Systems, Accidents, Incidents

Many years ago, Neil Websdale, a criminologist and professor at Northern Arizona University—by way of England—needed eye surgery. He arrived to his surgeon ophthalmologist’s office the morning of his operation and was greeted by a nurse who, without ceremony, marked a big X over his bad eye. Websdale, being both a researcher and a naturally curious person, asked why on earth they were drawing on him with marker. She said, “You want them to operate on the right eye, right?”

Indeed, he certainly did. It concerned him though that they had to make this mark on him. Was this the kind of thing a doctor normally got wrong?

The nurse told him he ought to read the research on accidents in medicine. It was amazing how many people were operated on inappropriately in the United States annually, tens of thousands at the time, she said. In particular, she told him to read the Atlantic articles on airline crashes and the literature on medical mistakes. Later, he did in fact read her recommendations, but on that day, when Websdale entered the surgical waiting room, he saw all these people on gurneys who had Xs over one eye or the other. “This was a simple remedy,” he said years later to a roomful of people at a video conference, “to prevent mistaken surgeries … And what we’ve found exploring errors in the fields of medicine, aviation, nuclear fuels is that we can correct problems fairly easily if we’re open to reviewing tragedies and accidents with a keen detailed analysis.”

Websdale is a youthful sixty-something who begins most days with a brisk run through the thin Flagstaff air, where he lives. His close-cropped hair is silver-white, his eyes a periwinkle blue. He rattles off statistics, facts, theories like a fast-talking character from an Aaron Sorkin screenplay; he is a born storyteller, with a British accent softened by decades in America. He holds views that he concedes are controversial. Like this: he believes abusers are as stuck as victims. “Everyone asks why the victim doesn’t just leave,” he said to me. “But no one asks why an abuser stays.” Here’s another one, the paradox of domestic violence, he calls it: that the literature on intimate partner abuse and advocates all say abusers are about power and control, but to Websdale, abusers are simultaneously powerful and powerless. Both in control and out of control.

Websdale is, in a sense, a connections and systems guy, in constant search of meaning and metaphor. Pre-surgical marking. Genius. Such a simple solution. What other solutions were out there, just waiting to be discovered? Solutions to our gravest mistakes. He went far beyond what the nurse that day suggested he read. He turned to other industries—not just the Federal Aviation Administration, but the nuclear fuel industry and the medical industry. How did they grapple with mistakes inside their industries? How did they build systems where the mistakes could be minimal? He learned about the National Transportation Safety Board and how their investigations increasingly made plane crashes more and more preventable. The NTSB built a timeline of the crash, looking into every single detail that mattered, from the ticket agent all the way to the pilot and flight attendants and mechanics and air traffic control and weather conditions. They looked for gaps in the system, moments the crew overlooked, safety mechanisms not yet in place. They worked not as individual experts, but as a team, sharing knowledge across titles and ranks. He read literature on medical mistakes, on nuclear fuels, on what we learned after Chernobyl and Fukushima. He spoke with a colleague named Michael Durfee, who was the medical coordinator for the Los Angeles County Department of Health Services Child Abuse Prevention team, who’d begun reviewing cases of child fatalities and abuse to try to find solutions. And like a slow churn, an idea began to form in Websdale’s mind. A way to take all this information, from all these different professions, and adapt it to domestic violence homicides. If systems were more efficient, people less siloed in their offices and tasks, maybe we could reduce the intimate partner homicide rate in the same way the NTSB had made aviation so much safer.

At the time, Websdale was traveling to Florida, researching what would become his third book, Understanding Domestic Homicide. For that book, he was looking at the state’s homicide cases, at old police reports, talking to law enforcement, when the ideas of what he’d been reading in other industries finally overlapped with the homicide files he researched.

