probation.

10. Fully staff the domestic violence units with probation officers who are able to commit their time fully to the unit (i.e. probation officers who are not on leave or assigned other responsibilities that take them away from the domestic violence unit on a regular basis). Regularly review the staff and case assignments within the domestic violence units to ensure that existing staff commitments adequately support the caseload for both misdemeanor and felony domestic violence probationers.

11. Evaluate victim advocacy services provided by the department to determine if a victim advocate or victim liaison position is necessary to improve communication between victim/survivors and the Adult Probation Department.

12. Review and evaluate existing training on domestic violence. Trainings should be developed for new probation officers (recommend 16 hours minimum on domestic violence), ongoing trainings for all probation officers (recommend four hours of domestic violence training annually) and for probation officers assigned to the DVRU (recommend 24 hours of specialized domestic violence training when assigned to the unit and at least eight hours of advanced training each year). In addition, the department should make funds available for probation officers to attend specialized trainings outside of the department.

13. Develop staff evaluation tools specific to the supervision of domestic violence cases. All staff with domestic violence caseloads should be evaluated regularly utilizing general department evaluation mechanisms and specialized domestic violence evaluation tools.

14. Review data collection procedures currently used by the Adult Probation Department and, where necessary, expand data collection to include documentation of the following domestic violence statistics:

a) probationers on domestic violence felonies,

b) probationers on domestic violence misdemeanors,

c) probation revocations,

d) probationers sent to jail for violations of probation,

e) probationers whose probation is extended after violation of probation;

f) probationers convicted of another crime while on probation and the type of crime committed,

g) cases where revocation is denied, and

h) cases of offenders who completed probation and were later sentenced to an additional probation sentence for another crime.

15. Establish evaluation tools to review and evaluate violence against women cases to ensure that all protocols are followed and cases are handled properly. These tools should incorporate feedback from victim/survivors, service providers including offender treatment programs, and probationers.

16. Develop an evaluation tool for offender treatment programs. Batterer intervention programs should be required to maintain and submit, on a regular basis, information on offenders sufficient for the Adult Probation Department to evaluate the effectiveness of the program's interventions. The Adult Probation Department should maintain data on program assignments, dropouts, completion records, and recidivism rates of offenders assigned to each program. This information should be available to the public.

17. Engage the expertise of other criminal justice agencies, victim services agencies, and expert consultants in batterer intervention and the development of educational and rehabilitative programs to assess the quality and effectiveness of current certified programs and new programs that apply for certification.

San Francisco Superior Court - Criminal Division

1. Establish protocols for regular and effective communication between the Criminal Court and the Civil Family Court, the Police Department, the District Attorney's Office, the Adult Probation Department, the Sheriff's Department and the Department of Human Services. At a minimum, these protocols should provide a mechanism for interdepartmental tracking of cases, criminal history of defendants, and sharing of information regarding changes in departmental processes and protocols.

2. Establish a Domestic Violence Court to handle felony and misdemeanor domestic violence cases. This court would build upon the model of the existing Domestic Violence Misdemeanor Court allowing for closer supervision of all domestic violence defendants and probationers.

3. Review current resources and staff committed to the Adult Probation Department to ensure it has adequate resources to supervise domestic violence cases effectively.

4. Conduct an annual review and evaluation of the Adult Probation Department's handling of domestic violence cases. Establish procedures to monitor the department's Domestic Violence Unit's compliance with offender supervision protocols and require the department to provide the court with information on the effectiveness of certified batterer intervention programs and their compliance with penal code requirements.

5. Ensure that adequate translation services are available for domestic violence victim/survivors and witnesses.

6. Ensure that protocols to refer offenders to Family Court for modifications of Stay Away Orders with regards to minor children do not compromise victim safety or provide support to batterers, allowing them to continue to intimidate their victims.

7. Prioritize domestic violence cases when scheduling trial dates.

8. Develop standards for domestic violence cases including protocols for lifting restraining orders, requiring defendant participation in education (including parenting classes where appropriate) and rehabilitation programs, and assessing fines. Fines should be assessed in all appropriate cases and funds should be directed toward services for victim/survivors of domestic violence.

9. Develop standards for criteria to assess in making bail decisions including the potential for re-offense, existing restraining orders or open applications for restraining orders, and a defendant's prior history.

10. Create a standard questionnaire to be used in sentencing, which would support full disclosure of relevant information from the District Attorney's Office and/or the Adult Probation Department.

11. Develop alternatives to incarceration of victims and/or witnesses in domestic violence cases. Victim/survivors who fail to testify against their abusers should not be charged with contempt of court.

12. Review and develop trainings on domestic violence for all court personnel working with violence against women cases. Trainings should be developed and implemented with participation from victim service agencies. San Francisco resources such as the SafeStart and the Greenbook Project should be used for specific training on issues related to children who witness or are exposed to domestic violence.

