Finding into death of DRF

Contributing factors

• Blunt force head trauma with subdural haemorrhage
• Warfarin anticoagulation increasing bleeding risk
• Advanced age and frailty
• Fall risk from mobility impairment and dementia
• Alleged elder abuse and family violence not adequately investigated or escalated
• Failure of police welfare checks and safeguarding response
• Lack of comprehensive adult safeguarding framework in Victoria
• Communication barriers (hearing impairment, language barrier, dementia) not adequately addressed
• Delayed and inadequate family violence support service engagement

Coroner's recommendations

1. Victoria Police consider modifying body worn camera units to emit an audible alert tone when muted, or alternatively amend section 3.7 of the Victoria Police Manual to prohibit muting during phone calls or contact with other police members while responding to incidents requiring BWC activation
2. Victorian Government implement adult safeguarding legislation to establish comprehensive assessment, investigation and coordination of responses to allegations of abuse, neglect and exploitation of at-risk adults
3. Victorian Government review circumstances of this case and CFT case together with safeguarding recommendations from ALRC, OPA and Disability Royal Commission when framing legislation
4. Adult safeguarding agencies be adequately funded to function effectively
5. New safeguarding agencies work cooperatively with service providers to facilitate timely support provision to at-risk adults
6. Victorian Government introduce legislation permitting adult safeguarding agencies to receive and share information timely with police, healthcare entities, government departments, OPA and other agencies
7. Victorian Government implement OPA recommendation to build capacity of mainstream service providers to identify and respond to abuse of at-risk adults
8. Victorian Government fund regular community awareness, media engagement and education campaigns about adult safeguarding function
9. Office of the Public Advocate conduct thorough investigations whenever aware of allegations of neglect or abuse of represented persons
10. Office of the Public Advocate review and update guidance about allocating orders and balancing risk of harm when making decisions