Finding into death of Noeline Michelle Dalzell

Contributing factors

• failure to notify victim of offender's release from custody
• inadequate information sharing between agencies
• passive monitoring rather than proactive management by FVIU
• lack of coordinated multi-agency risk assessment and response
• no lead agency identified for case coordination
• homelessness and lack of housing support
• failure to escalate to RAMP despite high-risk offender status
• non-investigation of family violence breach at critical time
• minimal victim engagement by police FVIU
• systemic barriers to Aboriginal victim's help-seeking including fear of child removal

Coroner's recommendations

1. Victorian Government investigate supplementing and enhancing the Central Information Point (CIP) to enable multi-directional flow of information relevant to perpetrator risk among all relevant Departments and agencies in a timely, proactive, complete and automated manner
2. Victorian Government immediately formalise the sharing of CIP reports by approving Child Protection practitioners as requestors
3. Victoria Police (in conjunction with DJCS) develop a policy to ensure victims of family violence or affected family members in active FVIO cases are notified of court outcomes within 48 hours in cases where offender is high-risk
4. If Recommendation 3 accepted, Victorian Government investigate enhancement to CIP to trigger automated notification when family violence offender released from prison, police cells or court
5. Victoria Police and The Orange Door in two regions as pilot collaborate to embed advanced family violence practitioners within each FVIU to assess, jointly respond to and manage repeat and/or high-risk family violence matters; independent evaluation of pilot program within two years
6. Victoria Police engage external independent suitably qualified person to conduct evaluation of effectiveness and skillset of FVIUs prior to rollout of CPRM to provide benchmarking information
7. DJCS and DFFH take immediate steps to complete work on multi-agency review recommendation 2 and identify who is to take leadership role, including implementing central contact person or agency with responsibility for coordinated oversight of family violence perpetrators, affected family members and service providers; this approach needs to include First Nations community organisations
8. Victoria Police make PTMI and MRTs for high-risk family violence offenders accessible to uniform police members who respond to family violence incidents
9. Attorney General consider reference to Victoria Law Reform Commission to consider legislative amendment to expand Serious Offenders Act 2018 scheme to encompass serious repeat family violence offenders who pose ongoing high risk of violence to affected family members
10. DJCS Corrections Victoria work with Court Services Victoria to investigate fast-track procedure for processing family violence offenders when they plead guilty to offence breaching CCO imposed for family violence offending, including enabling service of charge-sheet prior to release, facilitating assessment of non-compliance reasons, and empowering judicial officers to amend CCO orders including geographical exclusion orders
11. Corrections Victoria implement digital non-paper-based system for Corrections warrants to enable processing without relying on mail or DX