Non-inquest findings into the domestic violence related death of a First Nations woman
Demographics
31y, female
Date of death
2019-12-08
Finding date
2024-07-22
Cause of death
Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem decomposition
AI-generated summary
A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domestic violence services over 12 months, critical information was not shared between agencies. Court Link identified her as high-risk and attempted referral to a High Risk Team but the referral was never completed before her case closed. A domestic violence service assessed her as high-risk but closed her file without safety planning when she disengaged. The partner had a documented history of violence toward previous partners and was released from supervision orders despite identified risk of intimate partner violence. Key lessons: information sharing between services is essential; pregnant women in abusive relationships require escalated risk management; systems must accommodate reluctance to engage common among First Nations women; and supervision of high-risk offenders requires ongoing review.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Intimate partner violence with coercive control
- Perpetrator's documented history of violence toward previous partners
- Perpetrator released from sexual offender supervision despite identified risk of intimate partner violence
- Pregnancy as additional risk factor
- Victim's reluctance to involve police due to cultural shame and not wanting perpetrator imprisoned
- Victim's mistrust of government agencies
- Failure to share high-risk assessment information between services
- High Risk Team referral not completed before case closure from Court Link
- Domestic violence service closed victim's file without safety planning after disengagement
- Victim unable to escape due to coercive control and financial dependence
- Victim present with perpetrator during multiple service contacts, limiting her ability to disclose
Coroner's recommendations
- Improve information sharing between domestic violence services, court services, and other agencies involved with victim-survivors, particularly when high-risk assessments are completed
- Ensure High Risk Team referral processes are completed and tracked when high-risk assessments are identified, even if victim does not consent
- Develop protocols for services to maintain contact and safety planning with high-risk victims who disengage, rather than closing files without follow-up
- Enhance training for all service providers on recognising coercive control and its impact on victim engagement and risk
- Implement culturally appropriate approaches to domestic violence response that acknowledge First Nations women's reluctance to involve police and distrust of government services
- Ensure pregnant women presenting with domestic violence are identified as high-risk and referred for integrated multi-agency safety planning
- Improve communication between specialist courts (such as Murri Court) and support services regarding domestic violence risk information
- Review protocols for supervision and management of offenders with documented history of intimate partner violence following expiry of supervision orders
Full text
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