Bradford, Teresa and Bradford, David - Non-inquest findings

Contributing factors

• Escalating intimate partner violence and coercive control over 17-year relationship
• Perpetrator's untreated depression and suicidal ideation post-stroke
• Perpetrator's non-compliance with psychotropic medications
• Victim's isolation from support networks and family
• Victim and perpetrator treated by same general practitioner
• Fragmented service responses with poor integration despite victim's multiple help-seeking attempts
• Victim not informed of perpetrator's release from custody after arrest
• Inadequate victim safety planning and risk assessment
• Perpetrator risk assessment relied on self-report without collateral information
• Victim's physical injuries and trauma deprioritised in favour of perpetrator's mental health
• Family financial hardship and housing insecurity
• Mental health team requested victim attend family meeting with perpetrator despite documented violence
• Perpetrator released on day leave to court without informing police or victim
• Limited respite or in-home care support despite victim's documented inability to cope
• Bail granted despite police objections based on unreasonable risk of harm

Coroner's recommendations

1. Royal Australian College of General Practitioners should refine the 'White Book' (Abuse and violence: working with our patients in general practice) to be more prescriptive and provide definitive advice and decision-making pathways for general practitioners regarding treatment of both perpetrators and victims of domestic violence, with particular guidance on whether a GP should treat one, both or neither party
2. Mental health services should implement enhanced gatekeeper training to educate clinicians about the possibility of violence towards others as well as towards self, particularly in the context of depression and homicide-suicide risk
3. Mental health risk assessments should include systematic gathering of collateral information and should not be relied upon solely on self-reporting by the perpetrator
4. Services should avoid treating victim and perpetrator with the same provider and implement safety protocols when both parties are engaged with services
5. Victim notification systems should be implemented to ensure domestic violence victims are informed when the perpetrator is released from custody or receives variations to bail conditions
6. Mental health services should integrate domestic violence risk assessment into all assessments of patients presenting with mental health concerns, particularly depression and suicidal ideation in the context of relationship breakdown
7. Victims of intimate partner violence should not be requested to attend family meetings with perpetrators during periods of acute risk, and should have their physical injuries and trauma appropriately prioritised
8. Integrated service responses to domestic violence should operate effectively to reduce siloed practice, with clear communication pathways between health, mental health, criminal justice and specialist domestic violence services
9. Specialist domestic violence services should follow 'safe at home' principles including safety upgrades, maximising women's safety, preventing homelessness, integrated response involvement of partnerships, and enhancing women's economic security
10. Accommodation support services should provide active assistance to women seeking safe housing rather than requiring victims to follow up, to prevent victims falling through gaps
11. The Common Risk and Safety Framework should be revised to include protective factors, consider needs of priority populations including Aboriginal and Torres Strait Islander women, and reduce assessment tool length for improved usability by frontline workers
12. Services engaging with perpetrators of domestic violence should assess the impact of the perpetrator's behaviours on the familial network and victim safety as part of integrated care planning