Finding into death of Sharnee Ngatai

Contributing factors

• Domestic violence perpetrated by intimate partner
• Alcohol intoxication of both victim and perpetrator
• Inadequate parole supervision of perpetrator
• Victim's concealment of ongoing relationship with abuser from child protection services
• Victim's fear of losing custody of children
• Early post-natal period with youngest child less than 6 months old
• Perpetrator's non-compliance with parole conditions including drug use
• Lack of integrated family violence response mechanisms

Coroner's recommendations

1. Support the recommendations of the Royal Commission into Family Violence, particularly recommendations 10 and 37 regarding accessible information resources for those experiencing, witnessing or affected by family violence via 'The Lookout' website
2. Support the introduction and rollout of Support and Safety Hubs across Victoria to provide integrated family violence response, risk assessment, safety planning, and coordination of services
3. Improve parole system resourcing and supervision to ensure more active monitoring of parolees and prompt notification of breaches to the Adult Parole Board
4. Enhance mechanisms for third-party reporting of family violence concerns and provide education to family members and friends about recognizing and responding to family violence