Finding into death of Kelly Ann Thompson

Contributing factors

• failure by attending police to properly investigate or record alleged strangulation on 1 January 2014
• critical omission of strangulation allegation from L17 risk assessment form
• inadequate follow-up by Wyndham Family Violence Team due to flawed initial L17
• breaches of intervention order not acted upon promptly or with appropriate consequences
• multiple police-facilitated property collections that enabled continued contact and control
• failure of junior police officer to respond appropriately to concerned neighbour's call on 9 February 2014
• lack of cross-agency information sharing
• 5-day delay in serving interim intervention order
• victim not adequately informed of escalating risk despite multiple service interactions
• perpetrator's escalating stalking, controlling behaviour and explicit threats not appropriately managed

Coroner's recommendations

1. The Victorian Government, in implementing recommendations of the Royal Commission across the family violence sector, should adopt the practice that front line workers provide each risk assessment to the applicant, applicants legal representatives, local community family violence services, the magistrate during an IVO hearing, and to Victoria Police
2. Victoria Police should implement changes to require police officers attending property collections where an IVO is in place to: review available information before attending including past L17 assessments and LEAP notes; actively utilise the property exchange as an opportunity for risk assessment and risk management; give consideration to whether completion of a Form L17 is required; and record attendance and observations on LEAP
3. Victoria Police and the Magistrates' Court of Victoria should develop an information exchange system enabling details of intervention order applications made by self-represented or privately represented parties to be uploaded to LEAP in the same way as police-initiated applications
4. Victoria Police should examine the feasibility of developing a system for recording telephone calls to police stations by parties to family violence incidents, creating a record visible to members who subsequently check parties on LEAP
5. AFMs should be informed by police if the perpetrator is not charged with breach of the IVO within seven days
6. AFMs should be educated and advised by Victoria Police and other family violence agencies to call 000 to report breaches of an IVO