One ‘Forgotten Provisional Registration’ Delivered the Victim’s Address to the Perpetrator

In Iwakuni City, Yamaguchi Prefecture, the family register supplementary record of a DV victim was issued to the perpetrator. This supplementary record contains a history of addresses — meaning that the ‘place of escape’ that the victim had desperately tried to hide was handed directly to the perpetrator.

The city paid the victim 1.43 million yen in compensation. However, this is not merely about the amount of money. The core issue of this incident lies in the fact that a system designed to protect victims was turned into a ‘tool for perpetration’ due to a single missing step.

How Was the ‘Issuance Restriction’ System Supposed to Function?

Victims of DV, stalking, and child abuse can request ‘support measures’ to stop the perpetrator from requesting their resident record or family register supplementary record. Upon receiving this request, municipalities impose issuance restrictions in their basic resident register operations. Even if there is a request from the perpetrator or their representative at the counter, a warning is displayed in the system, and the issuance is refused — that is the intended flow.

In the case of Iwakuni City, there were two stages in the registration process for this issuance restriction: ‘provisional registration’ and ‘official registration.’ Because the staff did not carry out the provisional registration, the system remained in a state without restrictions. As a result, the supplementary record was issued to the perpetrator without any warning at the counter.

What is noteworthy here is the nature of the mistake. The staff did not hand it over knowing that they ‘should not issue it.’ The system simply did not provide any guidance. If the system is not designed to protect people, accidents can occur regardless of how diligent the staff may be. The problem lies not in individual attentiveness but in the design itself, where the protection disappears entirely due to a single missing step.

Can a System That Does Not Assume ‘Human Forgetfulness’ Be Called a System?

Administrative counter operations are a continuous routine of processing a vast number of cases with limited personnel. According to a survey by the Ministry of Internal Affairs and Communications, the number of cases eligible for support measures amounts to tens of thousands nationwide each year. Designing a system that requires ‘absolutely no forgetfulness’ for each registration task is hardly sustainable.

In principle, the design of a system should assume that ‘humans forget’ and ‘humans make mistakes.’ In the aviation industry and medical field, checklists, double-checks, and fail-safe mechanisms are incorporated, taking human error into account. Why does the administrative counter work, which deals with life-critical information, lack the same level of design philosophy? This raises a structural question.

Iwakuni City has reportedly proposed strengthening training for staff as a measure to prevent recurrence. However, conveying ‘let’s be careful’ in training and implementing a design where one cannot proceed to official registration without completing provisional registration in the system — or where an automatic alert is triggered during requests for unregistered individuals — are entirely different matters. The former relies on human effort, while the latter supports people through the system. It is clear which approach can more reliably protect victims.

‘Gaps in the System’ Have Repeatedly Occurred in Other Municipalities

This type of incident is not unique to Iwakuni City. There have been multiple reports of erroneous issuance of DV victims’ addresses in various municipalities in the past. In 2023, another municipality experienced a similar case of erroneous issuance due to a registration oversight in support measures, forcing the victim to relocate.

What is common among these cases is that they have all been treated as ‘individual staff mistakes’ without leading to a fundamental review of the system design. Each time an incident occurs, ‘prevention of recurrence’ and ‘strengthening training’ are repeated, but if the structure of the system does not change, the same gap will reopen elsewhere.

Looking at Hiroshima Prefecture, there are numerous instances where the weaknesses in administrative systems have been exposed, such as the mismanagement of documents related to government-sponsored bid rigging in Onomichi City and insufficient notification to residents regarding changes to polling places in Hiroshima City. What is common among these is that while rules exist, they do not keep pace with reality — or there are gaps between the rules and their implementation, and no design has been made to fill those gaps.

Placing the Question of ‘Who Benefits?’ at the Starting Point of System Design

The issuance restriction system exists to protect victims. However, the current design places the cost of protecting victims on the attentiveness of counter staff. A system that assumes staff can process accurately on their own is harsh for the staff and precarious for the victims.

When reviewing the system, the first question to ask should be, ‘Who does this make easier?’

By introducing fail-safes in the system, staff can be somewhat relieved from the pressure of ‘not forgetting.’ Victims can gain peace of mind knowing that their information is securely protected. When the system supports people, individuals can operate more reliably within that system. Creating that cycle is the essence of system design.

What is specifically required are responses such as the following:

• System Design Revision: Introduce a mechanism that automatically issues warnings during the issuance of certificates for the relevant individuals if provisional registration is not completed at the time of the request for support measures.
• Mandatory Double-Check System: Standardize the confirmation process by multiple staff members in registration and issuance operations related to issuance restrictions.
• Establishment of National Uniform Guidelines: Correct the current situation where operational procedures for support measures vary by municipality, and set minimum system requirements under the leadership of the Ministry of Internal Affairs and Communications.
• Notification System for Victims: Create a system to notify victims when the registration of issuance restrictions has been completed, allowing them to verify their protection status themselves.

These are not technically impossible to implement. Rather, the more pressing question is why they have not been standard equipment until now.

What the 1.43 Million Yen Compensation Represents

The amount of 1.43 million yen likely reflects the mental anguish and relocation costs incurred by the victim. However, the actual fear faced by victims whose addresses have been revealed to the perpetrator — checking locks every night, tensing up at unfamiliar footsteps, changing their children’s school routes, and having to explain the situation to their workplaces — cannot be quantified in monetary terms.

Compensation is a response after the fact, and if prior protection had functioned, this cost would not have arisen in the first place. The fact that 1.43 million yen was paid indicates that deficiencies in the system translate directly into financial burdens. Investing in systems that protect people is more rational, both ethically and financially, than responding after the fact.

Whether the System Can Protect People Depends on the Imagination of the Designers

What is most thought-provoking about this incident is how far the people who designed the system imagined ‘what happens when this step is missing.’

It is not the staff who forgot the provisional registration that are to blame. It is the system that did not design a way to ensure that victims are not endangered even if the provisional registration is forgotten that should be reexamined.

When DV victims flee, they are betting everything on their lives. Hiding their address means rebuilding the foundation of their lives from scratch and severing their ties to society. Can the administrative system truly grasp the weight of that decision?

How Iwakuni City will respond to this incident and what changes it will make. Whether other municipalities will examine their own systems with the question, ‘Are we okay?’ is what we should closely watch.

— A system that protects people can only truly protect them when it assumes that people make mistakes.