Mr M - Non-inquest findings

Contributing factors

• Failure by Queensland Police to correctly identify, respond to and investigate domestic violence incidents
• Failure to accurately assess and triage calls for assistance
• Inadequate resourcing and priority given to police responses to domestic and family violence
• Insufficient understanding and recognition of the dynamics of domestic and family violence by police
• Delayed service of final domestic violence protection order (13 days after being made)
• Failure to recognise and act upon multiple lethality risk factors
• Police did not take respondent into custody despite reasonable suspicion of domestic violence and imminent danger
• Lack of dedicated domestic violence training for police
• Poor information sharing and coordination between police responses
• Failure to conduct comprehensive risk assessment despite multiple escalating indicators

Coroner's recommendations

1. Implementation of dedicated domestic violence training for all Queensland Police Service officers (subsequently implemented)
2. Enhanced understanding of high-risk markers associated with domestic violence and homicides (subsequently implemented)
3. Development of standardised protection approaches through interagency case management (subsequently implemented)
4. Improved investigation and response to domestic violence incidents, particularly recidivist behaviour (subsequently implemented)
5. Specialised domestic violence training for civilian Client Service staff, particularly Policelink staff (subsequently implemented)
6. Appointment of dedicated station-level Domestic and Family Violence Coordinators for rural stations (subsequently addressed)
7. Enhanced information sharing across government and non-government agencies (subsequently implemented through amended legislation)
8. Review of Protective Assessment Framework to better identify and incorporate lethality risk factors (subsequently undertaken)
9. Embedding of Domestic and Family Violence Coordinators in Police Communications Centre (subsequently implemented in trial, extended to permanent)