Jack - Non-inquest findings

Contributing factors

• Failure of police, corrections, and health services to share information and work collaboratively
• Services responding to individual incidents in isolation without recognising escalating pattern of violence
• Jack's significant documented history of domestic violence perpetration not adequately considered when he entered new relationship
• Lack of enforcement of community supervision order conditions
• Failure to refer Jack to men's behaviour change programs due to transience and regional location
• Inadequate risk assessment by psychologist despite referral noting domestic violence history
• Police inattention to domestic violence disclosure during 26 March 2018 incident
• No domestic violence screening by health or mental health services for either Jack or Sally
• Custodial corrections staff not verifying protection order information provided by Jack
• Community Corrections staff accepting Jack's self-reported adherence to protection order without verification
• Lack of collateral checks between police and corrections
• Insufficient police case management response following 26 March 2018 flagging as repeat calls for service
• Staffing constraints in local police district
• Jack's escalating post-separation violence and breaches of protection order not adequately managed

Coroner's recommendations

1. Review all domestic and family violence training delivered to frontline services with focus on embedding trauma-awareness and trauma-informed service delivery
2. Explore trauma-informed options to improve accessibility, availability and acceptability of longer-term supports for victims and children beyond crisis point
3. Design, establish and adequately resource a state-wide network of perpetrator intervention programs in Queensland
4. Conduct independent review of defences and excuses in relation to homicide, including operation of section 304B Criminal Code
5. Improve legal practitioners' understanding of domestic violence, coercive control, self-defence and section 304B
6. Ensure agencies share information appropriately for cases that may not meet High-Risk Team threshold or are outside HRT locations
7. Better maintain visibility of high-risk and recidivist perpetrators when they enter new relationships or move to different service areas
8. Develop clear guidance for police and courts regarding identification of primary perpetrator and victim in cases involving resistive violence
9. Consider legislative amendments to strengthen existing provisions regarding misidentification of victims
10. Develop triage and case management approach for domestic and family violence related cases in courts to identify complex, high-risk or cross-application matters
11. Provide clear guidelines in Queensland Police Service Operational Procedures Manual regarding management of repeated domestic violence calls for service
12. Improve policing responses to domestic and family violence through evidence-based and trauma-informed training
13. Strengthen Queensland Police Service risk assessment processes for domestic and family violence
14. Ensure custodial corrections staff verify protection order information independently
15. Implement collateral checks between police and Community Corrections to verify offender compliance with protection orders and conditions
16. Enforce compliance with community supervision order conditions regarding men's behaviour change program participation and psychological treatment attendance