Inquest into the death of Ralph Donald

Contributing factors

• escalating coercive control of intimate partner
• failure of police to recognise coercive control as domestic violence
• failure to initiate domestic violence orders despite clear opportunities
• failure to seize firearms when investigating domestic violence complaint despite knowing firearms were present
• inadequate mandatory reports to child protection agency lacking critical information
• inadequate support services for men at risk of using violence
• lack of early intervention services for couples experiencing relationship problems
• alcohol abuse
• relationship breakdown and separation from child
• lack of accessible support services when perpetrator sought help
• vicarious trauma and unmet needs in specialist domestic violence sector

Coroner's recommendations

1. Establish and adequately fund a multi-agency Domestic and Family Violence Death Review Team (DFVDRT) convened by the NT Coroner or Deputy Coroner, including representatives from Aboriginal organisations, NT Police, Department of Children and Families, NT Corrections, NT Health, NAAJA, NT Legal Aid, Department of Education, non-government service providers, and lived experience experts, modelled on NSW Coroners Act 2009 Part 9
2. NT Police Force should prioritise delivery of face-to-face Prevent. Assist. Respond. (PARt) training to all officers responding to domestic, family or sexual violence incidents and JESCC call takers; ensure all officers undertake initial face-to-face PARt followed by online refresher modules; and fast-track officers falling substantially short of expected standards to complete face-to-face PARt training
3. NT Police should explore system architecture changes to SupportLink to enable inclusion of CRATs, PRSTs and other risk assessment documents and SerPro narratives in referrals, and to prompt referrers to indicate safe contact methods; and update the Domestic and Family Violence General Order accordingly
4. NT Government should enact legislative change to give police discretion to seize firearms when lawfully in a dwelling investigating a domestic and family violence complaint, with commensurate increase in police resourcing if required
5. Department of Children and Families should make system architecture changes to prompt and enable submission of CRATs, PRSTs and other risk assessment documents, and relevant SerPro narratives in reports alleging domestic and family violence
6. Department of Children and Families should embed a specialist DFV practitioner at Central Intake to assist in assessing reports alleging domestic or family violence, with training in RAMF, Safe and Together, and face-to-face PARt
7. Department of Children and Families should consider rolling out face-to-face PARt training to all employees responding to domestic or family violence allegations in their day-to-day duties, followed by online refresher and supplementary modules
8. NT Government should provide funding for an increased number of specialist DFV counsellors employed by services across the Territory including Relationships Australia NT, ensuring access for men and women, Aboriginal and non-Aboriginal people, in remote and urban areas
9. NT Government should urgently restore the $6.5 million Department of Logistics and Infrastructure funding to Dawn House to upgrade its facility and increase the number of crisis accommodation shelters
10. NT Government should implement the ANROWS recommendation for an outcome evaluation of NT Men's Behaviour Change Programs