Finding into death of Michael Andrew Power

Contributing factors

• Police misidentification of primary aggressor in family violence incidents
• Failure to complete family violence risk assessment following telephone report of FVIO breach on 22 November 2016
• Incident-based rather than pattern-based assessment of family violence by police
• Substance abuse by both parties (methamphetamine use by Edwards; methadone, heroin use by Power)
• Inadequate police response to family violence incidents on 25 August 2016
• Failure to properly record or follow up on telephone report of FVIO breach at 12:19am on 22 November 2016
• Escalating pattern of bidirectional family violence throughout relationship
• Mental health and family violence support services unable to prevent fatal outcome despite engagement

Coroner's recommendations

1. Victoria Police re-examine and potentially redesign the Family Violence Report and associated processes and guidance to support officers to identify the predominant aggressor before beginning risk assessment, particularly in ambiguous situations
2. Victoria Police clearly differentiate between the risk assessment (and referral) function for civil protection purposes, and any criminal incidents (particularly in cases where a victim has used force)
3. Victoria Police ensure alignment with Victoria Police policies and the Family Violence Multi-Agency Risk Assessment and Management (MARAM) Framework
4. Trial a review process involving the specialist family violence sector for any Family Violence Report where a woman is identified as a respondent (and possibly for other targeted cohorts) before it is committed to Victoria Police's LEAP database
5. Urgently review how family violence records are captured in LEAP to ensure that where misidentification is found, the record can be amended so a person doesn't continue to be incorrectly listed as a respondent
6. Establish and communicate clear processes to guide police responses where there is new information that suggests misidentification has occurred, including a contact point at Victoria Police that other agencies can use to raise misidentification
7. Establish an agreed process to make a determination that misidentification has occurred
8. Provide specific guidance for police on the actions they need to take once this determination has been made
9. Develop clear guidance for withdrawing family violence intervention order applications or criminal charges in cases of misidentification and give police prosecutors the authority to quickly facilitate this
10. Police amend policies to provide clearer instructions to police members responding to reports of family violence received via telephone, including reiteration of the need to complete a VP Form L17 in response to such reports