Finding into death of PLM

Contributing factors

• Failure of Victoria Police to conduct welfare check despite reports of perpetrator's suicidal ideation and threats
• Non-authorization of criminal brief against perpetrator in January 2021 despite sufficient evidence
• Failure of Family Violence Investigation Unit to accept family violence report in June 2021
• Inadequate risk assessment by NDIS-funded disability service providers
• Presence of intervention order considered protective factor despite perpetrator's history of non-compliance
• Victim-survivor's homelessness and dependence on perpetrator for housing
• Victim-survivor's reluctance to engage with police and formal services
• Inadequate coordination between multiple agencies providing support

Coroner's recommendations

1. That the Victorian Government work with the Commonwealth Government to expand the MARAM framework to include NDIS service providers in Victoria and make them MARAM-prescribed entities
2. That Victoria Police update its bail decision making policies/guidelines to note that the presence of an intervention order is not automatically considered a mitigating factor when deciding whether to bail an offender, particularly where there is a history of breaching intervention orders, bail and/or court orders. The decision-maker should consider the party's history of compliance with the order and/or bail as part of the decision-making process