Finding into death of Tracey Ellen Knowles

Contributing factors

• heroin use within 12 hours of death
• methylamphetamine use
• benzodiazepine use
• facial injuries consistent with assault
• homelessness following police misidentification as predominant aggressor
• history of family violence and trauma
• vulnerability and lack of safe shelter

Coroner's recommendations

1. Endorse State Coroner's recommendation (from finding into death of Noeline Dalzell) that Victoria Police and Department of Families, Fairness and Housing collaborate to embed advanced family violence practitioners within Family Violence Investigation Units as a pilot to assess, jointly respond to and manage repeat and/or high-risk family violence matters and improve proactive victim engagement, with independent evaluation within two years
2. Support State Coroner's recommendation that Victoria Police fully implement recommendation 5 of the Family Violence Reform Implementation Monitor December 2021 report, specifically to trial a review process involving the specialist family violence sector for Family Violence Reports where a woman is identified as respondent, with reviews conducted by police and specialist family violence sector workers together before commitment to LEAP database