Finding into death of Luke Geoffrey Batty

Contributing factors

• Paternal filicide by Gregory Anderson
• Failure of integrated family violence system to share information across agencies
• Inadequate follow-up investigation of knife threat disclosure
• Delays in warrant execution and criminal prosecution
• Unexecuted warrants not entered into police database
• Failure to mandate psychiatric assessment of perpetrator
• Ineffective risk assessments conducted in isolation by different agencies
• Ambiguities in family violence intervention order conditions
• Lack of engagement with perpetrator by child protection services
• Reliance on protective mother's capacity without systemic support

Coroner's recommendations

1. State of Victoria undertake empirical validation of the Common Risk Assessment Framework (CRAF) and risk assessment tools
2. All agencies in integrated family violence system use CRAF with risk assessments in writing, shared and accessible to all relevant agencies
3. State of Victoria and Office of Victorian Privacy Commissioner ensure clear rules for lawful information sharing between agencies
4. Remove legislative and policy impediments to information sharing in family violence system
5. All agencies clearly identified with roles and responsibilities in legislation/public policies
6. Expand Family Violence Court Division across State with Court Integrated Services Program
7. Ensure all family violence system staff receive CRAF-based training and professional development
8. Implement Risk Assessment and Management Panels (RAMPs) in all police regions
9. Compulsory referral process for cases assessed as 'high risk' for family violence
10. Consider creation of Family Violence Advocate service modelled on UK Domestic Advocate position
11. Attorney General review Bail Act 1977 to re-enact section 4(2)(c) requiring show cause for failure to answer bail in family violence matters
12. Close loophole where warrant cancels bail conditions until warrant executed
13. Family Law Council consider amendments to section 68R of Family Law Act to make suspensions operate until further court order
14. Chief Commissioner of Police require police to provide all L17s to relevant agencies, review previous L17s, check LEAP before completing L17
15. Police develop 'high risk' family violence perpetrator criteria with warning flags in LEAP
16. Police prosecutors have all previous L17s available and informant input before remand/bail applications
17. Prioritize service of FVIOs and execution of warrants within 24 hours
18. Set benchmark periods for commencement of prosecutions and authorization of charges
19. Ensure affected family members kept informed of FVIO proceedings, warrants, bail and criminal proceedings
20. Same police prosecutor assigned to both criminal and family violence matters for same parties
21. DHHS obtain CRAF from specialist family violence services during intake
22. DHHS include full text of all CRAF assessments in CRIS notes
23. DHHS obtain all L17s from Victoria Police before undertaking CRAF assessment
24. DHHS provide high-risk CRAF assessments to Victoria Police for FVIO applications
25. DHHS discontinue practice of requiring women to enter undertakings supervising perpetrator behavior
26. DHHS convene professional case conference before closing family violence files
27. DHHS provide support to protective parent when other parent assessed as non-protective
28. DHHS provide greater guidance on circumstances requiring reports to Child Protection
29. DHHS staff comply with specialist practice resource 'Working with families where an adult is violent'
30. Magistrates' Court simplify Application for Intervention Order form with CRAF checklist
31. Implement training for Registrars on CRAF and risk assessment
32. Family Violence Intervention Order staff receive specialist training
33. Applicant Support Workers complete CRAF with affected family member and supply to Victoria Police
34. Magistrates' Court revise FVIO forms to be clear and unambiguous including section 68R operation