Finding into death of Mr BT

Contributing factors

• History of depression and suicidality from age 17
• Substance abuse (methamphetamine use)
• Recent relationship breakdown with Ms SF
• Family violence incidents and family violence intervention order
• Inadequate completion of Victoria Police L17 risk assessment form not accurately reflecting suicide risk
• Police did not explicitly enquire about mental health status during final property exchange on 21 August 2018
• Child Protection did not establish concrete safety plans for children in his care
• Child Protection did not verify he was receiving mental health treatment before closure
• Insufficient coordination between police, child protection and mental health services
• Delayed psychiatric appointment (5 weeks waiting time)

Coroner's recommendations

1. Endorse Victoria Police's 2016 Mental Health Review and mandatory online training to increase mental health literacy
2. Support Victoria Police rollout of 'Responding to Mental Health Incidents' mandatory training for all frontline police
3. Endorse updated Victoria Police Practice Guide - Family Violence with strategies to identify perpetrators with mental health issues including referral to CAT Team
4. Continue implementation of Family Violence Liaison Officer quality assurance of L17 forms and Family Violence Training Officer coaching on L17 compliance
5. Ensure all 39 required questions in VP Form L17 are completed and accurately scored to identify risk levels
6. Strengthen coordination between Victoria Police, Child Protection and mental health services regarding risk assessment
7. Child Protection should verify that individuals with identified mental health risks are receiving treatment before file closure