Finding into death of DWI
Deceased
DWI
Demographics
63y, male
Date of death
2023-10-28
Finding date
2026-08-20
Cause of death
Traumatic head injury
AI-generated summary
A 63-year-old man (DWI) died from traumatic head injury after being struck with a golf club during an altercation in regional Victoria on 11 October 2023. DWI had a documented history of perpetrating family violence against his ex-partner SCB and her children, particularly her son GFT, including physical assaults and repeated threats with weapons. At the time of the incident, DWI threatened GFT with a meat cleaver. WQZ intervened with a golf club in self-defence of GFT; the assault charge was withdrawn on that basis. The coroner found DWI was the predominant aggressor despite Victoria Police repeatedly misidentifying him as the affected family member. Key systemic failures included police failure to identify his threats as family violence, failure to escalate high-risk incidents to specialist units, and repeated overriding of high-risk risk ratings. The coroner made recommendations for automated review mechanisms when police label both parties as predominant aggressors across multiple incidents, and for statewide expansion of co-responder programs.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- DWI's perpetration of family violence against ex-partner and her children over multiple years
- DWI's escalating threats and weapon brandishing directed at GFT and family
- Police misidentification of predominant aggressor—labelling GFT and HYT as respondents despite DWI's documented pattern of assault and threats
- Police failure to identify and record DWI's threats as family violence incidents
- Police failure to escalate high-risk family violence incidents to specialist Family Violence Investigation Unit despite automated risk ratings of high
- Repeated overriding down of high-risk ratings by frontline police without apparent justification
- DWI's unaddressed childhood sexual abuse trauma, PTSD, mental health issues and alcohol dependence
- Lack of therapeutic intervention or supervision following DWI's 2014 mental health crisis and suicidal ideation
- Police failure to take action in response to repeated explicit threats to kill or harm SCB and her children made directly to police
Coroner's recommendations
- That Victoria Police in consultation with the Predominant Aggressor Working Group (PAWG) implement a mechanism which triggers a review of the predominant aggressor in a relationship when police attend several family violence incidents and label both parties the predominant aggressor on more than one occasion. This trigger should be automated and should not depend on members reading and complying with a new practice guide. The review process should involve specialist family violence services, and should consider information recorded across time, including in FVR L17s.
- That the Victorian Government together with the Commonwealth Government provide ongoing funding for the expansion of the Alexis Family Violence Response Model across Victoria.
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