Inquest into the death of Holly Davidson

Contributing factors

• Domestic violence and coercive control by police officer partner
• Head trauma sustained 3-5 days prior to death
• Chronic alcoholism secondary to post-traumatic stress disorder
• Inadequate police investigation and failure to recognise domestic violence patterns
• Misidentification of primary aggressor by police
• Failure to apply for protective orders despite repeated reports
• Failure to recognise coercive control 'red flags'
• Police protecting fellow officer instead of victim
• Victim's distrust of police system preventing reporting
• Inadequate coordination and information sharing in police investigations
• Lack of crime scene protocols

Coroner's recommendations

1. Commissioner of Police establish a process where all complaints of domestic violence involving police officers are overseen by the Assistant Commissioner responsible for the Domestic and Family Violence Unit
2. Commissioner of Police ensure that processes and procedures for investigation of domestic violence involving police officers permit access by investigating officers to all relevant history and prior matters including any relevant workplace information
3. Commissioner of Police ensure that the General Order is updated to convey contemporary understanding of domestic and family violence (including coercive control) and that all police officers have training in identification of 'red flags' for coercive control
4. Commissioner of Police give consideration to developing a risk assessment process/tool to support police in identifying both the physical and non-physical aspects of domestic and family violence