Finding into death of Michelle Margaret Darragh
Deceased
Michelle Margaret Darragh
Demographics
32y, female
Coroner
State Coroner Judge Liberty Sanger
Date of death
2021-10-09
Finding date
2026-01-06
Cause of death
Stab wound to the back extending into the posterior neck, causing subtotal transection of cervical spinal cord at C3/C4 level with circulatory collapse and cardiac arrest
AI-generated summary
Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, financial abuse, obsessive jealousy, and controlling behaviours, though no prior physical violence occurred. Coman had attempted suicide days before the homicide after the relationship ended. Eastern Health admitted Coman to the mental health ward following his suicide attempt but did not complete a formal family violence risk assessment despite documented evidence of multiple high-risk factors including separation, substance abuse, access to weapons, and delusional beliefs about infidelity. The coroner identified that while Michelle minimised her own risk and appeared supportive of Coman, services failed to balance her self-assessment against evidence-based risk factors. A properly conducted MARAM assessment would have identified significant homicide risk. The case highlights that victims of family violence may downplay danger, that suicide attempts in the context of separation are a homicide risk indicator, and that professional judgment must augment victim self-assessment of safety.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to complete MARAM family violence risk assessment despite documented evidence of multiple high-risk factors
- Reliance on victim's minimisation of risk and self-assessment without adequately applying professional judgment
- No engagement with perpetrator regarding violence, controlling behaviours, or substance abuse
- Absence of victim safety planning or referral to family violence services
- No secondary consultation with specialist family violence clinician
- Victim's professional role as social worker may have influenced assessment and missed opportunity to reinforce evidence-based risks
- Separation as a triggering factor for escalation in a 'fixated threat' offender profile
- Recent suicide attempt not properly integrated with family violence risk assessment
- Pregnancy not explicitly identified as independent risk factor under revised MARAM
Coroner's recommendations
- Family Safety Victoria review the removal of pregnancy as a specific risk factor in the MARAM and consider if the evidence base supports its reinstatement
- Department of Health amend policy in all Victorian public hospitals such that when someone is assessed for suicidality after separation or end of a relationship, a MARAM risk assessment is also completed, including contacting the partner or ex-partner if willing
Full text
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