He received federal funding through the then-governor of Florida, Lawton Chiles, to form the country’s first domestic violence fatality review team. The idea was to use the NTSB model and adapt it to domestic violence homicide cases, not to, as he says, “blame and shame” but to hold people and systems accountable to better standards, more efficient programs. Websdale says he learned that planes often tended to crash for multiple reasons: mechanical failure, human error, safety breakdowns, et cetera. A combination of factors. “And that’s what we find in domestic homicide cases,” he says. There’s not any one single factor that can be pointed out and changed; instead, it is a series of small mistakes, missed opportunities, failed communications.

Fatality reviews act, then, in much the same way an NTSB investigation is run. Team members build a timeline of a case, gather as much information as they can about the victim and the perpetrator and gradually try to look for moments where system players could have intervened and didn’t or could have intervened differently. Today, the program Websdale began in Florida has spread across the country and even internationally. More than forty states now have fatality review teams—and many have multiple teams—as well as the UK, Australia, New Zealand, and others.1

About a year after Michelle Monson Mosure’s murder, an article in the local Billings newspaper caught Sally’s attention. The piece reported that a new team was forming in the state, Montana’s own Domestic Violence Fatality Review Commission (MDVFRC). Their aim, she learned, would be to investigate domestic violence homicides with an eye toward reducing the number of victims annually in the state. She saw immediately the possibility to get some answers about what happened with Michelle; if she couldn’t save her daughter’s life, at least maybe she could help out another family in their same situation. Sally could point to the moment her own charges against Rocky were accidentally dropped because they’d been filed in the same docket as Michelle’s recanted testimony. But that seemed like a human error, not a systemic one. And no one could really say what the impact might have been had those initial assault charges stuck. Rocky had only ever been facing a criminal mischief charge to begin with.

Sally drove to Bozeman, where a small conference about the new fatality review commission was taking place; after the keynote speaker was done, she made her way to him. His name was Matthew Dale, and he headed the Office of Consumer Protection and the Office of Victim Services, (which is housed at the Office of Consumer Protection) in the Montana Department of Justice. He and Websdale had a years-long friendship. Sally told Dale the story of Michelle and Kristy and Kyle, and he listened. She asked him outright to take on her case. It would be the first case Montana’s domestic violence fatality review team took on. How, they would all attempt to answer, might Michelle and her children have survived?

To get a sense of what a fatality review team did, I headed to a tiny town outside of Missoula and checked in to a hotel where the dominant aesthetic theme was taxidermy. An antler chandelier dangled from the cathedral ceiling. A stuffed deer head on one wall. The place had a warm, homey feel to it, with thick wood beams running across the ceiling. In a far back room, thirty-two people sat at long tables in the kind of carpeted, anonymous conference center ubiquitous to hotels across the nation. Outside, it was preternaturally beautiful. The October mountains were already snow-capped, and autumn leaves skittered across the parking lot in view from a wall of sliding glass doors along one side of the room. The hotel sat adjacent to a small river, and the air had that visible, sharpened-crystal quality seemingly unique to the American West. This could be a gathering for some extreme outdoor adventure—a hunting club, a fly fishing group—were it not for the subject matter that had brought everyone here. (According to the tenets of the team, I have agreed not to identify the victims in the case, and thus information like names, geographies, and specific markers like jobs and ages, has been redacted.)

Ruth was killed by her boyfriend, shot several times in the back and in one hand as she cowered to protect herself, and then once in her head. It was the kind of murder that law enforcement often refers to as an execution. Her crouched position while he towered over her tells them something about the couple’s dynamic. About power and control. Bullets zinged all over the room where she died, as if she’d run and tried to get outside before sinking into the position where he eventually killed her at close range. We’ll call him Timothy. After Timothy killed Ruth, he walked around the outside of the house several times. It’s typical for a lot of time to pass between the murder of one’s loved one and one’s own suicide. “It’s easier to kill someone else than kill yourself,” Websdale says. Eventually, Timothy shot himself. Unlike Ruth’s death, which was pandemonium, a scene of blood, turmoil, bedlam, Timothy’s suicide was tidy: two gunshots and he was done. In a few hours, the team will talk about this image and what it means.

