Coronial
VIChome

Finding into death of Steven John Bamblett

Deceased

Steven John Bamblett

Demographics

29y, male

Date of death

2020-01-14

Finding date

2023-01-17

Cause of death

Hanging

AI-generated summary

Steven John Bamblett, a 29-year-old Aboriginal man, died by hanging on 14 January 2020 following service of a Family Violence Intervention Order application. He had a documented history of untreated mental illness with frequent suicidal ideation, suspected ADHD, and repeated self-harm behaviour during family violence incidents. Critical failures included: Victoria Police did not conduct adequate risk assessment before serving the FVIO despite Person Warning Flags on his record indicating suicide/self-injury risk; a call for help from his partner's mother at 6:48pm was dismissed as a 'pocket dial' despite clear audible distress; and no Aboriginal Community Liaison Officer engagement occurred despite available resources and Mr Bamblett's documented fear of police. Systemic issues around culturally sensitive police engagement with Aboriginal communities and failure to escalate the evening call response contributed to a preventable death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatryforensic medicine

Error types

communicationsystemdelay

Drugs involved

cannabis

Clinical conditions

untreated mental illnessattention deficit hyperactivity disordersuicidal ideationself-harm behaviour

Contributing factors

  • Untreated mental illness with suicidal ideation
  • Recent service of Family Violence Intervention Order application causing acute distress
  • Failure by Victoria Police to conduct risk assessment prior to serving FVIO documentation despite Person Warning Flags indicating suicide risk
  • Failure to consult Aboriginal Community Liaison Officer or Police Aboriginal Liaison Officer despite available resources
  • Family violence history and separation stress
  • Financial stress related to Centrelink loan application
  • Police failure to appropriately respond to emergency call at 6:48pm reporting family violence distress
  • Dismissal of emergency call as 'pocket dial' despite clear audible distress
  • Fear of police and incarceration related to prior traumatic police contact
  • Lack of cultural competency in police engagement with Aboriginal community member

Coroner's recommendations

  1. Victoria Police to implement more rigorous risk assessment procedures prior to serving Family Violence Intervention Order documentation, including mandatory review of Person Warning Flags indicating mental health and suicide risk
  2. Victoria Police to enhance cultural competency training and ensure consistent engagement with Aboriginal Community Liaison Officers and Police Aboriginal Liaison Officers when interacting with Aboriginal community members
  3. Expansion and resourcing of Police Aboriginal Liaison Officer roles, particularly at Echuca, from part-time to full-time positions
  4. Victoria Police to finalise and implement Family Violence Protection Act Protocols in regions where not yet established (Echuca and Geelong) with culturally appropriate procedures
  5. Victoria Police to ensure appropriate investigation and response to emergency calls reporting family violence regardless of initial assessment of call characteristics, in compliance with Code of Practice for Investigation of Family Violence
  6. Enhanced training on recognition and appropriate handling of emergency calls involving family violence with clear escalation procedures
Full text
Official source Archived copy

Related cases

WAhome2026-05-27

Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…

psychiatrygeneral practicesystemcommunicationhaloperidol
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —