Finding into death of HCG

Contributing factors

• Assault by intimate partner causing significant blood loss
• Delay in calling emergency services (approximately 4-5 hours post-assault)
• Hepatic cirrhosis with associated clotting abnormalities
• Methylamphetamine use
• Housing instability and lack of safe accommodation options
• Victim's difficulty maintaining engagement with services
• Perpetrator's lack of accountability for family violence behaviour

Coroner's recommendations

1. That Victoria Police and Triple Zero Victoria work together to implement a system which automatically extracts family violence-related CAD information into FVR L17s, while excluding it from the subsequent referrals to family violence services.
2. That Victoria Police implement a mechanism which triggers a review of the predominant aggressor in a relationship when police attend several family violence incidents and label both parties the predominant aggressor on more than one occasion. This trigger should be automated and should not depend on members reading and complying with a new practice guide. The review process should involve specialist family violence services, and should consider information recorded across time, including in FVR L17s.
3. That the Department of Families, Fairness and Housing provide Safe Steps with the funding requested for the Sanctuary accommodation model in their 2025-26 budget bid, noting that this aligns with the March 2021 Legal and Social Issues Committee Inquiry into Homelessness in Victoria.
4. That the Department of Families, Fairness and Housing consult with Safe Steps on further expansion of the Sanctuary model to provide a range of Sanctuary facilities across metropolitan and regional communities, including provision of specialist Sanctuary facilities to accommodate people with complex needs.
5. That the Department of Families, Fairness and Housing scale up long-term investment in supported accommodation projects like the Sanctuary to replace the hotel model.
6. Endorse Recommendations 1-5 from Engaging in change: A Victorian study of perpetrator program attrition and participant engagement in men's behaviour change programs, relating to data quality, long-term participant trajectories, funding models, court-mandated program effectiveness, and completion reporting to courts.
7. Endorse Judge Cain's recommendations in the Thi Nguyen finding regarding increased primary prevention funding and Federal Government commitment to critical prevention infrastructure.
8. Endorse Judge Sanger's recommendation that the Attorney-General consider referring to the Victorian Law Reform Commission the creation of a new offence for abandoning a victim in medical need and/or amending the Family Violence Protection Act 2008 to include such abandonment.
9. Endorse Judge Cain's recommendation that Victoria Police fully implement recommendation 5 of the FVRIM December 2021 report regarding specialist family violence sector review of Family Violence Reports before commitment to LEAP database.