Some years, Montana has as few as three domestic violence homicides, and sometimes there are well over a dozen. The year Ruth was killed, there were eleven statewide.2

Matthew Dale leads this two-day meeting. The team has spent months gathering and sharing information, looking up old records, interviewing friends, family, coworkers, community members, neighbors, law enforcement, clergy, therapists, judges, probation and parole officers, former teachers, babysitters, nearly anyone involved in the lives of both victim and perpetrator. Fatality review teams don’t go over every intimate partner homicide in their own various states, but they’ll review a select few where the information might offer a tweak to procedures or systems that might have kept a victim alive. Perhaps bystanders or children were killed, or perhaps there was something left behind that could offer insights—diaries, letters, social media posts, or e-mail histories. Maybe they were unusual as a couple, very old, very young, wildly rich, or chronically poor. Maybe the families are cooperative, as had been the case with Michelle Monson Mosure. In the case of Timothy and Ruth, they both left written information behind, letters, social media posts, and histories that overlapped with law enforcement records.

Dale is a slight man with thick, bushy hair and a runner’s physique. He wears his cell phone on his belt and a tie daily, despite this being a casual affair. He tells the assembled team—who have driven from all corners of the state, some as far as eight hours away—that the crime scene photos are available for viewing on a private computer, but he will refrain from showing them to the group as a whole. The pictures are catastrophic and grotesque, full of blood, as might be expected, and terrifically sad, but they are also telling. Ruth was found in the kitchen, on her knees, slumped forward. Timothy lying in bed, a gun in each hand, his arms crossed over his heart and bullet holes in his chest. The details will emerge later and reveal important elements about both the perpetrator and the relationship itself.

Montana’s fatality review team is notable for two reasons. First, they do a deep dive. Dale calls it long and wide. Other teams do less investigating but cover more cases. The Montana team investigates, at most, just two cases a year. And second, it’s a state with a population such that lawmakers and judges—those with the power to actually change policy—are accessible. In fact, Montana’s attorney general is a member of the team, as is at least one judge. It’s arguably easier to change a law in a place like Montana than it is in an area with a much denser population, like New York City.

Teams like this have no regulatory or enforcement function, but rather through individual cases they try to determine if some systemic change could have made a difference. Maybe the judicial system might have played a larger role in locking up that abuser or keeping the victim safe? Might the police have done something different? Or the local church? There is, in fact, an infinite number of possibilities when it comes right down to it, so a team has to examine outcomes to some extent before they are even known. In the case of this particular murder-suicide, several elements drove them to take it on. First, the victim had a premonition of her own death; upon leaving her boyfriend, she knew she was in a dangerous enough situation that she spoke about her own funeral. The perpetrator, too, had enough of a history with local police that they anticipated a violent situation with him someday. “Suicide-by-cop” was how one police officer who knew him put it. That is, when someone compels police to shoot him by not, say, following orders to drop a weapon. Montana, for reasons no one quite knows, has one of the highest suicide-by-cop rates in the country. So, given that he was a known danger, and she feared for her life, why hadn’t the system protected her? What more could they have done? What more could they do in the future?

Along the front wall giant sheets of paper are affixed, and Dale opens the meeting by reminding the team of confidentiality; all files must be destroyed immediately afterward. They spent so many months interviewing families, friends, and coworkers prior to the review who knew the deceased that painful details emerge.