13. The Superior Court should review data collection procedures and, where necessary, expand data collection to include documentation of the following statistics regarding domestic violence:

a) domestic violence cases handled by the courts each year;

b) arrest warrants for domestic violence issued by the court;

c) dismissals of domestic violence cases;

d) domestic violence cases plea-bargained;

e) convictions resulting in state prison sentences, county jail terms, suspended sentences, probation, community services, mandated participation in offender treatment programs, and/or assessment of fines;

f) total amount of fines assessed by the court annually;

g) probationers who have probation revoked and the reasons for the revocation;

h) defendants who have Stay Away Orders issued against them;

i) defendants who have Stay Away Orders against them lifted;

j) defendants who fail to successfully complete an offender treatment program;

k) domestic violence defendants who fail to pay fines assessed against them;

l) domestic violence defendants who fail to appear in court as ordered; and

m) average jail and prison sentences for convictions resulting in jail or prison time.

San Francisco Superior Court - Family Division

1. Establish protocols for regular and effective communication between Family Court and the Criminal Domestic Violence Court, the Police Department, the District Attorney's Office, the Adult Probation Department, the Sheriff's Department and the Department of Human Services. These protocols should minimally provide a mechanism for interdepartmental tracking of cases and sharing of information regarding changes in departmental processes and protocols.

2. Consideration of the safety of domestic violence victims and their children as primary in any decisions made in the Family Court including visitation decisions. Court personnel should work closely with programs such as SafeStart and the Greenbook Project to ensure that children's issues are handled with sensitivity and appropriate cultural considerations are taken into account.

3. Ensure that adequate translation services are available and that separate certified translators are provided to all parties in cases that involve domestic violence, both in court and in mediation.

4. Ensure that all Family Court personnel are familiar with all mediation and resolution resources including the Mediation Model.

5. Review and develop training programs on domestic violence for all court personnel working with violence against women cases. Training should be developed and implemented with participation from victim service agencies and should include consultation with experts on batterer characteristics and appropriate intervention with batterers. San Francisco resources such as SafeStart and the Greenbook Project should be utilized for specific training on issues related to children who witness or are exposed to domestic violence.

6. The Superior Court should review data collection procedures and, where necessary, expand data collection to include documentation of the following statistics regarding domestic violence:

a) Emergency Protective Orders (EPO)s requested each year,

b) EPOs denied,

c) restraining order applications received,

d) restraining orders denied,

e) restraining orders granted,

f) requests to have restraining orders dissolved, and

g) restraining orders that were dissolved.

San Francisco Sheriff's Department

1. Establish protocols for regular and effective communication between the Sheriff's Department and the Police Department, the District Attorney's Office, the Adult Probation Department, and the courts (civil and criminal divisions). At a minimum, these protocols should provide a mechanism for interdepartmental tracking of cases and criminal history of defendants and for sharing of information regarding changes in departmental processes and protocols.

2. Establish a protocol to ascertain whether a defendant is in custody when they fail to appear in court.

3. Establish or enhance existing policies to ensure a warrant check is run on anyone being released from custody.

4. Establish evaluation tools for all offender treatment programs conducted in collaboration with the Sheriff's Department. Evaluation should demonstrate the efficacy of the program and should include input from victim/survivors.

Medical Examiner

1. Establish protocols for regular and effective communication between the Medical Examiner's Office and the Police Department, the District Attorney's Office, the Adult Probation Department, and the courts (civil and criminal divisions).

2. Develop or enhance existing protocols to evaluate and document any domestic violence connection to all deaths (particularly from violence, suicide, or substance abuse) even if the death is not obviously attributable to a domestic violence homicide. These statistics would document the connection between the experience of domestic violence and deaths from violence, suicide, or substance abuse. Additionally, domestic violence clearly contributes to many victim/survivors and their children becoming homeless. Wherever possible, the Medical Examiner should document the effect of domestic violence in the death of homeless people.

3. Document these statistics and report them annually to an oversight committee or the Department on the Status of Women.

Department of Human Services - Child Protective Services

1. Establish protocols for regular and effective communication between the Department of Human Services and the Police Department, the District Attorney's Office, the t Probation Department, the Sheriff's Department and the courts (civil and criminal divisions). At a minimum, these protocols should provide a mechanism for interdepartmental tracking of cases and sharing of information regarding changes in departmental processes and protocols.

2. Develop protocols regarding all legal options for ensuring the safety and well-being of children in situations where a non-abusive parent may be victimized in a domestic violence situation. These protocols must prioritize the safety of child(ren), especially in cases where the child has been a witness or exposed to domestic violence.

3. Review and revise protocols for emergency response in situations where a parent(s) is killed, seriously injured, or arrested. At a minimum, protocols should provide for:

a) trained staff to respond to an emergency situation and provide immediate assessment/intervention,

b) a review of emergency placement options to balance the best quality of care and highest safety available for the child(ren),

c) policies regarding placement of child(ren) with a parent or others who have a history of domestic violence aggression, and

d) permanent placement at the earliest possible opportunity.

