Finding into death of HD S

Contributing factors

• Extensive rib fractures with flail chest on left side
• Pneumohaemothorax from lung puncture
• Liver and mesenteric lacerations with abdominal haemorrhage
• Diffuse traumatic axonal injury to brain
• Subarachnoid haemorrhage
• Pelvic fracture
• Prolonged family violence by adult son
• Victim's physical disability and vulnerability
• Victim's protective attitude toward perpetrator
• Perpetrator's substance misuse (cannabis, alcohol, methamphetamine)
• Perpetrator's untreated mental health conditions
• Perpetrator's previous family violence convictions and breaches
• Inadequate police response to family violence incidents
• Failure of disability support worker to escalate family violence concerns
• Inadequate engagement of family violence services with both victim and perpetrator

Coroner's recommendations

1. That the NDIS Quality and Safeguards Commission engage with the Department of Families, Fairness and Housing to understand the requirements for prescribed bodies under MARAM and its applicability in the NDIS context, informed by this finding and Judge Cain's findings into deaths of William Heddergott and PLM
2. That the NDIS Quality and Safeguards Commission work with DFFH to expand the MARAM framework to include NDIS service providers in Victoria and make them MARAM-prescribed entities
3. That the Victorian Government provide ongoing funding for the expansion of the Alexis Family Violence Response Model across Victoria