Finding into death of Mrs A

Contributing factors

• History of family violence and controlling behaviour by perpetrator
• Financial difficulties and stress in the relationship
• Prior threats to kill made by perpetrator
• Perpetrator's depression and mental health issues
• Perpetrator's unemployment
• Inadequate family violence screening and documentation by healthcare providers
• Failure of mental health professional to inquire about or document violent behaviour
• Lack of communication between GP and mental health provider regarding family violence risk
• Victim's cultural and linguistic diversity creating potential barriers to service access
• Lack of awareness among family members about how to access family violence support services

Coroner's recommendations

1. Family Safety Victoria should develop a research-based strategy, in consultation with victim survivors, informal supporters and priority communities, to provide targeted information and services to informal supporters assisting persons affected by family violence
2. General practitioners should receive mandatory continuing professional development training in family violence identification and response
3. Mental health professionals should be trained to routinely screen for and inquire about family violence, particularly when treating perpetrators with marital discord
4. Healthcare providers treating perpetrators of family violence should assess the risk they may pose to family members, hold them accountable for their behaviour, and provide appropriate referral to specialist services
5. When a GP is treating both a perpetrator and victim of family violence, the GP should check with the victim about how they perceive the perpetrator is progressing and ensure the victim is receiving counselling from specialist family violence services
6. Healthcare services should be designed to meet the diverse needs of CALD communities, including use of interpreting services and culturally appropriate engagement
7. Improve access to family violence information and resources through websites such as the Orange Door portal for third parties, family members, and friends who may need to support victims