Inquest into the Death of Lynn Marie CANNON

Contributing factors

• Priority 2 downgraded to Priority 3 without adequate justification
• Change of address from Paul Cannon's home to Lynn's home redirected initial response
• Failure to recognize escalating coercive control and post-separation danger
• Lack of documented family violence history on system due to incidents not being reported
• Delayed dispatch due to unanticipated surge in triple zero calls (230 received vs 89 forecast)
• Inadequate police resources available that night
• Failure to update CAD with corrected address information
• SJA unable to reach police on designated line, causing delay in urgent notification
• Lack of integration between family/domestic violence risk assessment and dispatch priorities
• Insufficient understanding by dispatchers of coercive control dynamics and re-partnering as high-risk trigger

Coroner's recommendations

1. Full funding and implementation of the Family and Domestic Violence System Reform Plan (2024-2029) by the Department of Communities
2. Immediate and significant funding uplift for frontline specialist family and domestic violence services to address crisis response and ongoing support needs
3. Funding for face-to-face family violence training developed by the Family Violence Division to be provided to all frontline police officers
4. Support for WA Police's use of dedicated Family Violence Sergeants in SOCC to oversee and review all FV tasks for correct classification and prioritization
5. Continued implementation of requirement for senior sergeant approval for CAD priority downgrades with written justification
6. Continued notification to callers of police response time estimates and any subsequent downgrades
7. Support for alternative reporting pathways for family violence victims (multi-agency call centre, advocacy centres, anonymous platforms)
8. Enhanced information sharing between WA Police, Department of Communities, Department of Justice, and Department of Health regarding family violence risk indicators
9. Implementation of co-location of SJA paramedic at PAC for improved emergency coordination
10. State-wide, planned and coordinated approach to bystander intervention training and community education on family violence recognition and risk assessment
11. Development and implementation of Harm Assessment Risk Matrix (HART) tool to identify perpetrators capable of serious harm
12. Exploration of health service data sharing (GPs, mental health, alcohol/drug services) to identify risk factors in men presenting in crisis, particularly those exhibiting coercive control
13. Resourcing of community-based prevention initiatives focused on educating family, friends, neighbours and co-workers on family violence risk factors and intervention pathways