Finding into death of CDE

Contributing factors

• Intimate partner violence with escalating severity over two years
• Perpetrator's untreated mental health conditions including schizophrenia with paranoid features
• Perpetrator's substance abuse history
• Failure to prosecute perpetrator for January 2018 serious assaults
• Police treatment of family violence incidents as mental health incidents without completing family violence risk assessments
• Inadequate coordination between family violence and mental health services
• Limited FVIO in place but not enforced through criminal prosecution
• Inadequate follow-up and risk assessment after multiple emergency presentations
• Perpetrator discharged from hospital despite erratic behaviour and delusional ideation

Coroner's recommendations

1. No specific recommendations made by coroner for Monash Health or mental health services, as deficiencies were identified primarily within Victoria Police's family violence response
2. Coroner acknowledged that Victoria Police has since undertaken reforms since 2019 and has implemented systemic improvements including revised Victoria Police Manual procedures regarding family violence identification and the implementation of the Mental Health and Wellbeing Act 2022