Finding into death of Marilyn June Burdon

Contributing factors

• Inadequate 2014 police investigation into missing firearms registered to prohibited person
• Failure of Victoria Police Licensing and Regulation Division to follow up on missing firearms notifications
• Gaps in firearms regulation system allowing prohibited persons to retain access to firearms through associates
• Fraudulent firearms permit applications and forged documentation by prohibited person
• Lack of cross-referencing systems in LARS/LEAP to identify prohibited persons linked to firearm permit addresses
• Inadequate psychiatric assessment of family violence risk by private psychiatrist
• Absence of mandatory family violence training for private psychiatrists
• Intimate partner violence precipitated by deceased's rejection of perpetrator
• Perpetrator's severe depression, personality disorder traits, and history of fraud and dishonesty

Coroner's recommendations

1. Victoria Police must update IT systems so serial number searches provide all previous registered owners, or mandate contact with LRD when obtaining such information
2. Victoria Police LRD must check when assessing Permit to Acquire applications whether the witness is a previous firearm owner, a prohibited person, or if storage address is linked to a prohibited person, and investigate or refuse permit accordingly
3. Victoria Police must update policies so that upon notification of address changes, LRD establishes whether the new address is common to a prohibited person and commences investigation if so
4. Victoria Police must require immediate notification to LRD upon identification of missing/unregistered firearms, with LRD providing all relevant LARS intelligence and assistance
5. Victoria Police should consider updating firearms safety courses to include education about licence holder responsibilities and offences under the Firearms Act 1996, with demonstration of understanding required
6. Victoria Police should consider providing information brochures about licence holder responsibilities with renewals and new permits
7. The Victorian Attorney-General should consider requesting the Sentencing Advisory Council review sentencing outcomes under the Firearms Act 1996
8. The Royal Australian and New Zealand College of Psychiatrists should mandate that not less than four hours of the 50 hours annual continuing medical education required relate to Family Violence (identification, risk assessment, relevant frameworks) within a two-year period