Finding into death of Lynette Ann Kent

Contributing factors

• Perpetrator's documented history of family violence, assault, stalking and breach of intervention orders
• Escalating controlling and possessive behaviour by perpetrator
• Explicit threats to kill victim and her new partner made days before death
• Victim's reluctance to engage with police despite encouragement from neighbours
• Victim's failure to obtain restraining order despite considering it
• Perpetrator's apparent depression and deteriorating mental state not assessed or managed
• Lack of disclosure of domestic violence concerns to treating general practitioners
• Victim's non-engagement with domestic violence crisis services
• Relationship breakdown precipitated by victim's new relationship, increasing perpetrator's volatility

Coroner's recommendations

1. Enhanced training for general practitioners in identification and documentation of family violence indicators
2. Implementation of systematic enquiry about domestic violence in primary care consultations, particularly for patients in intimate relationships
3. Improved communication pathways between primary care, mental health services, and family violence agencies
4. Development of risk assessment and safety planning protocols for patients presenting with depression or suicidal ideation in the context of relationship breakdown
5. Greater awareness among health practitioners of the dangerousness of controlling behaviours, surveillance of partners, and threats in intimate relationships
6. Promotion of family violence crisis services and support to encourage victim engagement
7. Review of GP awareness of perpetrator risk factors including prior history of violence, stalking, and intervention order breaches