Finding into death of PLM

40y · Female·Stab wounds to the chest and abdomen

A 40-year-old woman was fatally stabbed by her former intimate partner who had an extensive history of family violence offending and multiple breaching intervention orders. Despite multiple service contacts in the days before her death—including reports to police about the perpetrator's suicidal ideation and threats—no welfare check was conducted. Key clinical lessons include: the importance of recognizing that intervention orders alone are insufficient protective factors when perpetrators have histories of non-compliance; the need for coordinated multi-agency risk assessment (RAMP referrals) for high-risk cases; and ensuring specialist family violence services actively engage vulnerable victim-survivors. Services including disability providers, homelessness agencies, and corrections missed opportunities to conduct family violence risk assessments and make appropriate referrals, though these likely would not have prevented the death.