Perhaps the most crucial element to a fatality review is something few team members discuss openly: that is, it forces them to ask how a system they’re involved in full of hardworking people with the best intentions failed enough that someone lost her life. Websdale’s phrase—“no blame, no shame”—is repeated often during the two days I observe and turns out to matter a great deal. Websdale told me that aviation has gotten considerably safer over the past two decades, whereas medical mistakes still happen far more often than they ought. (In fact, death from medical errors in hospitals is now the third leading cause of death for adults in the United States.)3 Websdale credits a burgeoning culture of openness in highlighting human error wrought by the NTSB as the primary reason for today’s relative flight safety. “If you go into a cockpit today,” he said, “and there’s a safety issue, that pilot is going to listen to his copilot, his flight attendants, what have you.” In medicine, however, there is a pervasive hierarchy that keeps the lines of communication closed. He cited the operating room culture, how the surgeon is god, and god is never second-guessed. But the systems that work best, Websdale says, across the country—whether they are police, advocates, social workers, probation officers, judges, or even just family members—are those that focus on working as a team. In domestic violence, the two main entities poised at the front lines are advocates and police. Two professions with entirely different cultures: the modern feminists and the traditional patriarchy. Indeed, in my near-decade of reporting and researching domestic violence all across America, the most successful cities and towns I encountered that had either lowered their domestic violence homicide rates or increased available services all had this in common: they’d broken down the cultural barriers between their police departments and their domestic violence crisis centers.

Dale begins by asking what we know of the victim’s life. One team member, in particular, was responsible for gathering as much biographical information on Ruth as possible. She’d grown up out West, but moved around for much of her life. Her grown children both still lived in the western part of the country. A member of the team named Beki begins writing down these known elements of Ruth’s life on the tacked-up sheets of paper with a Magic Marker.

Ruth had worked as an aide in a retirement home and had divorced her children’s father many years earlier. She and Timothy met online and began dating immediately. In letters, Timothy professed to finding her the woman of his dreams despite having spent only one week with her at that point. Letters and notes found after the murder give the team unique insight into Ruth’s mind-set and even Timothy’s at times. Ruth had visited him several times in the Montana trailer park where he lived, and after three months, he asked her to move in with him, which she did. Within a month or two, she’d sold off most of her furniture and household items in Utah, packed up her car, and moved to Montana to live with him. He promised her the trailer was temporary, that they’d find a nice small house soon.

Unable to find work in a retirement home, she took a job with an office cleaning service, though Timothy lived on disability and whatever part-time work he could get as a handyman. It meant she had to work nights and weekends, which seemed to make Timothy insecure in their relationship, even when he knew she was at work. Their volatility was immediate. He got mad when she worked too much, but then complained about never having money. He got mad when she refused to cook or didn’t clean up the kitchen and once when she slept in till noon. But Ruth, in a notebook that appeared to be left for her children, said she felt stuck. She’d left a decent job in a neighboring state, sold practically everything she owned, and now felt she had to give this “relationship the best try [she] could.” She believed Timothy when he told her he was in pain and his pain caused him to act erratically, to explode over small events, like when she was too tired for sex or when she didn’t feel like going fishing with him. Having seen up close what it really meant to be sick, she wrote, she understood how pain could mangle someone, how the wrong drug combination could affect a personality. Indeed, she wondered if she had been sent to Timothy to help him with these very issues, some sort of preordained destiny. Like maybe she alone could save him. Because when he was nice, when he came up behind her as she was pouring a cup of coffee in the morning, when he’d wrap himself around her on the couch in front of the television, he was as warm and comforting a man as she’d known. It had been so long since she’d been in love. Decades, she’d been lonely. And now she was alone no more.

The subtext to this biography, what the assembled team members kept in the back of their minds, was whether or not something or someone in Ruth’s life could have intervened enough for her to be alive today. Did her friends know of the violence, and if so, when? Did she attend church? If so, did any of the church members know? Perhaps the minister? Did she ever show up with visible injuries? What about her work history? Had she missed days? Had she been in other romantic relationships that had turned violent? If so, what had been the outcome of those? Was it ever possible to whittle down a murder to just one single moment that could have made it all turn out differently? The fact that the relationship got serious so quickly matters, too. Short courtships—let’s call it love at first sight—are a hallmark of private violence. Rocky and Michelle had this, too.

When they finish with her timeline, it fills several pages, and it’s midmorning now. With Timothy, they will fill the rest of the wall space, and the enormous sheets of paper wrap around the entire room.

