Finding into death of Sarah Louise Cafferkey

Contributing factors

• offender released on parole despite unresolved violent attitudes
• failure to communicate offending behaviour program risk assessment to parole board
• inadequate risk assessment tools at time of parole decision
• minimal drug testing despite extensive history of drug use and trafficking
• poor information sharing between clinicians and case managers
• over-reliance on self-reporting by parolee
• case worker and clinician focus on parole success rather than community safety
• inadequate supervision of serious violent offender on parole
• lack of clear protocols for reporting concerns to adult parole board
• ice (methamphetamine) use by offender at time of death
• absence of post-sentence supervision for serious violent offenders

Coroner's recommendations

1. Establish a statutory scheme for serious violent offenders analogous to the Serious Sex Offenders (Detention and Supervision) Act 2009, enabling post-sentence detention or supervision for those who continue to pose unacceptable risk of serious interpersonal harm
2. Develop clear guidelines and protocols for clinicians and case managers regarding mandatory reporting of risk factors and concerns to the Adult Parole Board
3. Implement structured working arrangements between offending behaviour program clinicians and case managers to enable joint intervention planning and information sharing
4. Strengthen information sharing protocols to ensure Offending Behaviour Program assessment reports and progress reports are routinely available to the Adult Parole Board
5. Establish drug testing as a standard condition for parolees with significant history of drug use and trafficking
6. Improve risk assessment tools used in pre-release assessment (note: VISAT has been replaced with LS/RNR)
7. Reduce case loads for Community Corrections Officers managing serious violent offenders to enable more rigorous individual assessment
8. Provide regular Case Management Review Meetings for all serious violent offenders on parole, chaired by senior management
9. Establish clearer criteria and triggers for escalation of concerns to the Adult Parole Board, moving beyond requirement to identify imminent specific threats
10. Implement training for case managers and clinicians on identifying and challenging pro-violence attitudes and risk factors that may be 'normal' within offender cohorts but unacceptable in community context
11. Monitor wait times for offending behaviour programs and prioritize access based on offender risk and therapeutic timing