Dower, Sarahjane - Non-inquest findings

Contributing factors

• Psychologist failed to notify police or health authorities of homicidal ideation despite explicit documented threats over 22 months
• Psychologist did not conduct domestic violence screening or risk assessment despite intimate partner violence context
• Psychologist made irrelevant considerations about likely response of authorities when assessing risk
• Lack of formal clinical handover to local services in Ayr at termination of therapeutic relationship
• Inadequate documentation of threat assessment in clinical notes
• Absence of supervision or peer consultation regarding high-risk client
• VVCS did not conduct independent risk assessment when notified of homicidal ideation
• Domestic violence protection order application struck out without notification to applicant
• Service of domestic violence application delayed 3 weeks; temporary order made without proof of service
• Applicant not informed of subsequent adjournments or striking out of application
• Police prosecutor failed to take instructions or adequately protect applicant's interests
• Acting Magistrate made incorrect assertion that adjournment notices were not standard practice
• Victim believed protection order remained in place when it had been struck out
• 14 identified intimate partner homicide lethality risk factors in relationship
• Perpetrator's relocation to same town as victim increased proximity and access

Coroner's recommendations

1. All third-party suppliers of ADF/veteran counselling services should be credentialed for domestic violence counselling (not merely anger management), with competency in recognizing intimate partner violence dynamics and perpetrator assessment
2. Mental health practitioners require training in comprehensive threat assessment of homicidal ideation, including context, motivation, planning, access to means, victim location awareness, exposure to stressors, history of violence, compliance with risk reduction strategies, and protective factors
3. Psychologists should seek supervision and peer consultation when managing clients expressing threats of serious harm to identified persons, as per APS Ethical Guidelines
4. When terminating therapeutic relationships with clients assessed as moderate or higher risk, formal clinical handover and referral to accessible local services should be documented and implemented prior to disengagement
5. Mental health practitioners should not presuppose the likely response or effectiveness of agency interventions when making duty-to-warn/notify decisions; this is a matter for the receiving agency
6. Information-sharing protocols between mental health services, police, and domestic violence support services should be established to enable comprehensive risk assessment
7. Domestic violence screening should be routinely embedded in mental health assessments, particularly for perpetrators of violence with access to victims
8. Family law courts should enhance screening for domestic violence risk and operate with updated practices to identify high-risk situations
9. Magistrates Courts must ensure applicants in domestic violence proceedings receive notice of adjournments and outcomes; adjournment notices should be generated, sent and recorded as standard practice
10. Police prosecutors should maintain active duty to the applicant in private domestic violence applications, including standing matters down to take instructions from applicants
11. Clinical note-keeping standards should reflect detailed threat assessment documentation including verbatim statements, context, risk factors assessed, and decision-making rationale
12. The APS Code of Ethics amendments removing the requirement for risk to be 'immediate' or 'specified' (enacted 2017) represent positive reform and earlier adoption is encouraged
13. Post-discharge monitoring protocols should be established for high-risk clients disengaging from mental health treatment