Finding into death of MF

Contributing factors

• pending separation/relationship breakdown
• history of family violence and threats by perpetrator
• perpetrator's mental health issues including paranoia
• controlling and possessive behaviour
• previous threats to kill documented by police
• victim's suicidal ideation
• inadequate police response despite disclosed threats
• lack of mandatory risk assessment completion by police
• general practitioner did not refer to family violence specialist services
• victim's social isolation and fear of leaving relationship

Coroner's recommendations

1. Victoria Police should continually consider approaches and ways for effectively responding to family violence, including evaluation of the Enhanced Family Violence Service Delivery 2011-2014 model designed for recidivist perpetrators and high-risk victims
2. General practitioners should be equipped to identify symptoms of family violence, assess risk, provide advice about referrals to specialist family violence services, and understand when legal intervention is required
3. Health services should serve as important pathways for referral to specialist family violence support services
4. Clinical guidelines for family violence management in general practice should be implemented and strengthened across the health care sector