The fatality review process in Hennepin County began in 1998 with a planning grant from the Minnesota Departmentof Children, Families and Learning to WATCH, a nonprofit court monitoring organization. As part of its work, WATCH routinely creates chronologies of cases involving chronic domestic abusers and publishes them in its newsletter. In doing so, it became aware of many missed opportunities for holding abusers accountable. The organization felt strongly that in the vast majority of cases, these opportunities were not missed because of carelessness or disinterest on the part of the individuals handling the cases. Instead, many opportunities were missed because adequate and accurate information was not available at critical decision points and because the sheer volume of domestic abuse cases created significant pressure to resolve them quickly, oftentimes forcing an outcome that was less than ideal.During the National District Attorney’s Conference in 1997 WATCH learned about a movement to conduct domestic fatality reviews. This movement was gaining interest nationwide and appeared to address many of the organization’s concerns about the many places for chronic abusers to slip through the cracks of the justice system. A team of private, public, and nonprofit representatives organized the procedures for reviewing domestic fatality cases. An extensive research effort underscored the need for enabling legislation to create the project, and to lay the foundation for important data privacy and immunity provisions. These provisions allow the project to gain access to confidential records related to these cases and to provide immunity to those who spoke openly to the Fatality Review Team about case information.  The Minnesota State Legislature passed data privacy and immunity provisions in 2000. Thus “A Matter of Life and Death: The Domestic Fatality Review Team, A Collaboration of Private, Public and Nonprofit Organizations Operating in Hennepin County” was created.Sometimes a careful look back is the wisest way to move forward. The Review Team altered the future by taking decisive actions to support victims of domestic violence. Since September 29, 1999 this 34-member task force has met monthly for several hours to sift through the tragic debris left behind after a domestic homicide. It is a grim task. It is also enlightening. We anticipate reviewing four to five more cases in the coming year. Members learned that it is impossible to make sense of the needless loss of life resulting from one human being’s need to exert power and control over another. However, the Team discovered that it is possible to identify periods in the family’s history where an improved response at a point of intervention by the justice system or other players may have prevented the death.  The Review Team has taken action to implement recommendations to address these opportunities.