Inquest into the death of Ms K

Contributing factors

• years of coercive control and emotional abuse by husband
• physical violence and threats to kill
• partner's alcohol misuse and depressive illness with psychotic features
• husband's delusional beliefs about infidelity
• victim planning to leave marriage
• escalation of controlling behaviour as victim asserted independence
• health professionals' failure to make protective referrals
• inadequate police risk assessment on 17 August 2016
• victim's isolation from support networks
• cultural factors permitting patriarchal control

Coroner's recommendations

1. NSW Police Force develop a framework for 1 January 2025 to 31 December 2027 to guide police training in domestic and family violence policing with identified intervals for refresher training, modes for course delivery, and protocols for integrating course evaluations.
2. NSW Police Force continue to consult with external subject matter experts and government and non-government stakeholders in development of policy and training content related to domestic and family violence.
3. Consider whether and how incident and criminal history information from other state and territory jurisdictions can be directly incorporated into the revised DVSAT and built into NSW Police Force IT system.
4. Pending implementation of the above, the revised DVSAT guide and instruction material specifically direct police officers to consult all accessible incident and criminal history information from other states and territories when assessing whether a matter should be upgraded to 'at serious threat' level, including total number of prior DV incidents in the past two years and presence of 'trigger offences' in the past two years from other jurisdictions.
5. The predictive accuracy of the revised DVSAT be reviewed at intervals of at least 12, 24 and 36 months post commencement.
6. As part of DVSAT reviews, consideration be given to inclusion of the offence of coercive control (section 54D Crimes Act 1900) within the last two years as a 'trigger offence'.
7. DVSAT Working Group consult with RACGP, RANZCP and Australian Psychological Society as to how the DVSAT should operate for non-police referrals into Safer Pathway system.
8. Department of Communities and Justice and NSW Police Force consult with RACGP, RANZCP and Australian Psychological Society to develop policy in areas of perpetrator identification, engagement and service referrals.
9. Attorney General consider, as part of statutory review into section 54D of Crimes Act 1900, amending the definition of 'abusive behaviour' in section 54F(2) of the Crimes Act 1900 and definition of 'domestic abuse' in section 6A(2) of the Crimes (Domestic and Personal Violence) Act 2007 to include behaviour that uses coercion, threats, physical abuse or emotional or psychological abuse to demand or receive dowry, either before or after marriage.