Finding into death of Simone Leslie Quinlan

Contributing factors

• Intimate partner violence and assault
• Failure of Corrections Victoria to identify Neil as high-risk despite clear indicators
• Inadequate supervision of offender on Community Corrections Order
• Inaccurate judicial monitoring reports prepared by Corrections Victoria
• Delay in arrest and interview of alleged perpetrator by Victoria Police
• Failure to execute outstanding warrant promptly
• Notification of alleged perpetrator prior to service of family violence intervention order
• Insufficient contact attempts by Women's Health West following domestic violence referral
• Victim isolation due to substance misuse and homelessness
• Perpetrator access to weapons
• Escalation in frequency and severity of violence prior to fatal incident

Coroner's recommendations

1. Victoria Police update the Code of Practice and relevant family violence policies and procedures to include advice recommending that police members do not contact alleged family violence perpetrators by telephone prior to the service of a family violence safety notice or intervention order, highlighting the vulnerability of affected family members and the potential for evasion of service
2. Corrections Victoria introduce an electronic case management system to enhance Community Correctional Services management of offenders' compliance with Community Corrections Orders, including automated schedules for condition completion, key milestones, and supervisory oversight of serious offenders
3. Corrections Victoria implement training for all Community Correctional Services staff state-wide involved in preparation of Judicial Monitoring reports regarding their composition and contents to improve quality and accuracy