Finding into death of Ms KSI

Contributing factors

• Family violence perpetrated by husband and extended family members including assaults
• Breach of Family Violence Intervention Order by husband who returned to residence
• Limited emergency accommodation options resulting in motel placement
• Social isolation and lack of family and community supports
• Immigration status tied to spouse creating vulnerability
• Inadequate mental health support and risk assessment by Safe Steps
• Lack of culturally appropriate services and support
• Inadequate information sharing and collaboration between Child Protection and other services
• Insufficient safety planning and risk assessment by Child Protection
• Threats to kill by extended family members not adequately addressed

Coroner's recommendations

1. Safe Steps must ensure all assessment practitioners have skills to assess and refer promptly to appropriate services including mental health support, CALD support, and RAMP referrals
2. Safe Steps must develop and implement a proactive case management approach using a trauma-informed framework
3. Safe Steps policy regarding Child Protection notifications should be reviewed to ensure staff are aware of alternate communication methods
4. All Safe Steps RAPID staff must be aware of their obligation to undertake effective assessments during contact
5. Safe Steps staff require training in trauma-informed practice
6. Safe Steps must review support to staff following critical incidents
7. Safe Steps must review response to critical incidents with a quality improvement focus
8. The Safe Steps board function and performance should be reviewed to ensure adequate oversight
9. Increased investment in purpose-built family violence crisis accommodation to replace motel placements
10. Enhanced social housing options for victim survivors of family violence
11. Improved information sharing protocols between Child Protection and Maternal and Child Health services
12. Mandatory MARAM training for Child Protection workforce with focus on risk assessment and perpetrator accountability
13. Enhanced training for Child Protection in engaging culturally diverse families experiencing family violence
14. Child Protection should establish systematic referral processes to culturally appropriate services for CALD families
15. Development of safety planning protocols for families with family violence