Coroner's Finding: Shepherdson, Kobi Anastasia Isobel and Shepherdson, Henry David (updated)
Deceased
Kobi Anastasia Isobel Shepherdson and Henry David Shepherdson
Demographics
0y, female
Date of death
2021-04-21
Finding date
2026-06-24
Cause of death
Kobi: head injuries; Henry: multiple injuries
AI-generated summary
A nine-month-old infant and her 38-year-old father died in a homicide-suicide at the Whispering Wall dam in South Australia. The father deliberately jumped 36 metres while carrying his daughter in an infant harness. The coroner found this death was preventable due to cascading systemic failures in the domestic violence response. Critical failures included: (1) police misclassified the infant and mother as medium-risk rather than high-risk on three separate occasions; (2) 149 illegal phone calls from prison went undetected, allowing the father to coerce the mother to withdraw charges; (3) prison authorities failed to report intercepted letters; (4) the multi-agency protection service (MAPS) was never engaged despite clear high-risk indicators; (5) an intervention order was varied on the day of death without knowledge of the father's coercive abuse. The coroner made nine recommendations addressing risk assessment procedures, prisoner communications monitoring, information sharing, and ensuring courts have access to risk classifications and violence history when considering intervention order variations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Systematic misclassification of victims as medium-risk instead of high-risk on three separate domestic abuse risk assessments
- Failure to activate multi-agency protection service (MAPS) for high-risk victims
- 149 undetected illegal phone calls from prison allowing father to coerce mother to withdraw criminal charges
- Father's sustained coercive control, manipulation, and verbal abuse of mother
- Failure by prison operator (SERCO) to report intercepted letters in breach of intervention order
- Variation of intervention order on day of death without knowledge of breach history or coercive behaviour
- Father's substance abuse: tramadol addiction and cannabis use
- Depression and personality disturbance in offender
- Lack of information sharing between police prosecution and risk assessment sections
- Inadequate resources in police family violence section
Coroner's recommendations
- Premier to consider adoption of Royal Commission recommendations 1, 5, 19, 21, 22, 37-42, 48, 50, 61, 67, 68, 70, 77, and 119; extend recommendation 119 to applications to vary intervention orders
- Review use of prisoner telephone system to prevent protected persons and domestic violence victims from being contacted illegally by remand prisoners
- Amend interim intervention orders under the Intervention Orders (Prevention of Abuse) Act 2009 to allow courts to easily identify defendants' previous convictions for breaching intervention orders
- Make DAR Assessment risk category and defendant's prior convictions for violence easily identifiable to courts considering intervention order applications
- Review section 31(3) of the Intervention Orders (Prevention of Abuse) Act 2009 regarding protection of coerced protected persons who have dependent children on the same order
- Review suitability of format and criteria of the Domestic Abuse Risk Assessment tool, including option for victims to confirm factors have been correctly selected
- Add further checks to Domestic Abuse Risk Assessment to ensure suspect or offender's criminal history is properly reviewed
- SAPOL liaise with Department for Correctional Services to review processes and practices for domestic violence remand prisoners regarding phone access and ability to contact alleged or proven victims
- Improve safety at the Whispering Wall dam site to prevent persons jumping from the top of the wall
Full text
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