Coronial
VIChome

Finding into death of Fiona Kellie Burke

Deceased

Fiona Kellie Burke

Demographics

32y, female

Date of death

2017-03-17

Finding date

2019-01-08

Cause of death

hanging

AI-generated summary

Fiona Burke, aged 32, died by hanging on 17 March 2017 following a prolonged history of family violence in her relationship with Darren Mather. The death occurred in a context of escalating intimate partner violence, alcohol misuse, mental health concerns, and prior suicidal ideation. Critical failings in service coordination were identified: DHHS (child protection) closed its investigation in February 2016 without confirming the perpetrator had left the home, despite multiple documented family violence risk factors and prior mental health assessments indicating increased suicide risk. Mental health assessment findings were not properly followed up. WAYSS (housing/family violence service) failed to conduct proper risk assessment when Ms Burke presented for housing support despite prior family violence contact and recent police referrals. These missed opportunities for sustained intervention and safety planning contributed to a preventable death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

paediatricspsychiatryforensic medicine

Error types

communicationsystemdelay

Drugs involved

alcohol

Clinical conditions

suicidal ideationdeliberate self-harmalcohol use disorderdepression/mental health disorderintimate partner violence

Contributing factors

  • family violence (intimate partner violence)
  • alcohol misuse/abuse
  • mental health issues
  • prior suicidal ideation
  • financial difficulties
  • social isolation
  • controlling and abusive behaviour by partner
  • failure to follow up mental health assessment indicating increased suicide risk
  • inadequate family violence risk assessment by DHHS
  • premature closure of DHHS investigation without confirming perpetrator departure
  • failure by WAYSS to conduct proper risk assessment at second presentation
  • inadequate information sharing between services

Coroner's recommendations

  1. Endorse Royal Commission Recommendation 2: amend Family Violence Protection Act 2008 (Vic) to require prescribed agencies to align risk assessment policies, procedures and practices with the MARAM (Multi-Agency Risk Assessment and Management Framework)
  2. Endorse Royal Commission Recommendation 3: implement sustained workforce development and training strategy including whole-of-workforce training for Child Protection on minimum standards for identifying, assessing and managing family violence risk
  3. Endorse Royal Commission Recommendation 26: strengthen Child Protection practice guidelines where family violence is reported but statutory threshold for intervention is not met, ensuring comprehensive safety planning and formal referrals to specialist family violence services
  4. Endorse Royal Commission Recommendation 27: improve DHHS risk management guidelines to ensure practitioners obtain relevant information from all VP Form L17s and risk assessments, record appropriately in CRIS, and provide own risk assessments to Victoria Police
  5. Endorse Royal Commission Recommendation 29: institute training and professional development regarding family violence and Child Protection practice guidelines for all Child Protection practitioners
Full text
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Source and disclaimer

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