Finding into death of Abuk Derder Akek
Deceased
Abuk Derder Akek
Demographics
19y, female
Date of death
2016-03-13
Finding date
2018-11-07
Cause of death
Stab wounds to the abdomen
AI-generated summary
Ms Abuk Derder Akek, a 19-year-old South Sudanese refugee, was fatally stabbed by her former de facto partner Makeny Banek during a violent assault at her home in Melton, Victoria on 13 March 2016. The finding identifies that Banek had a documented history of escalating domestic violence, controlling behaviour, and threats to kill. Key clinical and systemic lessons include: mental health services failed to adequately assess and manage the risk of intimate partner violence despite Banek's presentations with suicidal ideation and family violence history; mental health practitioners did not prioritise partner and child safety as required by contemporary guidelines; risk assessments were documented as 'low risk to others' without adequate reasoning or family violence-specific analysis; and specialist family violence training was absent from mental health and drug/alcohol services. The coroner emphasises the need for comprehensive family violence risk assessment frameworks, mandatory family violence education for mental health and substance use workers, appointment of specialist family violence advisors in major services, and culturally appropriate perpetrator behaviour change programs for diverse communities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- History of escalating intimate partner violence and controlling behaviour by perpetrator
- Perpetrator threats to kill victim and child
- Cultural beliefs about patriarchal gender roles and male authority
- Perpetrator unemployment and financial stress
- Perpetrator disempowerment related to migration and changed social status
- Victim separation from perpetrator
- Inadequate mental health risk assessment regarding family violence
- Failure of mental health services to prioritise victim and child safety
- Absence of family violence-specific risk management plans
- Limited culturally appropriate support services for victim
- Perpetrator's prior suicidal ideation and mental health engagement
Coroner's recommendations
- Support Royal Commission recommendations that organisations adopt minimum standards and core competencies in identifying, risk assessment and risk management of family violence in all mainstream and specialist services
- Provide mandatory training to medical, mental health, drug and alcohol workers in identification and management of family violence affecting clients
- Establish specialist family violence advisors within major mental health and drug and alcohol services
- Develop and implement guidelines on family violence risks associated with discharging or transferring care of persons receiving mental health services
- Ensure mental health and drug and alcohol services are represented on risk assessment and management panels for family violence cases
- Conduct research, trials and evaluation to help perpetrators of family violence understand the effects of violence on children and to develop better fathering skills
- Adopt coordinated practice models across men's behaviour change, mental health, and drug and alcohol services to deliver culturally appropriate perpetrator intervention programs
- Support development of community-based prevention initiatives addressing gender equality and respectful relationships within culturally and linguistically diverse communities including the Sudanese community
- Expand culturally appropriate family violence support services and specialist behaviour change programs in perpetrators' own languages
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