Montana’s team invites local players to their fatality reviews to offer context. These are not members of the regular team, but contribute to the discussion of any given homicide. In the case of Timothy and Ruth, several local police officers come and talk about what they knew of Timothy. He was an ex-service member who loved dogs. He had delusions of grandeur and would often boast about exploits with search and rescue, though he was never a member of any search and rescue team. He’d had several accidents—a car accident, an ATV accident—and was on prescription pain medication, and seemingly had several different sources of such medicine, from the VA and various local doctors. Like many Montanans, he had a small arsenal of weapons in his house, though unlike many, every single one of them was fully loaded and ready for Armageddon at every moment. Websdale says that often the rage an abuser feels is highlighted in the particular details of a shooting or a crime scene. One common scenario: multiple bullets in a victim’s body, evidence that the perpetrator kept shooting long after what was necessary for death, perhaps even emptying an entire chamber into his or her victim. Such crime scenes point to a level of rage held by the offender. Often the one who will offer the most resistance is killed first in a family (as with Michelle Monson Mosure). Or a stepchild who is the source of tension between a couple will have an inordinate number of bullets. Sometimes police will find a single deadly bullet in one victim and a constellation of bullets in another. These aren’t simply gratuitous details, Websdale says. They’re clues to the mind-set of an offender, details about the particular psychology of a couple, and often they speak to interventions that could have been made, for example, by mental health professionals.

In Timothy and Ruth’s case, the team begins to make connections that they’ve seen before in other cases. Timothy eventually did find them a house and move them from the trailer, but the house was in the middle of nowhere, completely isolating Ruth. Timothy’s tendency to fabricate stories of his own fake heroics spoke to a deep feeling of inadequacy and insecurity, and probably a clinical narcissism. As an ex-service member, he’d been in and out of the VA seeking various services, and he’d had run-ins with the local police, who knew him well. One officer called him a kind of Yosemite Sam. Another said he knew exactly what he could get away with and skirt the law. He had multiple restraining orders against him in other states that Montana’s law enforcement did not know about, because systems across states rarely communicate. Nor, presumably, did Ruth. Even today, in this world of hyper-connectivity, where we can get a drone to deliver our toilet paper and a robot to vacuum our carpets, we still seem unable to create a database that speaks across state lines and across civil and criminal courts when it comes to violent people and their histories. One of his ex-girlfriends told a team member that she kept track of him on social media just to keep herself safe and make sure he was nowhere near—this, though she lived over a thousand miles away now with a family of her own and hadn’t spoken to him in many years. In a couple of cases, he had temporary restraining orders filed against him, and he’d wait until they expired and a partner wouldn’t show up to renew them, and he’d start coming around again. It was one of the ways in which he would abut the law but not break it.

“He had all these temporary restraining orders with other women,” says one of the team members. “But not Ruth. He killed the one who didn’t leave.”

The team learns he was married once before but only briefly. His wife sought help from a pastor, who comes today to talk about his experience with Timothy and his ex-wife. The pastor is tall, with a mustache, and, like nearly everyone in the room with me that day, carries a gun at his belt, because Montana. One team member, a retired forensic nurse, is so outspoken about her hatred for guns that the other members tease her endlessly. Every time she says it, she’s holding needles, knitting away, wearing a sweater vest. When it comes time to make recommendations, she will take Beki’s giant Sharpie and write guns, guns, guns all over the white pages. “You want to get rid of homicide?” she’ll ask. “Get rid of guns.” She says this on and off for the two days we’re there.

The pastor talks about Timothy’s ex-wife. He went with her to file for a restraining order, and convinced her to tell the judge how terrified she was. The judge turned down her request. But the pastor knew she was in danger and he stepped in and created a safety plan for her. “We got her a new car,” he says, so Timothy couldn’t track her. And the church found her a safe place to live, though not before the church itself received threats. “We’re pretty sure he was behind them,” the pastor says.

Police, even local police familiar with Timothy’s odd history, knew none of this. They didn’t even know he’d once been married.

