Finding into death of Fiona Warzywoda

Contributing factors

• Failure by Victoria Police to properly investigate and record death threats
• Failure by Victoria Police to treat withholding of children as family violence breach
• Failure by Child Protection to conduct risk assessment or safety planning following death threat
• Failure by Child Protection to contact victim or police regarding death threat
• Failure by court security to report threat of violence to police
• Failure by Victoria Legal Aid to provide exception to caveat requirement for family violence victim
• Caveat requirement exacerbating perpetrator's financial stress and escalating risk
• Escalating family violence in months prior to death including previous strangulation, petrol threat
• Perpetrator stalking victim, accessing weapons, making death threats
• Missed opportunity by No To Violence to follow up with perpetrator after police contact

Coroner's recommendations

1. No To Violence/Men's Referral Service and Victoria Police should implement a system to monitor L17 referrals for perpetrators where police have not yet made contact, ensuring follow-up and engagement once police contact is made
2. Victoria Police should develop a system for recording telephone calls reporting family violence incidents on LEAP, with visibility to members checking parties, and update the Victorian Police Code of Practice for the Investigation of Family Violence accordingly
3. Victoria Police should update the Code of Practice for the Investigation of Family Violence to reflect that withholding of children is an act of control and abusive behaviour, with appropriate training to ensure consistent investigation of such incidents
4. Federal Court of Australia should develop clear guidelines and policies for security guards regarding recording and reporting threats of violence to appropriate authorities including Victoria Police and Family Advocacy and Support Service