Finding into death of FCP

Contributing factors

• complex mental illness including psychosis, depression, anxiety, PTSD
• alcohol and benzodiazepine use
• family violence and controlling relationship
• deterioration in mental health following visit to NSW
• medication overdose on 1 April 2020
• social stressors and interpersonal conflict
• systemic failure to accurately identify family violence victim-perpetrator dynamics

Coroner's recommendations

1. Victoria Police update policies to require members to document the reason for assigning roles of AFM (affected family member) and respondent in family violence incidents where roles are unclear, and document conversations held with respective parties/witnesses
2. Victoria Police amend the Code of Practice, Victoria Police Manual and new Predominant Aggressor Practice Guide to provide information on specific risk of misidentifying women with mental illness as primary aggressors when they do not present as 'ideal victims' due to perceived aggression, agitation, erratic behaviour, substance use, lack of calm cooperation with police, or use of violent resistance including self-defence
3. Victoria Police fully implement recommendation 5 of the FVRIM December 2021 report by establishing a review process involving specialist family violence sector for any Family Violence Report where a woman is identified as a respondent before it is committed to LEAP database, with reviews conducted jointly by police and specialist family violence workers