Coroner's Finding: ROBINSON Shane Andrew

Contributing factors

• Failure by Community Corrections to notify Parole Board of domestic violence allegations and supervision breaches
• Inadequate handling of domestic violence report by SAPOL call centre without identifying perpetrator or conducting proper risk assessment
• Failure to use PIMS to check perpetrator's identity and dangerous history
• Inadequate action by ANCOR officers on intelligence about Robinson not being at registered address despite high-risk status
• Failure to make mandatory child protection notification despite evidence of four teenage girls in home with registered child sex offender
• Lack of continuity and dedicated case management for high-risk ANCOR offender
• Administrative officer making inappropriate direct contact with domestic violence victim rather than police patrol
• Perfunctory and inadequate handling of domestic violence disclosure
• Limited resources for urinalysis testing during high-risk periods
• Poor supervision cover when Community Corrections case manager on leave

Coroner's recommendations

1. Commissioner of Police allocate proper resources to ensure that high risk ANCOR offenders have dedicated case managers and, as far as practicable, the same case manager monitor high risk offenders throughout their time under ANCOR
2. Commissioner of Police formally advise ANCOR staff and officers of their obligations to the protection of children, including requirement to make mandatory notifications of suspected risk and share information with other agencies
3. Commissioner of Police ensure all SAPOL call centre staff and officers have specific and regular skills training and procedural updates for responses to domestic violence disclosures
4. Call centre administrative officers (not police members) should not make cold calls to domestic violence victims; such contacts should only be made by appropriately trained police officers
5. Minister for Correctional Services implement random saliva testing system based on SAPOL's roadside drug testing model as supplement to urinalysis testing for high-risk parolees
6. Minister for Correctional Services ensure Community Corrections staff are specifically trained in procedures for domestic violence disclosures including standard risk assessment and relevant referrals to Family Safety Framework meetings