Inquest into the deaths of F and M

Contributing factors

• Failure to assess and identify risk to receiving parent (F) after custody transfer
• Gender-biased risk assessment by multiple agencies misidentifying perpetrator-victim dynamics
• Inadequate safety planning at point of custody handover
• Failure to provide explicit risk assessment and safety planning for receiving parent and children
• Mental health assessment identified lethal violence risk to children but not to ex-partner
• Narrow focus on managing risk during report release rather than after custody transition
• Lack of coordination between legal practitioners regarding risk to F after children placed in his care
• Unrecognised systems abuse (pattern of false allegations) by M against F
• M's unsubstantiated allegations not linked to domestic violence perpetration by M
• No discussion between legal counsel and F regarding safety precautions after custody order
• Court-ordered custody transition as acute trigger event for individual with borderline personality disorder and persecutory beliefs

Coroner's recommendations

1. Commonwealth Attorney-General to consider amendments to Family Law Act confidentiality provisions (ss 10Q-10W) to facilitate provision of information regarding participation in family safety risk screening or risk assessment/safety planning for purpose of examination of domestic and family violence related deaths or to domestic and family violence death review bodies.
2. Legal practitioners in parenting proceedings where radical change of residence is expected based on risk should maintain expansive consideration of risk of harm to receiving parent, particularly lethal violence, where: relinquishing parent has personality vulnerabilities predisposing acute crisis reactions; unsubstantiated persecutory beliefs about receiving parent; or receiving parent has alleged domestic violence or expressed fear of relinquishing parent.
3. Independent Children's Lawyers should seek specialist family violence assessment input (in addition to mental health assessment) to better understand and assess risk of harm to others in children's support network.
4. Family law practitioners should develop frank discussions with receiving parent about identified risks of harm to them with children in their care, escalate safety concerns, and develop comprehensive safety plans for handover and beyond.
5. Exploration by Chief Justice of extending Court Children's Service psychological and social work resources to support relinquishing parent when suppressed adverse mental health report is released in Court with likely outcome of immediate child custody transition.
6. Independent Children's Lawyers should proactively engage with co-located Child Safety officers from outset of ICL appointment in parenting proceedings where concurrent Child Safety involvement exists, to identify when specialist family violence input may be needed.
7. FCFCOA and Department of Families, Seniors, Disability Services and Child Safety to continue collaborative examination of opportunities to enhance information sharing protocol and program resourcing for earlier and faster exchange of information about active Child Safety involvement with families whose children are subject of parenting proceedings, including: operational requirement for Child Safety Officers to notify co-located team when assessment underway for children subject to family law proceedings; Child Safety to receive copies of FCFCOA orders as made; routine linking of Child Safety Officers in assessments with appointed ICLs; faster information exchange mechanisms without requiring court events.
8. Queensland Law Society to continue providing continuing professional development in domestic and family violence and coercive impact of family law proceedings on clients, with consideration of support services for solicitors managing clients with complex mental health vulnerabilities.
9. Development of training for FCFCOA judicial officers and staff on risk factors associated with domestic and family violence homicide, infanticide and filicide, and intersection of family violence with mental health issues and substance misuse.