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Blackmore, Rinabel Tiglao - Non-inquest findings

Deceased

Rinabel Tiglao Blackmore

Demographics

44y, female

Coroner

Wilson

Date of death

2015-01-02

Finding date

2019-04-04

Cause of death

Head injury sustained when exiting a moving vehicle

AI-generated summary

A 44-year-old Filipino woman died from head injuries after exiting a moving vehicle travelling at 100 km/h during an episode of domestic violence. Ms Blackmore had reported non-lethal strangulation and threats to police 40 hours before her death, but police did not adequately assess the high-risk situation or take custody of the perpetrator despite him being known to have a history of serious domestic violence. Critical failures included: police not interviewing the motel manager who witnessed threatening behaviour; not referencing the perpetrator's prior strangulation of former partners; failing to provide victim support services or safe accommodation; and not escalating to senior officers. The case demonstrates the importance of recognising non-lethal strangulation as a major homicide risk factor, proper risk assessment alignment with response, support for CALD victims, and cultural competence in police responses to domestic violence.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

forensic medicineparamedicineemergency medicineneurosurgery

Error types

communicationsystemdelay

Clinical conditions

domestic violenceintimate partner violencenon-lethal strangulationhead traumatraumatic brain injury

Procedures

intubationmechanical ventilation

Contributing factors

  • Prolonged domestic violence with multiple episodes of physical violence and threats over 48 hours
  • Non-lethal strangulation by intimate partner
  • Threats to kill the victim
  • Perpetrator's prior history of domestic violence against multiple former partners including strangulation
  • Inadequate police risk assessment alignment with response
  • Police failed to take perpetrator into custody despite high-risk assessment
  • Police did not interview key witness (motel manager)
  • Police did not provide victim with refuge or support services
  • Victim social isolation due to cultural and language factors
  • Victim's separation anxiety and fear escalated by perpetrator's controlling behaviour
  • Victim attempted to retrieve belongings without police escort, returning to perpetrator
  • Perpetrator controlled victim's phone and vehicle
  • Victim exited vehicle as desperate act of self-preservation while in fear for her life

Coroner's recommendations

  1. Police officers, particularly junior or inexperienced, should be encouraged or mandated to seek advice from senior officers (District Duty Officer) when attending domestic violence incidents
  2. Police should ensure their response aligns with their own risk assessment determinations
  3. Police should take custody of perpetrators where risk assessments indicate this is appropriate
  4. Police should interview all relevant witnesses at the scene of domestic violence incidents, including motel managers and other bystanders
  5. Police should provide referrals to women's shelters and domestic violence help lines as standard practice
  6. Police should offer to escort victims to retrieve belongings or divert them to police stations for safe retrieval
  7. Increased training on non-lethal strangulation as a predictor of homicide risk
  8. Enhanced cultural competence training for police officers working with culturally and linguistically diverse victims
  9. Improved assessment and response to separation-phase domestic violence risks
  10. Implementation of specialist Domestic and Family Violence Coordinators in police communications centres
  11. Enhanced interpreter services and cultural communication support for CALD victims engaging with police and justice system
  12. Greater focus on rehabilitation and behaviour change programs for perpetrators of domestic violence by Queensland Corrective Services
  13. Improved parole and probation supervision protocols for offenders with domestic violence histories
Full text

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