Finding into death of ZSQ

Contributing factors

• Intimate partner violence and escalating abuse from beginning of relationship
• Inadequate post-release risk management of perpetrator from custody
• Failure to place perpetrator on community corrections order upon release
• Ineffective engagement with specialist family violence services by both parties
• Deficiencies in interstate police information-sharing regarding family violence orders
• Poor risk assessment and missed identification of serious risk factors by Queensland Police
• Victim's reluctance to engage with support services and reporting despite disclosures
• Perpetrator's substance misuse (cocaine, benzodiazepines, alcohol), untreated trauma and possible acquired brain injury
• Short custodial sentence insufficient for meaningful behaviour change intervention

Coroner's recommendations

1. Department of Families, Fairness and Housing and Minister for Prevention of Family Violence to provide funding for expansion of co-responder programs across Victoria, noting numerous coronial recommendations about benefits of co-responder models
2. Corrections Victoria to investigate and implement a system to create real-time (or near real-time) notifications to Victoria Police when offenders are released from prison to improve risk assessment and management strategies
3. Victorian Government to urgently increase total quantum of primary prevention funding and prioritise longer-term funding across primary prevention system
4. Federal Government to commit to long-term funding for critical infrastructure for primary prevention of violence against women and family violence
5. Development of national database to share information about family violence incidents and orders across Australian States and Territories to improve interstate police risk assessments