1. Review and evaluate existing training on domestic violence. All Child Protection Services staff and any other division within the department working directly with or supervising domestic violence related cases should receive comprehensive initial training and ongoing trainings. The Department of Human Services should make funds available for staff to attend specialized and/or advanced violence against women and family violence trainings annually.

Community-Based Services

1. Review protocols, policies, and statutory requirements regarding confidentiality and communication between victim services and law enforcement to ensure that information about ongoing criminal incidents is provided where appropriate.

2. Provide intervention, shelter, transitional housing, and legal services for victim/survivors of domestic violence who have histories or current experiences with substance abuse or sex work.

3. Provide more culturally appropriate and multilingual accessible services for all victim/survivors of domestic violence. A study issued by the Department on the Status of Women titled Violence Against Women and Girls in San Francisco: Meeting the Needs of Survivors identifies that the communities most significantly underserved by existing programs are: sex workers, adult survivors of sexual assault, child and adolescent survivors of sexual assault, the disabled, the elderly, youth, lesbians, bisexuals, transgender women, recent immigrants, Muslim women, Asian American women, Native American women, African American women, and Latina women.

4. Provide more prevention and outreach programs addressing violence against women including domestic violence, sexual assault, and child physical and sexual abuse. Education and intervention programs are needed for youth exposed to domestic violence in their home or community. Specialized, community-specific programs are needed to address communities of color; the gay, lesbian, bisexual, transgender, and queer communities; and people with physical or developmental disabilities.

5. Review existing criminal justice advocacy services provided to victim/survivors to ensure that advocacy services are comprehensive, coordinated, seamless, and support victim/survivors throughout their interaction with the criminal justice system.


Conclusion

It has been said that a chain is only as strong as its weakest link. Domestic violence services should form a strong chain with victim services, social services, and the criminal justice system working together to make up the interconnecting links. Victim/survivors should be able to access the system at a number of different points and should be able to pass easily from one link to the next as their needs and situations demand. Victims and families should be able to rely on the strength and integrity of the chain as a whole in order to address the violence occurring in their homes and their communities.

The metaphor of the chain is particularly true for the criminal justice system, which victims of domestic violence frequently turn to only after exhausting other resources. By the time domestic violence situations are reported to the criminal justice system a pattern of physical violence has already been established. The heavy charge placed on the criminal justice system is that victims' lives depend upon the system's ability to affect an immediate end to the violence. The links of the chain that represent the criminal justice system must restrain violence, as a breakdown in these links places the lives of victim/survivors and their children in danger.

Since the Charan investigation report was issued in 1991, the City and County of San Francisco has prided itself on the establishment of one of the first systemic responses to domestic violence. While many important gains were made, the work is far from complete. Some of the general recommendations identified in the Charan report were implemented; others continue to need to be addressed. The areas of communication and coordination, data collection, training, access to services, and policy and protocol development all require on-going scrutiny, evaluation, and monitoring.

New areas identified in Justice and Courage: A Blueprint for San Francisco's Response to Domestic Violence include the utilization of technology for information management and the creation of an oversight committee. These are critical to the success of the recommendations outlined in the report. The oversight body is charged with ensuring that each link of the chain is strong and that the links work together to form a unified whole addressing violence against women. An oversight body maintains public accountability for the system and helps to hold each component of the system to the standards and services required to address domestic violence effectively within our communities.

In addition to providing background on the history of San Francisco's systemic response to domestic violence and the horrific murders of Veena Charan and Claire Joyce Tempongko, this report is a blueprint for a more cohesive, accountable, citywide response to domestic violence. Justice and Courage outlines practical recommendations and obtainable goals for city departments and the social service community to strengthen the chain and improve the response to violence against women. The recommendations outlined herein address important key issues such as centralized communication between agencies, standardized responses, tracking and documentation of domestic violence cases at all phases, children who have witnessed or experienced domestic violence, the prioritization of domestic violence cases throughout the social service and criminal justice systems, and, perhaps most importantly, the creation of a multi-disciplinary oversight body led by the Commission and Department on the Status of Women to facilitate collaboration amongst the agencies involved and to foster public accountability.

For Claire Joyce Tempongko and her family, the chain snapped in a final incidence of horrifying violence. The City Attorney's investigation into the system's response to Ms. Tempongko's attempts to seek help show that there are many points of weakness and instability within the chain. Ms. Tempongko's death is not due to any one catastrophic error but instead to a series of breaches, which compounded into a failure of the system as a whole. It is all of our responsibility now to begin to address these deficiencies, link by link, as the many different agencies, departments, and individuals addressing the problem of domestic violence work together to forge a strengthened and improved chain.

The Commission and Department on the Status of Women feel it is our responsibility and obligation to continue to work to strengthen the City and County of San Francisco's response to domestic violence. It is the responsibility and obligation of each of us, as individuals, to work to end domestic violence in our homes, our workplaces, our schools, and throughout our communities. Only then will there be no more victims like Veena Charan, Claire Joyce Tempongko, and those who loved them.

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Last updated: 2/8/2010 9:04:40 PM