Finding into death of TCW
Deceased
TCW
Demographics
43y, female
Date of death
2018-01-11
Finding date
2022
Cause of death
Neck compression
AI-generated summary
TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disorder with escalating inappropriate sexual behaviours, violence, and impulse control issues from childhood. Multiple services (psychiatrist Dr G., counsellor Mr Gould, school social worker Ms Booth, psychologist Ms Krupka) provided care but did not fully appreciate the extent of OMP's violence toward TCW at home. Critically, adolescent family violence was not identified or assessed. TCW reached breaking point after OMP stole a car and was arrested; she desperately sought residential care placement but faced significant system barriers. Services failed to complete family violence risk assessments, offer specialist family violence referrals, or ensure TCW's safety. The coroner identified missed opportunities in identifying adolescent family violence and recommended improved crisis accommodation for violent adolescents, better NDIS integration with family violence frameworks, and specialist training for AFV services working with disabled youth.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Intellectual disability with poor impulse control
- Autism spectrum disorder
- Hypersexual disorder
- Escalating violent and sexually inappropriate behaviours
- Failure to identify and respond to adolescent family violence
- Inadequate respite and crisis accommodation services
- Lack of specialist services for adolescents with disability who use family violence
- System barriers to accessing residential care placement
- Poor information sharing between treating clinicians and TCW's informal disclosures
Coroner's recommendations
- The Victorian Government develop additional crisis and longer-term supported accommodation options with attached therapeutic support for adolescents who use family violence in the home, including consideration of accessibility for young people with a disability
- The Victorian Government review whether NDIS service providers in Victoria are equipped to work with young people who have a disability who also use adolescent family violence and provide resourcing and/or training to address any deficiencies
- The Victorian Government review current Victorian AFV and AFVP service providers to determine whether they are equipped to work with young people who have a disability who also use adolescent family violence and provide resourcing and/or training to address any deficiencies
- The Victorian Government support ANROWS' calls for further research regarding people with disability who use family violence in order to build an evidence base for work in this area
- Organisations making referrals for respite care ensure that referrals are made to accredited organisations to ensure that carers have appropriate escalation points
Full text
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