It’s easy to look at the judge in such a case and lay blame, but the judge knew none of Timothy’s history of stalking other women or restraining orders he’d had with former girlfriends, because most of these incidents happened when he was living in another state, not Montana. And, perhaps even more important, restraining orders are generally a matter for civil courts; it’s only once those orders are broken that they become a criminal matter. And Timothy, of course, even with a history of restraining orders, albeit largely unknown, had no criminal history. The systemic gaps, across courts, bureaucracies, state lines, are epic.

So here, then, is where the work of the team becomes so crucial. They have the timelines for Ruth’s and Timothy’s lives. They’ve listened to local police and local clergy offer what information they had about the two. They’ve learned a little about the economy and culture where the incident happened, and now they put it all together and look for red flags. Timothy was known to law enforcement; he had unstable employment; he had a history of stalking and stay-away orders; he had significant amounts of pain medication; he had visions of grandiosity, profound narcissism, and a wicked streak of manipulation. He told lies about what he’d done in the military and posted on social media accounts of bravery and heroism that no one could ever find evidence of (local newspaper articles, for example). In the crime scene, his death was tidy; he lay himself comfortably in bed. There was very little blood. But Ruth’s spoke to frantic chaos, terror. For Ruth, she wrote of wanting to save him, of how the world had given up on him, but she wouldn’t. She, too, had unstable employment, but she also had very little support in the area—no family or friends. Just a minister at a church she sometimes attended. Ruth and Timothy’s relationship got very serious very quickly, and Ruth found herself nearly completely isolated. Timothy rarely allowed her to leave the house, citing his need for her. The variety of red flags are things everyone in domestic violence has seen before: the quick courtship, the isolation and control, the unemployment, the medications, the narcissism and lying and stalking.

The question now is where Timothy and Ruth interacted with the system in some way to see where interventions might have been possible. Slowly, they’re inching their way toward recommendations they can make in a report they prepare every other year for Montana’s legislature. The proverbial X over the eye, you might say.

The VA, where Timothy sought treatment, is the first place they identify. And then there was the court with his ex-wife. The police knew him, and he’d had that history of stalking and protection orders. He also had a home health aide who worked with him several times a week, who tried to warn her supervisor about his instability, and she was told to ignore it and just do her job. And then there was Ruth’s minister. “That’s five intervention points,” Matt Dale says. “The VA, mental health, law enforcement, the judiciary, and the clergy.”

One of the advocates raises her hand, says she wasn’t sure earlier, so she put in a call to someone in her office, and said that, in fact, Ruth had visited her office once, long ago. She hadn’t seen Ruth, but one of her coworkers had. That day, Ruth was driving around with everything she owned in her car. The advocate had no other information, whether this was during her relationship with Timothy or not or if Ruth had actually obtained any services, but it’s another possible intervention point for the team. If you count a homeless shelter, it’s just one more missed opportunity.

By lunchtime on the second day, the team asks everyone to call out recommendations. The retired nurse says, “Guns, guns, guns. Get rid of the guns.” Some of the police officers on the team laugh. “This is Montana,” someone else says.

“So what?!” she says. She is charming in that way of a grandmother—the knitting and all—but fierce in her opposition. She knows it’s a battle she’ll never win in this state, but that doesn’t deter her from fighting it.

Recommendations come from all sides of the room, five, ten, fifteen. The goal is to put all ideas on the table, and then they’ll whittle down the most realistic ones—those that will cost little or nothing to implement or those where the legislature might not have a big battle on their hands. One of the most significant is the gap between Timothy’s history of restraining orders and what local police who dealt with him knew. This becomes one of their primary recommendations: that they have access to a history of such orders in other states. Dale says they also ought to take a page out of the DUI statutes. DUIs now remain on a person’s record in Montana. That’s a simple fix, keeping the history of temporary restraining orders in the system, even after they’ve expired.

And there are other recommendations, too, all of them seemingly small tweaks, and some that have come from other fatality reviews: invite clergy to trainings so they know how to deal with domestic violence. (“More women talk to their pastors than police or domestic violence advocates,” Websdale told me once.) Talk to the VA about ways in which their medical treatments and prescriptions can be accessible to other doctors electronically. Close the technology gap in the courts. By the end, more than twenty recommendations are listed, but Dale and the team whittle them down, and ultimately only a handful will go on to be included in their report, and though the reports cover at least four reviews done by the team, the recommendations aren’t linked to any case specifically for privacy. So that by the time the team issues their report for the period in which I sat in on the review, I recognize only two or three as likely originating from the case of Timothy and Ruth, and they include expanding the use of lethality and Danger Assessments, training judges, law enforcement, and healthcare workers on the complexities and contexts of domestic violence cases.

They seem like such small changes that it’s almost disheartening. But Montana and other states have seen profound change with these seemingly small tweaks. One story Matt Dale likes to talk about is the case of the woman who had an active restraining order against her abuser, but when he broke the order and the police were called in, the officer on the scene couldn’t read her actual stay-away order for the most trivial of reasons: it was typed on a piece of paper. Paper, which degrades after a time. It had been issued from the court, and in the intervening time in which she’d been granted it, had become illegible. As a result, Montana eventually implemented something called the Hope Card. It is the size of a driver’s license and laminated and contains identifying information about the offender, including a picture, the active dates of the protection order, and any other pertinent information. Victims can get multiple Hope Cards and pass them out to coworkers, teachers and administrators at a child’s school or anyone else who might need to be made aware of the order of protection. Two other states, Idaho and Indiana, have implemented the Hope Card, and more than a dozen other states have looked into Montana’s program.

Michelle Monson Mosure and her children were the first case Montana’s fatality review team took on. Today, as a result of Michelle’s fatality review, Rocky wouldn’t have been allowed to bail out first thing in the morning. Meaning, he would have been held longer. It gives domestic violence advocates more time to connect with a client, to go over safety plans, a Danger Assessment and timeline, to offer up services like shelter or other emergency plans, to give a context for what victims and their families might not know they’re seeing or experiencing. Michelle had no time. The bear was coming at her. A domestic violence advocate would have met with Michelle and done a Danger Assessment on her. Billings now has a dedicated domestic violence police officer named Katie Nash; Nash would have followed up with Michelle, as she does with all the domestic violence cases that come through the department from street officers. They’d have come up with a safety plan that may have included changing the locks on the house, putting Michelle and Kristy and Kyle in a safe house or hotel for a few days, putting Rocky on a GPS bracelet. He may have also been prosecuted for several felonies: unlawful entry and remaining unlawfully within the home (burglary), vandalism, possible kidnapping, criminal endangerment, and possibly others. The police may have done home checks on Michelle. A judge may have ordered Rocky to abuser intervention classes. The range of possibilities is endless.

The Montana team made other recommendations based on her case as well. They recommended an automatic no-contact order with anyone arrested in conjunction with a partner or family assault; today, Rocky would have been barred from contacting her from jail. They also recommended a systematic method of warning victims when abusers are due to be released—either having served their time or after bailing out. So Michelle would have been warned far in advance of his release. They also recommended that any victim who rescinds his or her testimony, recants as Michelle did, be provided with domestic violence information, including area services. Hopefully they’ll be more aggressive in their evidence-based prosecution in years to come.

There are recommendations that appear from year to year in Montana’s and other states’ reports. They include the ever-increasing use of Danger Assessment and closing technology gaps, such as those that exist so often between civil and criminal courts or between advocates and police officers. More trainings, too, make the recommended list again and again. Gun control, however, at least in Montana, rarely does.

One of the things Sally stressed to me over and over was the moment Michelle learned Rocky had been bailed out of jail. She just instantly changed; all her resolve to leave disappeared, Sally said. “She really thought he’d be in there a while,” she told me. Maybe there’s no way of knowing if these changes would have kept Michelle Monson Mosure and her children alive. It’s like trying to prove a negative. The only sure thing is that doing nothing will ensure that nothing ever changes. And what everyone I ever spoke with in Montana was utterly and absolutely convinced of? That the death of Michelle Monson Mosure had saved many other lives.