KH - Non-inquest findings

Contributing factors

• Pattern of coercive controlling violence by partner
• Breach of protection order and bail conditions
• Inadequate monitoring of bail compliance by police
• Limited engagement with formal health and support services
• Victim reluctance and fear preventing engagement with services
• Social isolation and controlling behaviour by perpetrator
• Limited service provision in rural community
• Transient lifestyle disrupting continuity of care
• Health service focus on acute medical treatment without specialist referral or support
• No mandatory reporting of domestic violence by health practitioners at that time

Coroner's recommendations

1. Implementation of 'Not Now, Not Ever' recommendations including Recommendation 32 on workplace training programs for identifying and responding to domestic violence
2. Recommendation 59: Queensland Government work with DV Connect to develop a model providing immediate access to specialist domestic and family violence support referral services within public and private maternity hospitals and emergency departments
3. Recommendation 61: Ensure continuing professional development and accreditation requirements of health practitioners include education on recognising and responding to domestic and family violence
4. Recommendations 78-79: Enable information sharing arrangements between agencies with appropriate safeguards and develop clear guidelines for information sharing within integrated responses
5. Establishment of specialist domestic violence courts with jurisdiction over all related proceedings
6. Review and completion of domestic violence 'Bench Book' for Magistrates to guide decision-making
7. Implementation of state-wide police training on vulnerable persons and new domestic violence legislative framework
8. Enhanced bail monitoring and compliance checks for domestic violence offenders
9. Improved funding and service integration for specialist domestic and family violence services