Inquest into the deaths of John, Jack and Jennifer EDWARDS

Contributing factors

• Failure of NSW Police to properly investigate domestic violence allegations
• Inadequate recording and verification of COPS events documenting abuse
• Failure to conduct comprehensive searches of offender's history in COPS
• Systemic failures at Firearms Registry in applying 'fit and proper person' test
• Firearms Registry focus on mandatory refusal factors to exclusion of discretionary safety assessment
• Failure to disclose or verify family law proceedings in firearms applications
• Inadequate assessment of pattern of family violence spanning 35 years
• Independent Children's Lawyer misrepresenting police evidence and expert opinion to court
• Failure of gun clubs to report membership refusals or concerns to Registry
• P650 form allowing unlicensed firearms training without Registry oversight
• Family therapist, consultant and clinical psychologist concerns about risk not properly escalated
• Inadequate information sharing between police, family law courts, and firearms authorities

Coroner's recommendations

1. NSW Police ensure operational police are aware of dangers of recording pre-emptive approaches to police in family law context in COPS database with appropriate caveats (Recommendation 1)
2. NSW Police continue to prioritise domestic violence training in mandatory continuing police education (Recommendation 2a)
3. NSW Police develop mandatory training for general duties constables on DVSOPs and DVSAT (Recommendation 2b)
4. NSW Police implement annual comprehensive audit of DVSOPs compliance by officers (Recommendation 3)
5. NSW Police amend DVSOPs to give greater prominence to warning about family law proceedings at earlier point in document (Recommendation 4)
6. NSW Police develop mandatory training module for shift supervisors on verification of domestic violence incidents including DV Checklist (Recommendation 5)
7. NSW Government update prescribed offences in Firearms Regulation to include personal violence and domestic violence offences (Recommendation 6)
8. NSW Firearms Registry clarify systems so adjudicators can identify earlier false or misleading applications (Recommendation 7)
9. NSW Firearms Registry provide additional training on protocol for false or misleading applications (Recommendation 8)
10. NSW Government remove language 'other than an order that has been revoked' from s. 11(5)(c) Firearms Act (Recommendation 9)
11. Firearms Registry update Adjudication Decision-Making Tool with improved guidance on domestic violence (Recommendation 10)
12. Firearms Registry update DMT to include review of DVSAT attached to COPS events (Recommendation 11)
13. Firearms Registry conduct regular training on domestic and family violence including separation risks and non-physical abuse (Recommendation 12)
14. NSW Police and Firearms Registry standardise and clarify questions on family law proceedings disclosure (Recommendation 13)
15. NSW Police and Firearms Registry establish mechanism to verify family law proceedings information (Recommendation 14)
16. NSW Police and Firearms Registry establish system for notification of federal DV events from family courts (Recommendation 15)
17. NSW Government amend firearms licensing regime to suspend processing when federal DV event occurs (Recommendation 16)
18. NSW Government require notification to family law court when applicant/licensee involved in federal DV event (Recommendation 17)
19. NSW Government require disclosure of family law proceedings in firearms applications (Recommendation 18)
20. Firearms Registry amend DMT to require consideration of whether family law proceedings on foot and implications for risk (Recommendation 19)
21. NSW Government revoke P650 form and implement alternative scheme with Registry oversight for unlicensed training (Recommendation 20)
22. NSW Government require gun clubs to inform Registry if they refuse membership and reasons (Recommendation 21)
23. NSW Government amend Firearms Regulation to extend mandatory reporting obligation to all gun clubs (Recommendation 22a)
24. Firearms Registry consult to lower reporting threshold for clubs with concerns about prospective/current members (Recommendation 22b)
25. Firearms Registry research impact of allowing clubs to refuse firearm removal if concerns about risk (Recommendation 23)
26. Office of Legal Services Commissioner investigate disciplinary action against Ms Debbie Morton re ICL role (Recommendation 24)