Finding into death of Abigail Louise Cooke-Mitchell

Contributing factors

• Delayed emergency ambulance activation (called at 9.36pm instead of immediately when serious head injury symptoms reported at 5.14pm)
• Failure of home doctor service telephone triage to appropriately escalate symptoms of significant head injury as emergency
• Lack of clarity given to caller about estimated arrival time during initial call
• Significant delay between receipt of initial call (5.14pm) and doctor assignment (approximately 8pm)
• Doctor's workload and travel distance compounded delays
• Circumstances and timing of fatal head trauma remain unknown; evidence of unwitnessed falls
• Family violence context contributing to delayed disclosure of injuries and reluctance to seek medical care
• Financial dependence on partner limiting access to independent medical care

Coroner's recommendations

1. NHDS to ensure current policies mandating 000 activation for 'head injury' and 'loss of consciousness' are consistently applied
2. NHDS to improve telephone triage training for operators to identify and escalate head injury symptoms appropriately
3. NHDS to provide scripted information to callers about estimated arrival times and high demand situations to prompt alternative medical assistance
4. Implementation of streamlined processes ensuring doctor allocation within 15 minutes of initial call receipt with secondary triage to divert emergencies to 000
5. NHDS operators to ask clarifying questions about head injury symptoms including loss of consciousness, vomiting, drowsiness, and unwitnessed falls
6. Salvation Army Family Violence Outreach Program to conduct risk assessments and ensure appropriate referrals before ceasing contact with clients who move interstate, confirming living arrangements and safety measures
7. Ensure all services coming into contact with family violence victims are equipped to identify, assess and manage risk in line with MARAM framework
8. Victoria Police to prioritise charging perpetrators for FVIO breaches promptly to hold perpetrators accountable and reinforce deterrent effect
9. Victoria Police to conduct systemic reviews of family violence-related deaths where known history of family violence exists (Family Violence Death Assessments)
10. Victoria Police to adopt trauma-informed approaches in investigations involving family violence victims, particularly when interviewing victims who may be reluctant to disclose
11. Victoria Police to proactively review LEAP records for family violence history when responding to family violence incidents
12. Victoria Police to apply new Family Violence Report VP Form L17 requiring explicit checks of LEAP history and measures to support victim disclosures even with unwilling complainants