DM

Contributing factors

• Extensive history of domestic violence spanning 13 years
• Victim reluctance to engage with police and support services long-term
• Victim denial or minimization of abuse severity
• Perpetrator manipulation and coercion of victim into dropping charges
• Victim fear of police involvement due to concerns about child removal
• Multiple reconciliations despite repeated separations
• Inadequate inter-agency coordination and communication
• Lack of common risk assessment tools across agencies
• Absence of specialized domestic violence courts
• Limited perpetrator accountability in criminal justice responses

Coroner's recommendations

1. Establish additional Domestic and Family Violence Coordinator positions in Queensland areas where domestic violence is prevalent, and re-implement a state-wide coordination role within police headquarters
2. Address potential misclassification of domestic violence assaults as non-domestic assaults within Queensland Police Service processes
3. Develop simple guidelines to assist General Practitioners when treating both perpetrator and victim of domestic violence
4. Allow General Practitioners to report domestic violence concerns to police even without immediate severe threat to patient's life, to improve inter-agency information sharing
5. Examine the SCAN model and develop similar team-based approaches to supporting domestic violence victims
6. Establish an interdepartmental process to develop pilot 'Domestic violence centres' in appropriate Queensland locations
7. Implement a common risk assessment tool across Queensland to ensure agencies use consistent language and reduce communication difficulties
8. Strengthen the Domestic and Family Violence Death Review Unit within the Office of the State Coroner
9. Establish an independent multi-disciplinary Domestic and Family Violence Death Review Board
10. Extend Queensland Police Service training review to all officers likely to have contact with domestic violence situations
11. Improve hospital and health service responses to domestic and family violence and child harm
12. Enhance funding for specialist domestic and family violence services and perpetrator intervention initiatives
13. Improve court responses to domestic and family violence with focus on perpetrator accountability and specialist courts
14. Adopt pro-active investigation and protection policies in policing that consider victim safety as paramount