Brown, Tara Matekino - Non-inquest findings

Contributing factors

• Pattern of escalating intimate partner violence over 4 years
• Failure of Queensland Police to respond appropriately to victim's complaint on 3 September 2015
• Police failure to recognise 27+ lethality risk factors
• Police insistence on signed statement despite independent witnesses and documentary evidence
• Inadequate supervision of constable by shift supervisor sergeant
• Police failure to investigate assault and threats to kill
• Failure to obtain victim's statement from corroborating witnesses (employer, mother)
• Queensland Health failure to address DFV disclosure at antenatal appointment
• Hospital staff breach of DVPO by allowing respondent at birth despite knowing order was in place
• DFV Liaison Officer far behind on audits due to being pulled for other priorities
• Perpetrator's prior history of DFV against another partner with minimal consequences
• Perpetrator's prior mental health episodes and threats of self-harm
• Separation and child custody dispute as trigger for escalation
• Perpetrator's misogynistic attitudes and belief he had right to control victim

Coroner's recommendations

1. Queensland Police Service to continue implementation of reforms including improved training on DFV dynamics and lethality assessment
2. Continued use of DV-PAF (DV Protective Assessment Framework) by all frontline officers
3. Implementation of mandatory DFV refresher training for all officers
4. Recognition that DFV victims often cannot provide signed statements due to fear
5. Police to obtain independent evidence from corroborating witnesses when victims cannot sign statements
6. Supervision of frontline officers to ensure proper investigation of DFV complaints
7. Queensland Health to implement consistent DFV screening and documentation
8. Hospital staff to not breach DVPOs and to contact police when aware of protection order conditions
9. DFV Liaison Officers to receive adequate resourcing to conduct regular audits of DFV occurrences
10. Recognition of predictability of intimate partner homicides based on presence of lethality risk factors
11. Early intervention and accountability for DFV perpetrators to prevent escalation