Coroner's Finding: ABRAHIMZADEH Zahra

Contributing factors

• failure to arrest or charge the offender within 13 months of initial domestic violence report
• failure of patrol officers to conduct thorough searches using available contact information
• inadequate supervision of investigating officers by senior constables and detective sergeant
• failure to conduct mandatory 28-day case reviews
• lack of communication between investigating officers in different sections
• misinterpretation of domestic violence call centre report as administrative 'flagging' rather than safety concern
• failure to raise offensive police incident reports for threats to kill
• investigative officers prioritising victim contact over offender apprehension
• inadequate preparation of domestic violence restraining order prosecution
• late notification to victim of trial date
• acceptance of consent variation permitting offender to attend cultural religious events where victim also present
• lack of coordination between criminal investigation and prosecution functions
• use of unsworn administrative officers to manage domestic violence calls
• insufficient training of junior officers in domestic violence risk assessment
• excessive workload and resource constraints in Family Violence Investigation Sections and Criminal Justice Section
• poor case management systems with artificial separation of victim support and offender investigation
• failure to apprehend offender when he attended court for restraining order hearings

Coroner's recommendations

1. All aspects of domestic violence policing be characterised by a sense of curiosity, questioning and listening; risk assessment must be actually applied, not merely recited as a mantra
2. SAPOL Criminal Justice Section be staffed by legal practitioners so that domestic violence restraining orders can be properly presented before magistrates
3. All domestic violence calls to the SAPOL call centre are handled by sworn police officers with particular training in domestic violence risk assessment
4. Domestic violence training that cadets receive at the Police Academy from external domestic violence agencies occupy at least one day, rather than the half day it has been reduced to
5. All domestic violence safe houses be flagged with police communications in order to ensure consistency of approach when a response to an incident or report is made
6. Prosecutors appearing in domestic violence matters must, as a matter of course, seek out all available information about the longitudinal history of domestic violence offending, particularly from Family Court documents if those exist
7. Prosecutors appearing in domestic violence matters must, as a matter of course, establish the outcome of the offence PIRs underlying the application
8. Police officers do not ask domestic violence complainants whether they still wish to proceed unless there is some communication from the complainant that justifies such an enquiry
9. When a domestic violence victim makes a report at a police station, they are afforded an opportunity of privacy in an interview room
10. Priority A taskings should remain higher in priority than later, lower priority taskings and patrols should be enabled to return to incomplete Priority A taskings