Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

Contributing factors

• Intimate partner violence with escalating coercive controlling behaviour and emotional abuse
• Mr Lock's untreated mental illness with delusional preoccupation about reconciliation
• Dual diagnosis: depression, anxiety, personality disorder traits (Category B: narcissism and anti-social behaviour), and problematic cannabis and alcohol use not adequately addressed
• Inadequate domestic violence risk assessment and screening by primary care providers
• Failure of health services to refer Ms Lock to specialist domestic violence support despite clear disclosures
• Mental health discharge planning that released Mr Lock into Ms Lock's care immediately after suicide attempt despite ongoing domestic violence context
• Lack of information sharing between treating clinicians (GP, psychiatrist, psychologist, hospital mental health services)
• Failure of psychologist to seek clarification of psychiatric diagnosis from psychiatrist despite learning of Category B personality traits diagnosis
• Ms Lock forced to remain in shared residence with Mr Lock post-separation due to financial and housing constraints
• Absence of formal collateral information seeking from Ms Lock despite her known fear of Mr Lock
• Absence of integrated service response linking victim to specialist domestic violence services despite recent relocation
• Siloed service delivery with no evidence of coordination or joint safety planning

Coroner's recommendations

1. The 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 concurrent treatment of intimate partner violence victims and perpetrators.
2. Health services should implement routine screening for domestic and family violence as a standard practice across all service encounters, particularly mental health and primary care settings.
3. Health services should avoid treating intimate partner violence victims and perpetrators concurrently without clear protocols, risk assessment and coordination to protect victim safety.
4. Mental health services should ensure comprehensive information sharing between treating clinicians including GPs, psychiatrists, psychologists and hospital-based services to ensure coordinated care.
5. Mental health services should mandate collateral information seeking from family members when treating individuals with risk factors for intimate partner violence perpetration.
6. Psychologists and mental health practitioners should implement formal and validated risk assessment tools for violence risk and should escalate concerns when clients display risk factors for intimate partner violence perpetration.
7. Primary care providers should refer patients to specialist domestic violence support services when intimate partner violence is disclosed or suspected, rather than providing ongoing care without specialist input.
8. Mental health discharge planning should assess victim safety and avoid discharging perpetrators into the care of known victims without documented safety planning and risk mitigation.
9. Services should adopt integrated service response models that coordinate health, mental health, criminal justice and specialist domestic violence services to provide cohesive responses to families experiencing intimate partner violence.
10. Clinicians should receive enhanced training in violence risk assessment including awareness of homicide-suicide risk, particularly in the context of separation and psychiatric illness.
11. Health services should develop and implement evidence-based safety planning approaches for victims of intimate partner violence, including consideration of housing, economic security and protective factors.
12. Government should prioritise the development and implementation of accessible crisis and alternative accommodation options for victims of intimate partner violence who are unable to safely remain in shared residences.
13. The Common Risk and Safety Framework should be refined to improve usability, incorporate protective factors, address risks and needs of priority populations including Aboriginal and Torres Strait Islander victims, and extend beyond intimate partner violence to address family violence.
14. Services should strengthen focus on perpetrator accountability and behaviour change within integrated service responses to domestic and family violence.