Finding into death of Mr A

Contributing factors

• History of family violence perpetration
• Mental illness including bipolar disorder, schizophrenia, and PTSD
• Prior suicide attempts and suicidal ideation
• Substance misuse (methamphetamine, alcohol, cannabis)
• Childhood and early adulthood exposure to family violence
• Impulsivity and unstable emotional state
• Recent incarceration
• Lack of family violence risk assessment prior to release
• Inadequate information sharing between Child Protection and Community Corrections
• Release to address directly across the road from former partner and child
• Breaches of Interim Accommodation Order
• Lack of proactive pre-release planning

Coroner's recommendations

1. Department of Justice and Community Safety and Department of Families, Fairness and Housing should review and update existing protocols between Justice Services and Child Protection to ensure MARAM aligned information sharing, risk assessment and risk management activities take place prior to release of offenders imprisoned for family violence related offences who pose a risk to children with pre-existing Child Protection engagement
2. Department of Justice and Community Safety should review existing protocols with Department of Families, Fairness and Housing to ensure Victoria Police and Orange Door are notified to proactively share risk information and provide additional supports to affected family members