Inquest into the death of Michelle Michell

STATE CORONER'S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Michelle Daphne MICHELL Hearing dates: 4 - 6 September 2023, 8 March 2024 Date of findings: 28 March 2024 Place of findings: State Coroners Court of New South Wales at Lidcombe Findings of: Magistrate Joan Baptie, Deputy State Coroner Catchwords: CORONIAL LAW - domestic violence - homicide - NSW Police Force - Domestic Violence Safety Assessment Tool (DVSAT) - Apprehended Domestic Violence Order - crossagency responses to domestic violence File number: 2021 /00188952 Representation: Counsel Assisting: Ms K Edwards SC instructed by Ms K Zielinski of the NSW Crown Solicitor's Office Commissioner of NSW Police Force: Mr A Mykkeltvedt instructed by Ms R Atherton of the Office of General Council Leading Senior Constable B Neppl: Ms J Ghabrial instructed by Mr M Burns, McNally Jones Staff Lawyers Non-publication order: The Court has made orders for non-publication of certain evidence, pursuant to section 7 4 of the Coroners Act 2009.

Details of these orders can be found on the Registry file.

I ~indings: !The identity of the deceased I !The person who died was Michelle Daphne Michell.

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'' Date of Death Michelle died on 30 June 2021.

Place of Death Michelle died at 187 Glenn Innes Road, lnverell.

Cause of death The cause of Michelle's death was Multiple Stab Wounds to the Abdomen and Chest.

Manner of Death The stab wounds were deliberately inflicted by Neville Michell.

Recommendations: !ro the Commissioner of Police: I

1. That a requirement be introduced to ensure that police officers completing a DVSAT review any prior DVSATs completed by the complainant, including any available narrative (Facts Sheets and/or DVO applications) for incidents in the last 12 months.

2. That the DV Registry create a bespoke training model whereby: a) police officers observe (remotely, where appropriate) WDVCAS officers administer DVSAT tools and WDVCAS officers observe police officers administer DVSAT tools; and b) police officers and WDVCAS officers subsequently attend an in-person seminar to share reflections, commentary and feedback about administering those tools.

3. That consideration is given to the Domestic and Family Violence Registry (DV Registry) within the New South Wales Police Force (NSW Police Force) being connected to ( or at least given the opportunity to comment on) recruitment and education at the NSW Police academy.

4. That consideration is given to a pilot of a PACER style co-responder program involving the attendance of Women's Domestic Violence Court Advocacy Service (WDVCAS) officers at domestic violence 'call outs' during daylight hours.

5. That a working party be formed including members of the DV Registry, Crime Prevention Command, WDVCAS and Legal Aid to develop the pilot co-responder program.

6. That the working party also work on methods of improved information transfer and phone calls between police and WDVCAS.

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7. That urgent consideration is given to whether police officers are sufficiently trained in the professional judgment component of the current DVSAT and if further training is warranted prior to i the introduction of the new DVSAT.

Table of Contents The legality of police seizing house keys of a person charged with DV offences or Second triangulation request - Evidence of Detective Senior Constable Matthew Domestic Violence Death Review Team (DVDRT) Secretariat review and report of

Introduction 1 This inquest concerns the death of Ms Michelle Daphne Michell.

2 Ms Michell was born on 30 January 1971 and named Michelle Daphne Kemp. She died on 30 June 2021, at lnverell, in the state of New South Wales at the age of 50 years.

3 Ms Michell died from injuries sustained as a result of her estranged husband, Mr Neville Michell, stabbing her fatally to the head, chest and abdomen in her home.

4 The identity, date and place of Ms Michell's death are not in dispute.

Similarly, Ms Michell's cause of death is not in dispute. This inquest has focused on the manner of Ms Michell's death and the relevant contributing circumstances, including police procedures, policies and training for the protection of domestic violence victims.

5 Ms Michell is the mother of three adult children. Ms Michell was also a step-mother, mother-in-law, grandmother, sister, aunty and a loyal and supportive friend and a hardworking member of the lnverell community.

Members of her family have been constant advocates for her and have been unwavering in their determination to ascertain the reasons for her unnecessary and violent death. Various family members and friends have participated and contributed during these proceedings, and I acknowledge the profound loss and anguish felt and experienced by her family and friends. I would like to express my sincere condolences for their loss of the woman they knew as their loving daughter, mother, sister, aunty, grandmother and friend. I hope that Ms Michell's memory has been honoured by the careful examination of the circumstances surrounding her death and the lessons that have been learned from the circumstances of her passing.

The role of the Coroner and the scope of the inquest 6 A coroner is required to investigate all reportable deaths and to make findings as to the person's identity; as well as when and how the person died. A coroner is also required to identify the manner and cause of the person's death. In addition, a coroner may make recommendations, based on the evidence adduced during the inquest, which may improve public health and safety.

7 During these proceedings, a brief of evidence containing statements, interviews, photographs and other documentation, was tendered in court and admitted into evidence. In addition, oral evidence was received from numerous witnesses. A conclave of experts was convened to assess the policies surrounding domestic violence programs, reforms and participation.

8 All the material placed before the Court has been thoroughly reviewed and considered. I have been greatly assisted by the written submissions prepared by counsel assisting, Ms Kirsten Edwards of Senior Counsel, and Mr Anders Mykkeltvedt, counsel on behalf of the NSW Commissioner of Police. At times, I have embraced their descriptions in these findings.

9 In these findings I have referred to Ms Michell at various times as Michelle.

This is not meant as any disrespect to Ms Michell or her family. Rather, it is to acknowledge her as the person who has been described as "funny, loved the colour purple, was so happy when listening to music, enjoyed her TV shows and loved hanging out with all of us. She was such a beautiful person, she was our home and her presence was our light in the dark. She deserved the world. But now she is our Angel and forever our hero and we miss and love her so much." A Brief Overview of Michelle's Life 10 Michelle was the second eldest child of her parents, Katherine and Colin.

Michelle grew up with her four siblings, Judy, Lindylee, Des and Peter.

11 Michelle's first child, Christopher was born in 1989, and Michelle's relationship with Christopher's father ended shortly afterwards.

12 Michelle met Neville in 1992, although there are some conflicting accounts as to when their intimate relationship commenced.

13 At the time their relationship commenced, Neville had five children from previous relationships.

14 During their relationship, Michelle and Neville had two more children, Jennifer and Brendan.

15 Michelle and Neville moved from lnverell to Bonshaw, Texas, Tamworth, Nambucca Heads and Armidale for Neville's work on farms and in abattoirs. Michelle was the full-time carer for their children.

16 In 2016, Michelle, Neville, Jennifer and Brendan moved into the Brae Street, lnverell home.

17 On 2 March 2019, Michelle and Neville were married.

18 In December 2019, Neville's employment at the local abattoir was terminated and the family experienced significant financial issues while they were reliant on Centrelink payments.

19 Family and friends reported that Michelle and Neville's relationship was often very volatile, with both constantly arguing. They also reported that over time, Neville started exerting control over Michelle's movements and friendships.

20 In October 2020, Michelle, Neville, Brandan, Jennifer and her infant son moved from Brae Street to 187 Glen Innes Road, lnverell.

21 In early 2021, Michelle found regular employment at the RSM Motel in Evans Street, lnverell.

22 In April 2021, Neville became increasingly paranoid about Michelle having an affair with one of her work colleagues.

23 In May 2021, Michelle's son and daughter in law, Christopher and Christina moved into the Glen Innes Street home, with their two young children. At around this time, neighbours reported hearing regular intense verbal arguments between Jennifer, Michelle and Neville.

Background 24 On 17 June 2021, Neville was arrested and charged with assaulting both Michelle and Jennifer at their home in Glen Innes Road, lnverell.

25 Neville was granted bail by the police and an Apprehended Domestic Violence Order (ADVO) was made for the protection of both Michelle and Jennifer. The conditions of the ADVOs included prohibitions on Neville contacting, approaching or being within 50 metres of either woman. After he entered into his bail and ADVO conditions, Neville did not return to the house in Glen Innes Road and stayed at Michelle's brother's home for the next few nights.

26 On 21 June 2021, Michelle made a complaint to the police that Neville had breached the ADVO on two separate occasions. The two alleged breaches were firstly, that Neville had phoned Michelle's mobile phone and secondly, had driven past her place of work at the motel. Neville was cautioned and indicated to police that he may have "pocket dialled" Michelle. No action was taken in regard to that breach. CCTV footage was obtained and reviewed by police which indicated that Michelle may have mistaken Neville's motor vehicle for another vehicle.

27 At 2.15am on 30 June 2021, Neville broke into Michelle's home. At that time, Michelle and her family members Brendan, Jennifer and her infant son, Christopher and Christina and their two young daughters were also asleep in the premises. Neville entered Jennifer's room and stabbed her repeatedly to her head with a knife, causing significant injuries. Michelle intervened and was stabbed multiple times to her head, chest, upper limbs and abdomen by Neville.

28 Brendan and Christopher confronted Neville. Neville pointed the knife at Brendan and then left the premises.

29 Police arrived at the location at 2.22am and Michelle was declared deceased by ambulance officers. Jennifer was transported by ambulance to hospital in a critical condition.

30 Neville's whereabouts remained uncertain until 7.45am, when his motor vehicle was located by police on Kings Plain Road, lnverell near a property known as 'Glenrock'. He was found hanging by a rope from a tree. It is unknown how long he had been deceased before he was discovered by police.

List of issues considered during the inquest 31 The following list of issues was prepared before the proceedings commenced and was considered and provided focus during the inquest, namely: i. The NSW Police Force's response to the domestic violence incident on 17 June 2021, including decisions in relation to charging and the process involved with the Domestic Violence Safety Assessment (DVSAT); ii. The actions and assessments taken by the NSW Police Force after a reported breach of the AVO on 21 June 2021; and iii. Whether there was a delay in ordering phone triangulation to determine Neville's whereabouts after killing Michelle, and if so, why.

Domestic Violence incident on 17 June 2021 32 At around noon on 17 June 2021, Neville became involved in an argument with Jennifer in the lounge room of their home. Michelle intervened on behalf of Jennifer and pushed Neville in the chest. Neville responded by grabbing Michelle from behind and placing her head in a headlock, causing an obstruction of her airway. Jennifer then attempted to get Neville off her mother by grabbing at him and scratching him in the process. Neville then took hold of Jennifer by her throat and pushed her up against the wall in the dining room. In the process, he applied enough pressure to severely constrict her breathing and caused visible injuries to her neck.

33 Police were contacted and attended shortly afterwards. The police involvement was captured on Body Worn Video. On arrival, the police saw Michelle, Jennifer and Brendan at the front of the premises. Constable Osborne recorded the brief conversation he had with the three on Body Worn Video.

34 Constable Osborne was informed that Neville was out the back of the house, and he then went to speak with Neville. The conversation was recorded on Body Worn Video. Neville was told he was under 'caution' and commenced telling Constable Osborne that he was the victim of the assault, or alternatively, he had been acting in self-defence. Constable

Osborne arrested Neville, and he was transported to lnverell police station where he later participated in an electronically recorded interview with a suspected person (ERISP).

35 Constable Osborne spoke with Michelle and Jennifer separately at the scene and recorded their immediate complaints and responses on body worn video. In anticipation of criminal proceedings, Police completed a formal DVEC (Domestic Violence Evidence in Chief) recording with both Michelle and Jennifer at the scene.

36 Constable Osborne also completed a Domestic Violence Safety Assessment Tool, (DVSAT) questionnaire with Michelle. A DVSAT is a template risk assessment tool used by NSW Police and other organisations in NSW and forms a central component of the 'Safer Pathway' response to domestic violence.

37 Constable Joshua Osborne noted that both Michelle and Jennifer appeared 'nervous' and Michelle told Constable Osborne that Neville had recently told her that "If you leave me, I will find you and kill you." Constable Osborne sought to reassure both Michelle and Jennifer by informing them that he would be seeking a provisional ADVO naming them both as persons in need of protection from Neville. Constable Osborne also provided Michelle with the details of a service called "Staying Home Leaving Violence".

38 Constable Osborne had been advised by Michelle that Neville had taken her phone and was in possession of the house keys and she was concerned that he would gain access to the house, despite the ADVO.

39 Constable Osborne gave evidence that he spoke with Neville at the police station and asked him to return the keys and phone to him. Neville refused to comply with the police request. At some stage Constable Osborne sought advice from his supervisor, Leading Senior Constable (LSC) Neppl as to his legal powers to direct the return of the phone and the keys.

40 Three significant issues arose during this inquest in relation to the events on 17 June 2021. The first was the administration of the DVSAT, the second the suitability of the charge selection and the third, the legality of the police seizing house keys from persons charged with domestic violence offences or the subject of Apprehended Domestic Violence Order (ADVO) conditions.

Michelle's DVEC and DVSAT 41 The DVSAT has been in operation since 2014, and the use of the DVSAT became a mandatory reporting tool for police and certain other services from 1 July 2015.

42 In June 2021, the DVSAT was divided into two components. Part A was comprised of a Risk Identification checklist with 25 "risk indicator"

questions which are required to be answered with either a 'yes', 'no', 'unknown' or 'refused to answer'. Part B was referred to as the "Professional Judgment" section which required the person completing the survey on behalf of the victim to make an assessment of risk, "based on their knowledge, skills and experience, including taking into consideration the victim's own perception of the threat to their safety." 43 After answering the 25 questions, the victim is assessed as either "at threat", having answered 'yes' to between one and eleven questions; or "at serious threat", having answered 'yes' to twelve or more questions.

44 A person who has been assessed as "at threat" will then be referred to a non-government domestic violence service such as the Women's Domestic Violence Court Advocacy Service (WDVCAS), whilst those assessed as being "at serious threat" are also referred to a Safety Action Meeting (SAM). A SAM is conducted on a fortnightly basis and attendees represent both key government and non-government services in a local area, such as police, WDVCAS, the Department of Education and the Department of Communities and Justice (DCJ).

45 At each SAM, "the various service providers discuss victims assessed as being at 'serious threat' to build a comprehensive picture of their situation and identify practical actions that can be implemented to reduce the threat to their safety. The aim of the SAM is to promote the safety and well-being of victims of violence by developing a targeted and timely co-ordinated response by service providers." 46 Currently, a working party comprising NSW Police, BOCSAR (Bureau of Crime Statistics and Research), Legal Aid and DCJ have recommended that the number of questions be reduced to eleven questions. This was in part a result of a 2018 study by BOCSAR which identified that 1 in 5 administrations of the DVSAT by NSW Police resulted in an officer recording "no/unknown/refused" for all 25 questions, "which resulted in dramatic inconsistencies in risk assessment outcomes and essentially rendered the tool ineffective." 47 Constable Osborne gave oral evidence that he had administered between 20 - 30 DVSATs, prior to conducting the DVSAT with Michelle on 17 June

2021. He also confirmed that he had received some training at the Police Academy regarding the administration of DVSATs.

48 Constable Osborne gave evidence that he conducted the DVEC with Michelle prior to administering the DVSAT. He confirmed that the process for conducting the DVSAT that day included completing a sticker in his notebook which replicated the 25 questions. He indicated that he did not perceive that Michelle had any difficulty understanding any of the questions that he put to her during the DVSAT.

49 Constable Osborne confirmed that his usual practice was to ask each of the 25 questions sequentially and enter the victim's responses in his

notebook. He further confirmed that it was not his practice to elicit information from other sources for the purpose of answering the 25 questions prior to speaking with the victim.

50 He indicated that if he became aware of information subsequently, he would data enter that information which would then appear with a "P" notation for police, rather than a "V" notation connoting the "Victim".

51 The DVSAT that was completed by Michelle and Constable Osborne is appended to these findings.

52 Constable Osborne confirmed that Michelle answered "yes" to questions 7, 8, 9, 11, 14, 15 and 16, giving her a score of 7, which placed her as being "at threat". During his oral evidence, Constable Osborne explained that when he entered the responses into the computer he had inadvertently recorded a "no" response to questions 1-3, 13,and 23, rather than a "yes" response. For question 15 he entered a "yes" response rather than a "no".

He confirmed that this appeared to have occurred at a later time when he was transferring the responses recorded on the sticker in his notebook onto the computer system at the police station at the same time he was completing the Computerised Operational Policing System (COPS).

Constable Osborne indicated that he had inadvertently accessed another sticker in his notebook which related to another criminal matter and inputted those responses, rather than Michelle's.

53 Constable Osborne candidly accepted that some of the other responses appeared to be incorrect. These included the responses to questions 12 and 13. Question 12 asks "Does your partner of the relationship have financial difficulties, to which the answer was recorded as "unknown'".

Question 13 enquires "Is your partner unemployed" to which Michelle's response was recorded as "No".

54 Constable Osborne indicated that when he is administering question 24, "Has your partner ever done things to you, of a sexual nature, that made you feel bad or physically hurt you?" he invariably prefaces the question by telling the victim that "These questions are rather personal and if you don't want to tell me you don't have to answer these questions." Constable Osborne stated that he perceives that female victims may feel uncomfortable speaking to a male police officer about such matters and that many female victims would not answer that question honestly unless that were specifically making a complaint about a sexual assault. He confirmed that he had not been trained to approach this question in such a compassionate fashion but had adopted the strategy as part of his usual practice. It is noted that Michelle was recorded to answer "no" to this question despite evidence that Neville may have coerced Michelle sexually.

55 Constable Osborne confirmed that he had interviewed Neville in a formal ERISP commencing at 5.40pm and concluding at 5. 58pm on 17 June 2021.

56 Constable Osborne gave oral evidence that throughout his experience as a general duties officer he was alive to the risk that the perpetrator in domestic violence offences may appear to be calmer than the victim when answering questions from police. Constable Osborne's demeanour during the Body Worn Video (BWV) recording, as well as the ERISP with Neville, was professional at all times.

57 During the ERISP Neville was asked, "What's been going on for a fortnight?", to which he responded "Oh, well, if I ask for sex or anything, she, sometimes she'll give it to me .... " Constable Osborne perceived that this response was potentially illustrative of sexual coercion within the relationship. It was also clearly at odds with Michelle's answer in the negative to question 24. Constable Osborne did not seek to review Michelle's response in light of Neville's apparent admission in his ERISP.

58 In relation to Part B of the DVSAT, Constable Osborne confirmed that he did not know the significance of the overall score of the DVSAT. In particular, he was unaware that if there was a score of 12 or more in Michelle's DVSAT, her risk assessment would have been deemed to be assessed as "at serious threat", and her matter would have been referred to SAM.

59 Constable Osborne was also unaware at that time that he could unilaterally exercise his professional judgment and identify a victim he believed was at 'serious risk', although the DVSAT score was less than 12.

This would then result in the victim being provided with the additional resources and safeguards for their protection.

60 In Part B, Constable Osborne had recorded that Michelle was "afraid" in response to the question "How fearful is the victim of their partner" and in response to "What concern did the victim express (What the victim think the partner might do and to whom)" (sic), he recorded "Fear that her partner would attend the house and hurt her".

61 Constable Osborne was unable to provide an explanation as to why he had not recorded Michelle's assertion, contained in her DVEC recording, that Neville had threatened to kill her, in Part B.

62 Constable Osborne was clearly enlivened to Michelle's significant concerns for her safety, her concerns that Neville had threatened her previously and had stated that he would attend her home and hurt her when released on bail. He indicated that he was now aware that he could exercise his professional judgment during the administration of the DVSAT and effectively override the standard number of risk indicators required to escalate a case.

63 Constable Osborne was aware that domestic violence survivors may be financially compromised as a consequence of violence, whether they remain in their home or need to leave. He contacted Michelle and her

family to advise them of services that could provide financial support; as well as providing reassurance and referrals to the 'Staying Safe at Home' program. This program is designed to provide some practical assistance to a complainant/survivor, such as changing the locks on a house or installing CCTV.

64 The events on 17 June as well as 30 June 2021, clearly had a significant impact on Constable Osborne. He presented as a thoughtful, serious and diligent police officer.

The suitability of the charge selection process 65 Michelle had made an allegation on 17 June 2021 that Neville had choked her with his two hands from behind, applying "fairly good pressure" and that her throat was sore as a result of that pressure. This may well have satisfied an element of the offence of strangulation, as it was at that time.

66 During the ERISP conducted by Constable Osborne with Neville, Neville admitted that he may have hurt Michelle's throat 'a bit' and caused a muffle in her voice. This may have amounted to an admission that he had contact with her throat and adversely affected her throat and airway.

Although Neville made no admissions as to his intent at the relevant time, this would not have prevented a charge being laid.

67 Constable Osborne conceded that he had been told by Michelle that Neville had threatened to kill her on at least two to three prior occasions.

Constable Osborne agreed that he had not recorded Michelle's assertions in the police Facts Sheet and agreed that it would have been prudent to record such threats in the Facts Sheet, as it would have been relevant to any Bail determination in the Local Court.

68 Constable Osborne did give evidence that he had sought the advice of a more senior officer, Senior Constable Neppl as to the appropriateness of a charge of strangulation. Constable Osborne indicated that Senior Constable Neppl advised him that there was insufficient evidence to warrant a charge of strangulation, based on the lack of evidence of Neville's intent; as well as a lack of consistency as to where Neville had placed his hands on Michelle.

69 The Commissioner of Police's legal representative has submitted that the four charges relating to Michelle, "adequately and appropriately address(ed) the criminality alleged and enable(d) the matter to be dealt with fairly and expeditiously accordingly to law." It was further submitted that the "prospect that he would have received a full-time custodial sentence in respect of his alleged offending on 17 June 2021 is vanishingly small. Equally, there is very little chance that an additional s 37(1A) charge would have impacted on his bail status; in the unlikely event the additional charge prompted police to refuse him bail, it would have almost certainly have been granted by the Local Court".

70 It is noted that Neville had a very limited police record for domestic violence, however it is likely that any Local Court Magistrate presented with allegations by two different complainants being strangled in a domestic setting would regard such allegations as an indication of serious offending. Sentencing statistics from JIRS for one count of strangulation, indicates that 38% of offenders are sentenced to a period of full-time custody.

71 The Commissioner of Police's submission that "a period of incarceration might have led to a further deterioration in Neville's mental state such as to increase rather than decrease the prospect that he would engage in violence or harm himself' is a reasonable submission.

The legality of police seizing house keys of a person charged with DV offences or ADVO conditions 72 Constable Osborne confirmed that he had asked Neville to surrender the house keys and Michelle's mobile phone whilst he was at the Police station and under arrest. Neville refused the request. Constable Osborne sought the advice of Senior Constable Neppl and stated that he was advised that he had no legal basis to require that Neville surrender either item.

73 In circumstances such as these, where Neville was placed on both bail conditions and an ADVO with conditions, which required him not to approach or enter the premises that they had previously both occupied, it is clearly an issue which requires legal advice.

7 4 The Commissioner of Police has advised that legal advice has been sought in relation to the legality of seizing house keys from a person accused of domestic violence offences.

Alleged breach of ADVO on 21 June 2021 75 At around 1.30pm on 21 June 2021, Michelle called Jennifer in a panicked state. Michelle told Jennifer that Neville had just driven "really slowly" past the RSM Club Motel where she worked. Jennifer told her mother to contact triple zero and shortly afterwards collected Michelle from work and drove her to the lnverell police station.

76 Michelle spoke with Probationary Constable (PC) John Gilbody at the front counter of the police station and indicated that she believed that Neville had breached the current ADVO by driving past her work, as well as making a phone call to her mobile phone at 10.15am.

77 PC Gilbody took Michelle and Jennifer to a private room to take a notebook statement and administer the DVSAT, confirming in his evidence that he wanted to make Michelle feel comfortable and safe while making

her complaint. PC Gilbody recalled Michelle presenting as "rattled, she seemed nervous but not erratic. She was in control I suppose." 78 In relation to the first alleged breach, PC Gilbody confirmed from Michelle that Neville's mobile phone had contacted her mobile phone at 10.15 am that morning. She indicated that she was unaware of the call at the time and realised that she had a 'missed call', with no message being left on her message bank service to confirm the identity of the caller. PC Gilbody took three photographs of her phone log which confirmed her assertion.

79 In relation to the second alleged breach, PC Gilbody recorded that Michelle had told him that "I believe he was looking towards me as he drove past" her place of work. PC Gil body stated in his oral evidence that "at the end of the statement while she was signing it, the more I read it something just didn't feel right and I thought I need to clarify whether Neville had made any gesture, whether he'd snapped his - like rapidly moved his neck towards her .... So I wanted to try and close in on that evidence and focus on her actually observing him and identifying him as the driver of that car, and that he had made that eye contact or some kind of gesture in case it was a threat. Or whether he made any of those kind of advances whilst driving past." 80 PC Gilbody stated that Michelle then said, "Come to think of it I don't actually think it was him." Interestingly, Michelle's first version given during the triple zero call, has her recorded as saying I "don't know if he saw me standing out the front." 81 PC Gilbody then spoke with his supervisor, Sergeant Prescott and advised him of the details of Michelle's complaint. PC Gilbody indicated that both he and Sergeant Prescott were of the view that there was insufficient evidence to sustain a charge of breaching the ADVO in relation to the Neville driving past her that afternoon. PC Gilbody contacted Neville and asked him to attend the Police station.

82 PC Gilbody interviewed Neville and put both allegations to him. In relation to the phone call, Neville indicated that he must have inadvertently 'pocket dialled' Michelle's phone. PC Gilbody gained access to his phone and confirmed that his phone had contacted a number which was identified as Michelle's although the number was not saved as a contact number for 'Michelle'. PC Gilbody noted that Neville also had Jennifer's number saved under 'Jennifer' in his contact list. PC Gilbody directed Neville to delete both numbers from his phone whilst at the police station.

83 PC Gilbody indicated that Brendon was present when his father, Neville, was being interviewed. Brendon told PC Gilbody that "I sometimes use Dad's phone, but I'm, unsure whether I made that phone call or not." 84 In relation to the second allegation, Neville told PC Gilbody that he did not believe that he had driven past Michelle' workplace, although he had seen her earlier in the day near the Centrelink office and had avoided coming

into contact with her. Neville stated that he had been doing various jobs around town and named a number of places that they had visited that afternoon, including the local bakery.

85 PC Gilbody perceived Neville to be non-aggressive and apologetic. PC Gilbody recalled Neville said "I'm really sorry mate", and PC Gilbody perceived that "he was genuine." PC Gilbody candidly agreed that he was unaware of the possibility that DV perpetrators often present as calmer than the victim. PC Gilbody also assessed Neville as presenting with "no hint of mental health".

86 At the time he was taking Michelle's statement regarding the two alleged breaches of the ADVO, PC Gilbody re-administered the DVSAT with Michelle.

87 PC Gilbody confirmed that he had never personally administered a DVSAT prior to administering Michelle's, although he had "probably observed or assisted" on previous occasions.

88 At the conclusion of the questionnaire a score of 11 out of 25 was recorded. A "yes" response was recorded for questions 1, 2, 3, 7, 11, 13, 14, 16, 17, 21 and 23.

89 Somewhat confusingly, question 8, being "Is the violence/controlling behaviour escalating?" was recorded on 17 June as a "Yes" but was subsequently recorded in PC Gilbody's administered DVSAT as "Unknown". Similarly, question 9, being "Has your partner stalked, constantly harassed or texted/emailed you?" was originally recorded as a "Yes" and in the second DVSAT was recorded as a "No". Given the score of 11, Michelle's matter was not referred to a SAM, however, a referral was made to the WDVCAS.

90 Jennifer was present for some of the DVSAT questions put by PC Gil body to her mother, Michelle. Jennifer gave oral evidence that when she heard some of the responses given to some of the questions by her mother, she thought the answers were contrary to her knowledge of events. Jennifer didn't say anything because "it was Mum's questions." Jennifer confirmed that she perceived that Michelle may not have understood the questions completely given her "neurological" issues. Jennifer suggested that some of the "wording could've been a little bit different" in the DVSAT, which may have assisted Michelle's comprehension.

91 PC Gilbody recalled Michelle paused and was unsure in answering some of the questions, including whether there had been an escalation in violence or threatening behaviour. PC Gilbody accepted that there were potential inconsistencies in her answers, for example when she answered 'yes' to Neville being unemployed and 'no' for whether your partner or the relationship have financial difficulties. He indicated that he had not second guessed her responses as he assessed her as being clear in those responses.

92 PC Gilbody confirmed that he was unaware that a DVSAT had been administered to Michelle two weeks prior to his interview. He acknowledged that he was therefore unaware of the earlier inconsistencies with the DVSAT he had administered.

93 There were critical gaps in PC Gilbody's training and knowledge of the DVSAT. In particular, he gave evidence that he did not know the significance of the score of the DVSAT, which meant that he didn't appreciate that those assessed as being at serious risk would be referred to a SAM for consideration of additional safety measures. He gave evidence that he was also unaware that he could exercise his own professional judgment to nominate Michelle as being at serious risk, which would have triggered additional safeguards to protect Michelle.

94 As an inexperienced police officer in 2021, PC Gilbody impressed as being prepared to embrace advice and training, both formal and 'on the job' training from more experienced officers.

95 His oral evidence was clear, direct and he was prepared to make admissions contrary to his own interests. He commented that his experience relating to Michelle's death had been an "horrific experience" which had left him with an "incredible amount of self-doubt and blame from that result," and that he had reflected very deeply on his involvement.

96 Detective Chief Inspector (DCI) Roger Best was the Crime Manager for the New England Police District and Chair of the New England DVSAM and Crime Manager. On 1 July 2021, he commenced an internal investigation and review of the police conduct leading up to Michelle's death and the serious wounding of Jennifer.

97 In his first statement dated 8 August 2021, DCI Best reviewed PC Gilbody's investigation relating to Michelle's complaint of the two breaches of the ADVO on 21 June 2021.

98 DCI Best compared the information provided by Michelle to the triple zero operator and the police at lnverell on 21 June 2021. He noted that Michelle had informed the triple zero operator that "I don't know if he saw me standing out the front" and compared that to Michelle's statements to PC Gilbody, which included her stating in the notebook interview, "I believe he was looking towards me as he drove past." He further considered the two versions contained in the COPs event being, firstly, that she was unsure if Neville had seen her, and secondly, that at no time had Neville looked at her or made any gestures towards her.

99 DCI Best concluded that PC Gilbody should have taken a second formal statement from Michelle to clarify which version was to be relied upon. PC Gilbody conceded in his oral evidence that he should have taken a second clarifying statement from Michelle regarding the events on 21 June 2021.

100 In his second statement, dated 17 July 2023, DCI Best indicated that he had reviewed the phone call made on 21 June 2021, from Neville's phone to Michelle' phone.

101 DCI Best noted that the phone call was recorded as being of nine seconds duration. He noted that no message was recorded on Michelle's message bank at all. He considered Neville's explanation that he must have 'pocket dialled' Michelle's number by mistake. DCI Best noted that if that had occurred, he would have expected that a message would have been recorded on Michelle's message bank consistent with a recording of background noise. He concluded that Neville had been untruthful to PC Gilbody.

102 DCI Best stated that PC Gil body was unaware of the details of the nine second call. He expected that had he been aware, that this detail would have affected the DVSAT score and may well have resulted in Neville being charged with breaching the ADVO. DCI Best noted that if Neville had been charged with the breach of the ADVO, he would be unlikely to have been bail refused by the police.

The Women's Domestic Violence Court Advocacy Service (WDVCAS) 103 The Women's Domestic Violence Court Advocacy Service (WDVCAS) provides "information, advocacy, safety planning and referrals for victim survivors, for example to family support and counselling services, accommodation and health services, legal advice on ADVOs and other legal issues such as family law, debt, immigration, victim's compensation and tenancy. WDVCAS also provide support for victim-survivors through the court process at all local court across NSW".

104 After police record a complaint of domestic violence on WebCOPS, women are automatically referred to a WDVCAS by police via an online Central Referral Point as part of the Safer Pathway, multi-agency system.

Male victims are referred to a different support service, the Local Support Service.

105 The Safer Pathway system has five key components, being: a. undertaking a DVSAT to identify the level of threat; b. a central referral point to electronically manage and monitor referrals, primarily from the NSW Police Force; c. a state-wide network of support services for victims, collectively known as the Local Co-ordinated Point services delivered by WDVCAS and Local Support Service (LSS) for male victims; d. Safety Action Meeting (SAM); and e. information sharing under Pt 13A of the Crimes (Domestic and Personal Violence) Act 2007 which allows service providers to share information about victims and perpetrators.

106 After receiving a computerised referral, the WDVCAS is required to contact the victim within 24 hours of the next business day. The electronic referral contains the victim's contact details, the other party's name and a DVSAT completed by the police. The referral does not annex the DVEC nor witness statements. On some occasions, the ADVO narrative is forwarded with the referral. COPS entries or criminal histories are not included, however, on some occasions limited historical information may be included in the referral.

107 Ms Jasmine Chaffey, manager of the WDVCAS in the New England Police District, commented that access to the COPS entries, together with a referral, would greatly assist the WDVCAS workers to determine if there is a pattern of behaviour or repetitive behaviour.

108 During the initial contact by WDVCAS, a DVSAT is conducted, unless it is determined that it is not the most appropriate time to conduct the survey. A face-to-face meeting is arranged and the DVSAT is undertaken if not previously completed over the telephone.

109 Ms Chaffey confirmed that on 23 June 2021, WDVCAS received a referral from police relating to the allegation of the breach of the ADVO on 21 June

2021. On 28 June 2021, the WDVCAS received a further referral relating to the earlier allegations of assault occasioning actual bodily harm from the incident on 17 June 2021.

110 Ms Chaffey stated that one of her colleagues contacted Michelle on three occasions after receiving the 23 June 2021 referral, with no response from Michelle. Ms Chaffey further confirmed that after receiving the referral dated 28 June 2021, they successfully contacted Michelle on 29 June 2021.

111 On 29 June 2021, Michelle consented to receiving court support and the reimbursement costs for the change to security locks on her home, as part of the Staying at Home Leaving Violence program. Michelle declined the offer of a free counselling referral.

112 Ms Chaffey perused the records at the WDVCAS and could not locate a completed DVSAT relating to either of Michelle's referrals.

113 Ms Chaffey confirmed that the WDVCAS administers the DVSAT from a trauma-informed approach by attempting to encourage the client to answer the questions by adopting a conversational approach, rather than simply asking the 25 questions. The support staff are cognisant that the client has recently experienced the DVSAT questions (potentially just 24 hours earlier) with the police and "we don't want them to feel like it's the same questions being asked and re-triggering the client as well." 114 Ms Chaffey stated that her staff receive their training through a foundation program facilitated through Legal Aid. The training program runs for two

days. Ms Chaffey was unsure as to whether the police receive the same training.

115 Ms Chaffey indicated that her staff were aware that clients will advise the interviewing police of one answer and provide a different answer to the WDVCAS support worker.

116 Ms Chaffey confirmed that there have been times when clients have told WDVCAS staff that they didn't understand the question. She stated that this was often the case with the strangulation question in the DVSAT, which states "Has your partner ever choked, strangled or suffocated you or attempted to do any of these things?". Ms Chaffey explained that her staff prefer to ask the client if the "other party has ever put his hands near or around her throat or neck, regardless of the pressure. Because we found that previously when we were using the strangulation question, the way it's worded, our clients thought that it meant that they were either struggling to breathe, stopped breathing, or passed out." 117 Ms Chaffey confirmed that the question relating to sexual assault and sexual coercion was approached by her empathetically by telling the client that they were going to be asked personal questions and that if they were not comfortable answering them, they were not obliged to answer.

118 Ms Chaffey agreed that when a client answered with an "unsure" response to police that an effective option would be to allow the police officer to record something to the effect of "Would you rather talk to a woman" or "would you rather talk to a WDVCAS officer".

119 Ms Chaffey confirmed that she was aware that she could refer a client who scored less than 12 but was assessed by her as being the subject of a serious threat to a SAM. Ms Chaffey further stated that "a lot of weight" should be attached to a client's self-perception of risk, as they know the "other party better than anybody else." 120 Ms Chaffey indicated that the following circumstances should result in an automatic referral to a SAM, whether or not the score was 12 or less than

12. They included where the partner had indicated that "If I leave him, he's going to come here and kill me", or where the self-assessment box rating was "terrified", or where there is a non-fatal strangulation indication. In addition, Ms Chaffey was of the view that a threat to harm or kill himself (the alleged perpetrator) or the victim should also result in an automatic referral to SAM as it constituted a serious threat.

121 Ms Chaffey indicated that the SAM meets every second Thursday in Armidale. An agenda is prepared the Thursday prior to the meeting and the agenda is revised on the Monday immediately prior to the Thursday meeting. The revision has been designed to capture serious threat assessments made between the two referral periods.

122 Ms Chaffey confirmed that government agencies such as police are mandated to attend each meeting, whereas non-government agencies will usually only attend if a client has been identified as requiring assistance on the Monday prior to the Thursday meeting.

123 Information shared during the SAM provides the basis for further investigations, as well as ongoing support to clients. For example, NSW Corrections may direct further monitoring of an offender where that person is the subject of community corrections orders, or the Department of Education representative may contact the child's school to enquire if there are any behavioural issues or concerns related to DV in the home. Police may undertake bail or ADVO compliance checks.

124 Ms Chaffey indicated that there are various supports available to women referred to her service. The Staying at Home Leaving Violence program is designed to provide security upgrades to a client's home, including changing locks, providing security screens and CCTV free of charge.

Often the police will have already made the referral prior to the involvement of the WDVCAS.

125 Ms Chaffey advised that her service does not have ongoing brokerage to provide funding for crisis accommodation for clients, however, the WDVCAS does refer clients to women's shelters to assist with temporary accommodation.

126 Ms Chaffey confirmed that many women experience financial difficulties which prevent women leaving a violent domestic relationship. Ms Chaffey indicated that financial support is available through Victims Services and the Wesley Mission Service, providing funding for relocation, trauma and counselling referrals.

127 Ms Chaffey stated that her service frequently assists clients in the preparation of paperwork and applications, which is often too overwhelming for the client.

128 Ms Chaffey gave oral evidence, confirming that a pilot program, known as a co-location program, is currently being trialled in Armidale. The co location program is designed to have a representative from the WDVCAS available at the police station in Armidale on weekdays to facilitate a liaison between female victims and police. The WDVCAS will advocate on behalf of their client and assist police by building a relationship between them. The WDVCAS have built a strong rapport with the Domestic Violence Liaison Officers (DVLO) at Armidale Police, including advising police of the needs, requests and reasons for ADVO and bail conditions from the victim's perspective. Ms Chaffey commented that "whilst police do the application (ADVO) for them, we can still advocate for either stronger conditions or maybe different conditions that would suit the family best. We then attend Court either on their behalf or in support with them at Court".

129 Ms Chaffey confirmed in her evidence that the current pilot has been funded for a further 12 months, as of September 2023.

130 Ms Chaffey indicated that both her service and the police at Armidale are supportive of having a WDVCAS worker attend scenes of crime once they have been secured by police. Ms Chaffey stated that such an early intervention may result in greater acceptance of help, support and referrals being made to assist victims, who are often in a heightened emotional state at the scene.

131 Ms Chaffey gave oral evidence about the Court support service provided by WDVCAS. As at September 2023, the WDVCAS in Armidale was funded to provide support on ADVO list days only and was not funded to provide support during any contested hearing. Ms Chaffey noted that Courthouses were designed so that everybody uses the same entrances, which results in female clients coming in direct contact with alleged perpetrators and their families. Ms Chaffey indicated that this often results in female victims being too afraid to attend Court. Her service is able to attend in their client's absence and later advise the client as to the outcome of the Court listing.

132 Ms Chaffey confirmed that she had become aware that Michelle and Jennifer's assault cases were listed for mention at Armidale Court on 1 July 2021.

133 Ms Chaffey was asked whether any offender-based programs were available in the New England area. Ms Chaffey indicated that "There's a men's behavioural change program - I'm not sure if it's rolled out in Armidale yet - that's run through Centacare." Ms Chaffey noted that offender-based programs were usually undertaken on a voluntary basis, rather than on a Court mandated attendance basis.

Delay in Police notifying WDVCAS explained 134 Detective Senior Constable Samantha Prescott provided a further statement dated 13 September 2023. Detective Prescott had reviewed the Event Number created by Constable Osborne and the associated events on the NSW Police COPS system relating to the 17 June 2021 complaint.

135 Detective Prescott was able to confirm that the Event history on 17 June 2021, indicated that an "Electronic transfer to visicase victim was disseminated. It shows this was completed by Constable Osborne. This is an automatic dissemination and sent when the officer in charge created the event." 136 On 17 June 2021, Constable Arthur attached the Body Worn Video to the Event, which allows for other material such as statements and notebook entries to be added to the COPS system. Leading Senior Constable Neppl reviewed and resubmitted the Event to Constable Osborne as Michelle's address and date of birth were incorrect.

137 On 19 June 2021, Sergeant Laing resubmitted the Event to Constable Osborne seeking to have the incorrect address corrected. On 20 June 2021, Senior Constable Eggins resubmitted the Event to Constable Osborne to correct the date of birth and the DVSAT question "no DV relationship".

138 Between 20 June to 28 June 2021, Constable Osborne was not at work and corrections remained outstanding. On 28 June 2021, Constable Osborne corrected the outstanding items and Sergeant Prescott, the Shift Supervisor disseminated the Event to WDVCAS.

Days leading up to the murder of Michelle and serious assault on Jennifer 139 On 21 June 2021, Mr Des Kemp asked Neville to leave his house as his daughter was due to stay. Neville's son, Chris, assisted in arranging alternative accommodation at the John Wills boarding house in Henderson Street, lnverell.

140 At 2.50pm on 21 June 2021, Michelle attended at the real estate agency, Nurtrien Harcourts Davidson Cameron and Co and spoke with Mr Todd Anderson and his colleague, Amanda. Michelle showed Mr Anderson and Amanda a copy of the ADVO and asked him to change the locks on the premises she had leased at 187 Glen Innes Road, lnverell. Mr Anderson recalled Michelle's demeanour as "anxious and concerned," which was unlike her usual friendly demeanour. Mr Anderson confirmed that the locks to the premises were changed on 22 June 2021 and that Neville never approached him for access to the new keys.

141 According to Jennifer, Neville called Michelle's phone at 7.30pm on 21 June 2021, while Michelle, Jennifer and Brendan were having dinner.

Neville then called Brendan and informed him that he had accidentally contacted Michelle's phone whilst he was attempting to delete Michelle's contact details, which appears to contradict the evidence of PC Gilbody that he had been directed to delete the contact numbers at the police station earlier that day.

142 On 25 June 2021, Neville posted on Facebook, "how much pain can a daughter cause. So much pain and your wifey taking her side." 143 During the weekend of 26-27 June 2021, Ms Lindylee Kemp noticed that Neville had changed his relationship status on his Facebook profile to "widowed". During the murder investigation, Police examined Neville's Facebook posts and discovered the following post dated 30 June 2021, "they have pushed me to my limits can't take anymore love yous".

144 On 26 June 2021, Neville attended the Big W store in lnverell with Brendan. CCTV footage showed Neville purchasing a utility knife set and a Wiltshire knife. A copy of the receipt of purchase was later recovered by

police. Brendan later told police he thought Neville had purchased the knives for cooking.

145 Brendan indicated to Police that during this period Neville would say that he should "go there and slit their throat and then do him, do himself, like, right after." Brendan told police that Neville would make comments about getting a gun and shooting Michelle and Jennifer and then himself.

Brendan also recalled Neville speaking about buying a rope and when Brendan asked him "why", Neville had told him "you should know why." 146 On 29 June 2021, Neville attended an appointment with his solicitor, Mr Kemp in relation to the 17 June 2021 charges. Police were later informed that Neville was very agitated about attending Court on 1 July 2021, and that it took some time for him to calm down.

147 Later that afternoon, Brendan and Neville were seated in Neville's car.

Neville told Brendan that he should kill Michelle so that she would be unable to 'cheat' on him with a work colleague, Kyle. Both were crying and hugging each other. Brendan recalled that Neville said to him "that's probably gunna be the last hug." 148 Later, Neville contacted Brendan by text and enquired whether Michelle and Jennifer were home. Neville sent a series of messages to Brendan, including, "Love you all my heart and soul praying for to get through this painful life we caused you love you son, I'm going to heaven or hell tonight love you always son." 149 During the murder investigation, Police located the following internet searches, conducted by Neville from 28 - 29 June 2021: a. "where would be the best place to kill someone with a kitchen knife", b. "where on a human the best place to stab a heart located", and c. "What the easiest way to commit suicide." The murder of Michelle and serious wounding of Jennifer on 30 June 2021.

150 On the evening of 29 June 2021, Michelle was at her home at 187 Glen Innes Road, lnverell. Her extended family were also present, consisting of Brendan, Jennifer and her infant son, Chris and Christina and their two young children.

151 At 2am, Christina was woken by Brendan's dog barking. She then recalled hearing three or four loud bangs. Christina got out of bed and moved to the loungeroom, when she heard the backdoor open and could see a lit cigarette. Christina then saw Neville and ran to wake up Chris. By the time Christina returned, Neville had locked the hallway door.

152 Jennifer was asleep in her room with her infant son. She was woken by her bedroom door banging and saw Neville with something silver in his hands. As he approached her, Jennifer kicked Neville in the stomach and

he commenced stabbing her in the head. Jennifer heard her mother say "stop or I'll get Chris" and then recalled seeing her father stabbing her mother to her head. Jennifer collapsed and lost consciousness.

153 Brendan was woken by Christina and went to Jennifer's bedroom. He saw Neville pointing a knife at him, with a string or rope in his hand which he believed Neville was going to use to strangle Jennifer. Chris was also present and was telling Neville to leave. Neville stated, "I just want my bag" and left. Christina contacted triple zero. Chris noticed that the back door was open, and the lock was smashed.

154 Constable Brodie Casburn and Constable Claudia Gilmore were the first responders. Senior Constable Angela Sheedy arrived shortly afterwards.

Constable Gilmore noted that Jennifer was breathing and making noises, however the other female, being Michelle, was unresponsive. Constable Gilmore commenced CPR on Michelle until the paramedics arrived shortly afterwards.

155 Jennifer had sustained 13 wounds from the attack and was transported by ambulance to lnverell Hospital and was later transported by helicopter to Tamworth Hospital in a critical condition.

156 Michelle was declared deceased at the scene by attending paramedics.

157 Senior Constable (now Detective) Angela Sheedy prepared three statements in these proceedings, dated 11 July 2021, 21 October 2022 and 26 May 2023.

158 Detective Sheedy was the most senior officer present and was cognisant of the need to secure and co-ordinate the scene. Detective Sheedy was aware that two persons had been stabbed and that the offender appeared to have left the property.

159 Detective Sheedy contacted Sergeant Wilkins at lnverell police station and stated that "I want everyone", meaning she needed extra police to assist logistically, to control and preserve the scene, secure medical attention for Jennifer, ensure the safety of officers and witnesses and provide information to other officers to assist with the detection and arrest of Neville.

160 Detective Sheedy ensured that the family members were relocated to a neighbouring property and commenced interviewing Chris on her body worn video (BWV) device. During this preliminary interview, Chris advised Detective Sheedy about the assault on 17 June 2021 and the associated ADVO and that Neville had left the house in a Nissan Triton motor vehicle.

161 During that interview, Detective Sheedy received various phone calls, including one from Sergeant Ian Campbell, Duty Operations Inspector (DOI) at the State Coordination Unit. Detective Sheedy stated in her oral evidence that she cannot recall the details of that conversation, although

she believed that she would have provided Sergeant Campbell with an appraisal of the scene, including that there was one person deceased, another critically injured and that the offender had left and was not at the scene.

162 At the time of the first phone call with Sergeant Campbell, Detective Sheedy was unaware that any threats had been made to any other members of the family outside the immediate household. Detective Sheedy perceived that the attack on Michelle and Jennifer appeared to be 'very targeted' and that Neville had left without physically hurting anyone else.

163 At that time, (2.59am), Detective Sheedy did not perceive that she was participating in a triangulation request with Sergeant Campbell. She based her perception on the information that was available to her at that time and the high threshold that existed at that time to have a triangulation request approved.

164 Detective Sheedy stated that her experience with triangulation requests at that time "have largely centred around missing persons that have indicated an immediate intent to harm themselves. But my other knowledge of why you would get a triangulation is things like a bomb threat, threat to a member of Parliament, a serious offence has occurred and that the offender's going to hurt someone else. But I, I didn't receive any information like that at, at the scene." 165 Detective Sheedy acknowledged that the situation was very serious with one person dead and another in a critical condition in hospital and noted that "there was six other people in the house, and they hadn't been harmed. So not, not saying that I went- well he hasn't hurt those other people so he's not a threat. But certainly - he'd left, he hadn't hurt anyone else. It appeared very targeted ... " 166 Detective Sheedy agreed that her previous experience in requesting a triangulation had been primarily in cases involving a missing person and that the threshold had been difficult to meet. Detective Sheedy stated that "In my experience contacting the DOI to, to request a triangulation can be met with gruffness and often those triangulations can be rejected if it hasn't met the threshold in their view. I would say I've had more matters rejected than accepted. So I do know that it's a, it's a high threshold to meet. I can't say why, but that's my experience." 167 At 3.13am the Police Computer-Aided Dispatch (CAD) identified a Facebook post on Neville's site, stating, "They have pushed me to my limits. Can't take anymore. Love you." Detective Sheedy confirmed in her third statement that she was unaware of the existence of this post until she had left the crime scene and returned to the Police station.

168 At 3.32am, Detective Sheedy conducted a BWV interview with Christopher Kemp. During the interview, Christopher asked "Have you got him or not".

He then told Detective Sheedy that "There's some people I'd like you to check on .... Yeah like my Nan and stuff because I don't know what's going on in his head." Triangulation requests made by investigating police on 30 June 2021 169 The Radio Operations Group of the NSW Police Force oversees three major communication roles. The first area of oversight provides the triple-0 response and dispatch to police. The second area of oversight relates to rescue coordination and activates rescues throughout the state and the third area of oversight is the management of the State Coordination Unit.

170 The State Coordination Unit is responsible for the "effective co-ordination of specialist resources in support of front-line policing activities across the State; the timely reporting of "Serious", "Unusual" or "Noteworthy" incidents to the Executive; and the activation of various plans in response to critical incidents and acts of terrorism. Other duties of the State Coordination, in any shift, includes:

• "Administers accesses to external agency information systems that can assist in the investigation of matters such as IPND (Integrated public number database) call trace and mobile triangulations.

• Provides a written Executive Briefing at 5am and 5pm daily

• Co-ordinates available and on call resources for the NSWPF

• Activates various plans in response to critical incidents and action plans for major disasters

• Provides 24/7 response to high level enquiries and requests from the operational field for specialist resources.

• Triangulation requests

• External mental provider requests for assistance for call trace for clients who are at risk of self-harm." 171 Section 287 of the Telecommunications Act 1997 (Cth) empowers a State Coordinator (SCU) in the State Coordination Unit to grant an application from a NSW Police officer for a live mobile location request, known as a triangulation.

172 In June 2021, a SCU was required to consider whether a request for a triangulation met the threshold that it was reasonable to believe that a serious and imminent threat exists to the life or health of a person/persons and that a triangulation is reasonably necessary to prevent or lessen that threat. The legislation has subsequently been amended, removing the requirement that the "threat" be determined to be an "imminent" threat.

173 While it is not entirely clear on the evidence, it appears that up to three 'requests' for a triangulation were considered by two different SCUs on 30 June 2021, in relation to the location of Neville's phone.

First Triangulation Request

17 4 As discussed above, Detective Sheedy received a telephone call from Acting Inspector (A/lnsp) Ian Campbell at 2.59am. At that time, Detective Sheedy was performing various tasks associated with the preservation of the crime scene, the transportation of victims and ensuring the safety of witnesses. Understandably, Detective Sheedy had little recall of the specifics of the conversation she had with A/lnsp Campbell. Detective Sheedy provided oral evidence that she did not consider that she was making an application for a triangulation at that time.

175 A/lnsp Campbell recalled that he waited some twenty minutes before contacting Detective Sheedy as he had wanted to give the officers at the scene an opportunity to process the scene prior to speaking with him. He confirmed that he spoke with Detective Sheedy for 32 minutes. Prior to calling Detective Sheedy, A/lnsp Campbell reviewed a CAD report of the incident at 2.55am.

176 He further confirmed in his oral evidence that he had not recorded the conversation he had with Detective Sheedy and made sparse notes. In oral evidence, he stated "The problem is there wasn't a formal request.

Usually, usually I would take more notes and I was surprised I didn't take as many notes as I usually do. If anything, I'm usually you know the comments that i made, not that they're seen that, that often that I take a lot of notes so that I don't have to rely on my memory and so that if the matter is passed on, it will scrutinise that they are all there. So I'm surprised that I, I didn't record it in that much detail." 177 A/lnsp Campbell was asked whether he now accepted that he should have recorded the conversation with Detective Sheedy. He responded "No" and when pressed, indicated "That, that, that, that they should have? Because a number of things can happen in this situation. I could've got a call five minutes later with pertinent information and a triangulation could've been authorised, as I said, there are a number of different possibilities." 178 A/lnsp Campbell gave oral evidence that he told Detective Sheedy that "you don't have enough for the, for the triangulation at this stage." The following exchange appears in the transcript of his oral evidence: "Q. So you've said that notwithstanding that fact that a request wasn't made?

A. Yeah, that's right because I like to let them know where they, where they're situated in, in respect of that. There's no point in me talking to them

• we've got, we've got, we've got to be clear to you know clear to in that communication.

Q. In terms of clarity did you tell her what she needed?

A. What - no, no because she, she would've realised that from the conversation.

Q.How?

A. Cause the first thing, the first thing I asked is anyone, is anyone else under threat.

Q. I'll stop you there. It's the first time you've given evidence that you asked that question. Are you sure you asked that question?

A. That I asked her whether anyone else? Absolutely, I remember, I remember from this incident. It was the number one question. Where are they? And is anyone else under threat from this person?" 179 A/lnsp Campbell was taken to the Standard Operating Procedures (SOPs) in force at the relevant time. The SOPs listed some basic examples of threats against a person, including where a request has been made by investigative police for a geographical location of a phone where a person has committed a murder and left the scene. He agreed that he was aware the Neville Michell fitted that description and additionally, the SOPs required consideration of whether Neville would be regarded as dangerous and likely to commit another crime.

180 A/lnsp Campbell was also taken to the "basic investigation questionnaire sheet" which contains "Information required by the DOI (formerly the SCU) for consideration of activating a triangulation". He agreed that some of the questions he posed to Detective Sheedy accorded with the questionnaire.

A/lnsp Campbell could not recall if he had enquired with Detective Sheedy whether Neville was in possession of a mobile phone. He indicated that 90% of people have a mobile phone and that most of them would have the phone switched on.

181 A/lnsp Campbell was asked whether he accepted that determining whether the person had a phone was crucial to whether a triangulation could be performed, he responded, "Yeah, but that's for an entirely different, very different situation to this one. As I said, they're at various different situations that present themselves for the field and they're mainly for I would say less, less pressing matters than what was, what was happening in this particular incident." 182 A/lnsp Campbell confirmed that he can access information from the Real Time Intelligence Centre which undertakes its own intelligence research independently from investigating police and can advise the SCU of relevant information. He confirmed that "the radio operators on that particular channel are doing research as soon as the, the job is created.

As soon as the, as I said, those entities, vehicles, addresses, persons are known. So they look at yeah, criminal histories, AVO matters, sentences, good behaviour bonds", as well as DVSAT reports.

183 A/lnsp Campbell indicated that based on all available information in his possession, he did not perceive that there was sufficient information to confirm that Neville was "dangerous and likely to commit another crime." He noted that "it was domestic related, there were specific, specific persons were attacked in specific circumstances and I was given some information about there being a history there by just by the existence of the, the mention of the AVO in particular." He agreed that in his assessment, Neville had already "attacked the people that he wanted to."

184 A/lnsp Campbell agreed that his logbook entry did not record any persons as being "at risk", however, he was certain that he had specifically asked Detective Sheedy that question. Further, he stated that Detective Sheedy had given him "a definitive answer at that time" however he could not recall specifically being told that she had "checked with the family and confirmed he's no threat." 185 This was despite confirming that he became aware of the CAD entry at 3.13am from Neville's Facebook page which read "They have pushed me to my limits. Can't take anymore. Love you." A/lnsp Campbell indicated that he did not consider the post to contain a threat of self-harm, nor that a person who has just engaged in acts of extreme violence may then consider committing suicide. He confirmed that in his assessment, this post was insufficient to meet the triangulation threshold test.

186 A/lnsp Campbell was questioned as to whether he accepted that part of his assessment of dangerousness should also consider whether this person of interest was a threat to the community in general. His responses were confusing and evasive.

187 A/lnsp Campbell confirmed in his oral evidence that he had not recorded in his logbook that the case had not met the threshold for triangulation and the reasons why the application had been declined because Detective Sheedy had not made a formal request for a triangulation at any time.

188 A/lnsp Campbell stated that he had spoken with Inspector Posner who was to relieve his shift and informed him that "there'd been no further evidence that had come to light that would strengthen the application and cause the application to be approved," and that "specifically we hadn't identified a threat to any other person, family or otherwise or a threat of self-harm".

Second triangulation request - evidence of Detective Sergeant McDonald 189 Detective Sergeant Casey McDonald was urgently called to duty at around 3am on 30 June 2021. He was stationed at Armidale, which is approximately a ninety-minute drive from lnverell. He received a briefing at Armidale police station and then travelled with Detective Matthew Robertson and Detective Leah Harman to lnverell. At that time, they were aware that Michelle had been murdered, Jennifer was in a critical condition and Neville had left the crime scene in a Nissan Triton motor vehicle, with a known registration number.

190 Detective McDonald also became aware that a request for a triangulation had been refused, which he stated came as a surprise to him, given the known facts. He indicated that these types of matters "require all sorts of different responses, however, it was my opinion driving over there and mine only that it would be likely that after an incident like this the offender could possibly want - wish to harm themselves."

191 Detective McDonald indicated that he was focused on apprehending Neville and ensuring that he had effective crime scene management tasked and activated. He noted that, as he commenced assessing the known information, public safety was paramount. He stated that offenders may "hide and it takes time to locate them" or they may "take their own life" or they may attack someone else.

192 He confirmed that his team were monitoring Real Time and the Facebook message authored by Neville (the 3.13am CAD) gave him further concern.

He also recalled becoming aware through Real Time intelligence that Jessica, one of Neville's daughters was living in Tamworth. Although there did not appear to be any specific threat levelled at his daughter Jessica, a police car was despatched to check on her welfare later that morning.

1-93 Detective McDonald confirmed that he had spoken with Detective Prescott at lnverell police station and had been provided with information regarding the investigation. He did not recall specifically asking Detective Prescott if Neville had made any threats to any other family member.

194 Detective McDonald recalled Detective Robertson leaving the briefing at lnverell police station to call the SCU to make a further triangulation request at around 6am. He recalled Detective Robertson returning and confirming that a triangulation had been approved. He could not recall if Detective Robertson had returned prior to him stating that he had been granted the triangulation.

195 Detective McDonald confirmed that a triangulation map was produced, and a search was then co-ordinated resulting in the police locating Neville at 7.45am. He stated that when located Neville was cold to the touch, with some minor rigor mortis evident.

196 Detective McDonald noted that it is invariably senior police, holding the rank of sergeant or above, that communicate with the SCU for triangulation requests. He agreed that it would be of assistance if ongoing training could be provided for the SCU and senior police to ensure that the most meaningful questions are asked and addressed by both parties during the application process.

Second triangulation request - Evidence of Detective Senior Constable Matthew Robertson 197 Detective Senior Constable (DSC) Robertson prepared a written statement dated 15 May 2023. He recalled being advised that Neville was a suspect in the murder of Michelle and the serious wounding of Jennifer and that he had left the scene in lnverell.

198 During the road trip from Armidale to lnverell, DSC Robertson became aware that an initial application for a triangulation of Neville's phone had been declined. DSC Robertson was asked by Detective McDonald to make a further application once they arrived in lnverell due to the patchy

phone reception available during the car trip. DSC Robertson stated that he formed the view that "despite the absence of any direct threats of harm, he (Neville) should be considered an imminent threat to himself and other family members".

199 DSC Robertson recalled speaking by phone with Inspector Posner at around 5.40am, Uust prior to him contacting Tamworth police at 5.44am).

He understood from this conversation that Inspector Posner had some knowledge of the earlier application. DSC Robertson recalled being told by Inspector Posner that his application was insufficient, and that he would need to provide more cogent information than simply seeking to locate Neville.

200 At 5.44am, DSC Robertson contacted Tamworth Police station and requested that local police travel to Jessica's home to ensure that she was safe.

201 At 6.37am, DSC Robertson spoke with Inspector Posner, who had been delayed due to attending to another urgent matter. At the end of their conversation a triangulation was approved. At 6.41am a triangulation map was provided to DSC Roberston who forwarded the map to his search co ordinators, who commenced the ground search for Neville.

Second triangulation request - Evidence of Inspector Stewart Posner 202 Inspector Posner prepared a statement dated 9 September 2022. He had relieved Sergeant Campell at 6am on 30 June 2021 and had been advised that there had been a homicide in lnverell. He indicated that he had little recollection of the details of his involvement in the request for a triangulation made by DSC Robertson and had relied on the contents of his notations in the Police Force Radio Logbook to prepare his statement.

203 Prior to giving his oral evidence, Inspector Posner was provided with a copy of DSC Robertson's statement. Inspector Posner accepted that there had been two conversations that morning, with the second conversation being the one he referred to as taking place at 6.28am.

204 Inspector Posner indicated that "once he'd (DSC Robertson) supplied information that he believed there was another daughter at risk" he had no concerns in approving a triangulation. He stated that as far as he was aware, "they didn't have an address or a phone number for her, so she was uncontactable. So based on that, I believed there was some urgency around trying to locate Neville Michell." It would appear that Inspector Posner is referring to his activation of the triangulation at 6.28am.

205 Inspector Posner accepted that he must have advised DSC Robertson at the conclusion of the first phone call that he had provided insufficient information for the triangulation. He accepted that he had not recorded that determination in the Radio Logbook, which would be best practice. He confirmed that if he decided to decline an application, it was his usual

practice to advise the officer seeking the triangulation what further information needed to be gleaned in order to satisfy a further application.

206 He also accepted that the first call between himself and DSC Robertson occurred at around 5.40am and that he had been required to deal with another urgent matter involving a major motor vehicle accident in Sydney.

Inspector Posner gave oral evidence that "at 6.28 I would've already started the process of doing the triangulation and I would've said to him at that time I'll call you back when I get the results". It remains unclear why there had been a delay of almost one hour between the first and second call between the two officers.

Superintendent Jill Walters, Radio Operations Group, NSW Police Force 207 Superintendent Walters provided two statements dated 19 July 2023 and 31 August 2023, relating to her role as the Commander of the Radio Operations Group (ROG).

208 Superintendent Walters confirmed that the State Coordinator Unit (SCU) "operates 24 hours a day, 7 days a week from the Sydney Radio Operations Centre, located within the Sydney Police Centre. The SCU is staffed by eight inspectors." 209 Superintendent Walters stated that the "State Coordinator is responsible for the effective coordination of specialist resources in support of front-line policing activities across the State; the timely reporting of "Serious", "Unusual" or "Noteworthy" incidents to the Executive; and the activation of various plans in response to critical incidents and acts of terrorism." 210 Amongst other duties, the "responsibilities of the ROG include responding to and managing requests for the activation of a triangulation [ ... ]The criteria for obtaining a triangulation is recorded in the ROG Procedures which is published on the ROG NSWPF intranet page, accessible to all Police Officers." 211 Section 287 of the Telecommunications Act 1997 (Cth) (the "Act") was amended in April 2023, by removing the word "imminent", effectively lowering the threshold test for triangulation requests. Superintendent Walters confirmed that this this has resulted in very few triangulation requests being declined by the ROG.

212 In her oral evidence, Superintendent Walters indicated that she expected that her inspectors were sufficiently experienced to provide guidance and support to police making a triangulation application; as well as analysing the information that they were being provided in support of the application.

213 Superintendent Walters annexed an amended version of the Standard Operating Procedure (SOP) approved on 21 January 2022 to her statement dated 19 July 2023.

214 The amended SOP provides an additional definition of a "threat" against a person to include "A request from investigative police for a geographical position of a phone where a person has committed murder and has left the scene." In assessing whether this perceived 'threat' was serious and imminent, "would require consideration of whether the person is thought to be dangerous and is likely to commit another crime that would threaten the health and safety of another person or persons." 215 Superintendent Walters confirmed that as a result of the proposed Recommendations from this Inquest, a new SOP is in the process of being added which states: "A person has committed a murder or crime of serious violence and their geographical location is unknown and there are family members or others who may be at risk or the person has done or said anything to indicate risk of self-harm", and that this "is likely to be considered a serious threat," rather than "this would require consideration of whether the person is thought to be dangerous." 216 In her oral evidence, Superintendent Walters confirmed that a triangulation did not cost anything to her department. She also confirmed that no officer in NSW has been charged with breaching section 287 of the "Act". In relation to the suggestion that some police have experienced "gruffness' from some SCU's, Superintendent Walters commented that from her experience years ago that a SCU can have "like up to seven or eight triangulations running at one time. It's not a case of just processing it and then forgetting about it. You have to manage those triangulations with everyone wanting updates. You're getting calls from mental health providers, you're getting calls from the field, you're trying to get the briefing done at the same time, you're having to monitor CAD, so you do have an awful lot of things going sometimes." She agreed, however, that it was important the 'gruffness' did not deter an officer from seeking a triangulation.

217 Superintendent Walters confirmed that an audit of triangulations indicated that about "11 triangulations a month out of roughly about 450 a month" were declined, which translated to approximately 2 percent of all applications during 2023-24. Superintendent Walters also conceded that the circumstances surrounding this triangulation, "could've been better." 218 Superintendent Walters stated that as a result of this inquest a new procedure had been adopted whereby officers can now seek a review of a decision where their request for a triangulation is refused. In addition, consideration was being given to requiring a SCU who has declined a request for a triangulation to inform the requesting officer that that officer has a right of review of the SCU's decision.

Cause of Death

219 On 5 July 2021, Dr Donovan Loots performed a forensic post-mortem on Michelle. Dr Loot concluded that the direct cause of Michelle's death to be from "Multiple Stab Wounds to the Abdomen and Chest." 220 Dr Loots noted that "Macroscopic and microscopic examination showed multiple sharp force injuries (incised and stab wounds) chiefly to the head and face, left upper limb, left chest and anterior abdominal wall. There are defensive injuries noted to the left wrist and hand." Domestic Violence Death Review Team (DVDRT) Secretariat review and report of Michelle's homicide 221 A report was prepared by Ms Anna Butler, on behalf of the Domestic Violence Death Review Team (DVDRT) Secretariat, reviewing the circumstances surrounding Michelle's death. The DVDRT is a review body which "undertakes quantitative and qualitative analyses of domestic violence related deaths occurring in NSW." 222 The DVD RT was established in 2010 under the Coroners Act 2009 (NSW) to review deaths occurring in the context of dom~stic violence in NSW. In addition, the DVDRT reports to the NSW Parliament biennially, setting out findings and recommendations from case analysis. "The philosophy of the DVDRT like death reviews nationally and internationally, is to enhance our collective understanding of the scourge of domestic violence in our communities by learning from these tragic, radiating and serious cases." 223 In Ms Butler's report on Michelle's death, she referred to findings reported in the 2019-21 report to Parliament as the 2022-3 report was tabled after the close of evidence in this inquest.

224 Ms Butler noted that DVDRT's 2019-202 report "presents almost two decades of data findings regarding intimate partner homicides (IPV) in NSW. Between 1 July 2000 and 30 June 2018 there were 314 intimate partner homicides. 62 of these homicides were homicide-suicide cases. 52 of those cases were identified as having occurred following a history of domestic violence and almost all involved a male homicide offender killing their current or former female partner before committing suicide. This finding was consistent with other Australian and international research which identified a male homicide offender as being responsible for killing a female intimate partner before committing suicide." 225 Ms Butler commented that "Separation, and particularly those who remain 'separated under one roof, has been identified by the DVD RT as a factor that is likely to increase the risk of further violence for victims and accordingly the DVDRT has emphasised the need for systems and services to be cognisant of, and responsive to, this heightened risk. This risk appears even more pronounced in cases of IPV homicide-suicide."

226 Ms Butler further reported that the duration of an IPV relationship varied from 12 months to 45 years in length, demonstrating that "IPV homicide suicides can occur at any stage during a relationship, and just because a victim has managed to survive many decades of abuse in a long-term relationship does not mean that they are at a lesser risk of being killed by their abuser." 227 Ms Butler's expert opinion was that "Neville was the predominant domestic violence abuser in the relationship, who used a suite of coercive and controlling tactics against Michelle, the predominant domestic violence victim". Ms Butler noted that this "distinction acknowledges that victims of domestic violence are rarely passive and may resist abuse in many ways.

This may include using retaliatory violence as a defence mechanism to protect themselves, their children, their dignity, or as a consequence of their victimisation and trauma." 228 Ms Butler noted that there is evidence that "Neville used: emotional/psychological violence; sexual violence; physical violence; social violence; and stalking during relationship and in the brief period after the relationship with Michelle ended." Ms Butler commented that "while it is evident that Neville did physically assault Michelle on at least one occasion, like many IPV homicide-suicide offenders, he primarily used non-physical tactics of abuse to coerce and control her." 229 Ms Butler reviewed Neville's reported social violence against Michelle, including Jennifer's reflection that her father, Neville was "very controlling of mum and her interactions with people" and "It was like Dad wouldn't allow anyone into our family circle. It was normal at the time but looking back now, I can see that it was his very controlling behaviour and the things he would do to make sure mum done what he wanted." 230 Ms Butler noted that Michelle had commenced taking driving lessons in 2009, until Neville started questioning her about her male instructor.

Michelle ceased taking the lessons and was then constantly dependent on Neville to provide her with transport in a regional country town with limited public transport options. Neville's behaviour escalated when Michelle commenced working at the RSM motel. Again, he accused her of infidelity.

In his police interview on 17 June 2021, Neville stated that when he went to take Michelle's phone "she said she's so independent she don't need anything from me." 231 Ms Butler opined that the "work of the DVD RT has sought to emphasise the importance of the recognising the risk of harm to victims of violence who demonstrate increasing independence and resistance to a partner's ongoing abuse. In many of the Team's cases, victims were killed at the point when they were reasserting independence and demonstrating autonomy over their lives. The fact of a victim demonstrating greater independence may be overlooked by responders as a factor that can pose a significant risk to a victim's safety because it is generally seen as a positive reclaiming of agency by the victim. However, it also represents a

definitive loss of control for abusers who may respond with a serious or fatal act of violence." 232 In addition, there is evidence from a family member that Neville was engaging in stalking or victim surveillance, including having a tracking device on his phone which was able to monitor Michelle's movements.

After Neville refused to return Michelle's phone on 17 June 2021, he relied on their son, Brendan to report Michelle's movements.

233 Ms Butler considered whether there were' any "apparent risk factors that could have predicted Neville's lethality and/or were there missed opportunities to interrupt the course of his abuse and prevent the fatal outcome." 234 A not-for-profit research organisation established under Australia's National Plan to Reduce Violence against Women and their Children 2010-2022, known as Australia's National Research Organisation for Women's Safety (ANROWS), identified 16 factors which appeared to be associated with a higher likelihood of recurring violence, serious injury or death in intimate partner violence. Of those 16 identified factors, Ms Butler identified nine as being evident in Michelle's relationship with Neville.

235 Those nine factors included: a. History of domestic violence and/or coercive control; b. Separation, c. Intimate partner sexual violence, d. Non-lethal strangulation/choking, e. Stalking, f. Threats to kill, g. Victim's self-perception of risk, h. Court orders, i. Suicide threats and attempts.

236 In relation to Court Orders, Ms Butler noted that "research has found that police investigations and family, criminal or civil court proceedings can trigger an escalation in the aggressive and violent behaviour of perpetrators and heighten risk to the partner and children. The research found that transition points such as these should be treated with great caution." 237 Ms Butler stated that it is "important to appreciate that the relationship between these factors and the risk of lethality is far from straightforward, and no one factor can be considered singularly 'causal'. While they may be characteristics observed across domestic violence homicides, these factors are also present in many more cases that are not fatal. It is not possible, therefore, to rely on these static case characteristics to predict the likelihood of a fatality."

Domestic Violence Expert Conclave 238 A conclave of expert witnesses was convened on 8 March 2024.

239 The conclave participants were as follows: a) Ms Anna Butler, manager of the Domestic Violence Death Review Team (DVD RT). The DVDRT was established in 2010 under the Coroners Act NSW 2009, to examine domestic violence-related deaths.

The role requires a quantitative review function, including the analysis of data and trends for all domestic violence-related deaths that occur in NSW. In addition, the role also requires a qualitative review function, where the team undertakes in depth case reviews into individual cases.

Ms Butler provided a 45-page report reviewing the death of Michelle by Neville.

b) Superintendent Danielle Emerton, Commander of the Domestic and Family Violence Registry at the NSW Police Force. In the course of 2023, the Domestic and Family Registry (DFV Registry) was established as part of the NSWPF Domestic and Family Violence Reform Strategy. The function of the DFV Registry is to provide advice and support to both the NSWPF Commissioner's Executive Team on operational, legal and corporate issues; as well as "prioritising the intervention of repeat offending by addressing perpetrator behaviour, while maintaining oversight, training and enforcement of domestic violence offending." Superintendent Emerton provided two statements for these proceedings.

c) Ms Jasmine Chaffey, manager of the WDVCAS New England service.

Ms Chaffey prepared one statement and gave evidence in these proceedings on 6 September 2023.

d) Detective Superintendent Roger Best, Director of the Investigations Directorate of the Professional Standards Command of the NSWPF.

Detective Superintendent Best provided three statements in these proceedings.

e) Ms Pip Hetherton, Director of the Women, Family and Community Safety service with the Department of Communities and Justice.

f) Ms Alice Stiles, Manager of the Women's Domestic Violence Court Advocacy Program at the Legal Aid Commission of NSW.

240 Superintendent Emerson confirmed that the NSWPF had adopted the NSW Domestic and Family Violence Plan - 2022-2027 (the "plan"). The "plan" comprises of four pillars:

1. Primary Prevention. "Primary prevention works to stop violence from occurring by identifying the underlying causes of violence"

2. Early Intervention. "Early intervention refers to targeted responses that aim to identify risks to safety and ensure that timely responses are delivered before risks escalate to violence or to more severe violence."

3. Response. Domestic Violence requires an "holistic, integrated and trauma-informed service responses. Response often included, but is not limited to, services such as case management, crisis counselling and housing assistance, as well as child protection, police and justice responses, legal services and perpetrator interventions. These efforts aim to support victim-survivors to secure immediate and long-term safety, hold perpetrators to account, and prevent the reoccurrence of violence."

4. Recovery and Healing: "It is important to ensure that victim-survivors are supported to access trauma-informed, culturally safe and evidence-based responses. Recovery recognises that victim-survivors and their children often need to access supports and services to recover from the financial, social, educational, psychological and physical impacts of violence."] 241 Pillar 3 notes that the "Safer Pathway program is the primary multi-agency response system for victim-survivors of DFV across NSW, providing a consistent, coordinated and collaborative cross-agency response." The Safer Pathway agencies include, NSW Police, the Department of Communities and Justice, Legal Aid and BOCSAR." 242 Pillar 3 contemplates an improvement in "the effectiveness of integrated, cross-agency responses" by utilising the Domestic Violence Safety Assessment Tool, the DVSAT and the Safety Action Meetings, together with continuing to monitor and assess the co-location of WDVCAS workers in police stations. It further contemplates providing ongoing case management through WDVCAS and LSS for victim-survivors with "complex circumstances and higher support needs" and improving IT systems to manage coordination between Safer Pathway agencies.

243 In addition, a common risk assessment framework is being developed by all agencies and providers.

244 Ms Butler stated that in the current DVSAT there are a number of areas which could be improved. These include replacing confusing and "double barrelled" questions. In addition, Ms Butler noted that there is an unintended bias against older women with a number of questions focusing on the female victim as having childcare responsibilities. Further areas of concern to her included where inconsistent approaches were adopted to questioning; as well as multiple applications of the DVSAT to the same victim relating to the same complaint of violence and the nature of the questions, particularly when they relate to sexual violence.

245 The conclave noted that a new DVSA tool was currently in development.

The most significant change to the DVSAT was to reduce the number of questions from 25 to 11.

246 The eleven revised DVSAT questions are: i. In the last 12 months have you separated or changed your living arrangements or are you thinking about doing this?

ii. Are they jealous or controlling of you?

iii. Have they ever followed you, tracked you on social media or used other technology to monitor you?

iv. Do you feel unsafe when they are drinking alcohol or taking drugs?

v. If they have a mental illness, do you feel unsafe when they are experiencing symptoms?

vi. Have they ever used physical violence against you?

vii. Have they ever hurt you with a weapon or other object?

viii. Have they ever put pressure on your neck or tried to stop you breathing in any way?

ix. Have they ever threatened to seriously hurt you or someone close to you?

x. Are you scared that they might seriously hurt you?

xi. Are you pregnant or do you have a baby under one year old?

247 A significant change to administering the DVSAT by police is to upgrade the Police issued MobiPol camera to permit an application (an app) to receive prompts and record the victim's responses on the MobiPol device, rather than having to record the responses in a police notebook. Police then transfer those responses onto the police computer system. The MobiPol device will then have the capacity to upload the interview directly to the COPS system. The app has been developed by BOCSAR.

248 It is contemplated that the victim's responses to the new eleven questions will not require a numerical rating by the police officer administering the questions. In the new model, the app installed on the MobiPol will rely on an algorithm that will provide the weighting of responses to determine a referral to a Safety Action Meeting (SAM) or otherwise.

249 Superintendent Emerson confirmed that there will also be "trigger offences" in the new DVSAT where an offence such as "Assault Occasioning Actual Bodily Harm, Grievous Bodily Harm, genital mutilation, predatory driving or strangulation" would be "pushed straight into a serious threat" category. The professional judgement component would continue to be applicable, with the app triggering a "forced function" requiring the officer completing the DVSAT to consider the professional judgement category.

250 Ms Stiles confirmed that the WDVCAS will "incorporate the Part A from police so that we can still have a level of consistency, so if police determine someone to be at serious threat we don't have an argument

about whether that is correct, but there will be a more fulsome secondary part completed by WDVCAS and that part is still in development." 251 Superintendent Emerson confirmed that with the current 25 question DVSAT, "since 2021, since this incident with Michelle Michell, there's now a prompt on COPS so when you do your DVSAT and you've finished the 25 questions there's actually a screen that pops up that says, "Do you want to elevate this from threat to serious threat?" There is a SAMs option now and it says "Safety Action Management meeting" and your evidence, "This evidence on the DVSAT could be required at Coroner's Court." There's actually - it says that in the prompt in COPS." 252 The conclave participants discussed a number of other proactive improvements, training and support which are referred to in the next section dealing with the proposed Recommendations.

Recommendations 253 At the conclusion of the evidence, a number of draft Recommendations were provided to the legal representatives for the NSW Commissioner of Police. Counsel for the Commissioner of Police indicated in his written submissions that "a number of the recommendations are likely to yield significant benefits and should be implemented in whole or in part. In several instances, the proposed recommendation has already been addressed by the NSWPF." Recommendation 1: That a requirement be introduced to ensure that police officers completing a DVSAT review any prior DVSAT's completed by the complainant, including any available narrative (Facts Sheets and/or DVO applications) for incidents in the last 12 months.

254 Constable Gilbody completed a DVSAT on 21 June 2021. This was the second DVSAT completed with Michelle, with the first having been completed on 17 June 2021 by Constable Osborne. There were a number of inconsistencies between the two versions.

255 Ms Anna Butler noted that the lack of continuity between multiple applications of the DVSAT was a concern and suggested that police officers should be encouraged to review previous DVSATs to have a "holistic" view of the situation, rather than an "incident focus".

256 Superintendent Emerson agreed that police should have reference to previous DVSATs which had been completed within a specific time to properly assess risk.

257 On behalf of the Commissioner of Police, this recommendation is not supported owing to concerns that such reviews would increase the workload for officers and would complicate the DVSAT process rather than simplifying that process. It is submitted by Police that such a review could be undertaken by the WDVCAS and by Domestic Violence Officers

(formerly Domestic Violence Liaison Officers) who are already tasked with reviewing prior incidents.

258 It would seem self-evident that limiting the review to 12 months would reduce the burden placed on officers as compared to an open-ended review period. Importantly, such a process would provide a review whereby glaring inconsistencies between two DVSATs could be analysed and corrected, to ensure that there is not a lost opportunity to refer a victim to a Safety Action Meeting due to an inaccurate score on the DVSAT.

Recommendation 2: That the DV Registry create a bespoke training model whereby: a) police officers observe (remotely, where appropriate) WDVCAS officers administer DVSAT tools and WDVCAS officers observe police officers administer DVSAT tools; and b) Police officers and WDVCAS officers subsequently attend an in person seminar to share reflections, commentary and feedback about administering those tools.

259 Constables Osborne and Gilbody indicated in their oral evidence that they could see a benefit to them and other officers by having further training on the role of WDVCAS and the trauma informed approach that the WDVCAS adopted when administering the DVSAT. Ms Jasmine Chaffey, Manager of the WDVCAS stated that she perceived that her officers would derive a benefit from observing police administer the questionnaire, as well as building stronger relationships between the two services.

260 During the conclave, general support was offered by the conclave participants, including the opportunity for greater engagement and "cross fertilisation" concerning the administration of the DVSAT.

261 The NSW Police Force have indicated that they do not support this recommendation. The NSWPF stated that they consider "such a training exercise is likely to pose significant logistical difficulties that are disproportionate to the benefit likely to be gained. There are significant differences in the role and constraints facing NSWPF officers and WDVCAS officers in the context of responses to DV incidents and the completion of DVSATs." 262 The response continues by stating that "NSWPF officers are the first responders to a DV incident and are the initial contact with the victim of DV. The completion of the DVSAT is to identify the threat level of future harm to victims and promote their safety. The DVSAT is a means for police to identify what level of protection from a law enforcement perspective is required and apply for protective orders with relevant conditions. The completion of the DVSAT by WDVCAS workers is also to identify the threat level of future harm to DV victims, however its purpose is to link victims with more comprehensive support services. This may include safety plans, housing assistance, legal advice etc. Extensive training is already provided to officers, initially at the Goulburn Police

Academy where students are taught the DVSAT and then apply their learning in scenario-based training. This is further developed when officers complete the DV Fundamentals course (which is mandatory as part of the Constables Development Program.) In the DV Fundamentals course officers learn the application of the DVSAT. Officers are also provided training as part of the Constables Education Program (CEP) and online training modules." 263 It is noted that the above response does not provide details of what the "logistical difficulties" are specifically.

264 It was clear from the oral evidence of the junior police in this inquest that they were provided with initial training at the Academy, which was supplemented by on-the-job training, usually facilitated by older police officers on an ad hoc basis. The anecdotal evidence available during this inquest suggests that many police statewide were not completing the questionnaire correctly, or at all. In addition, the junior police in this inquest had personally developed a nuanced approach to some of the questions, rather than a rote delivery of the 25 questions, suggesting that an alternative, and more trauma-informed delivery of the questions may assist both the police and the victim.

Recommendation 3: That consideration is given to the Domestic and Family Violence Registry (DV Registry) within the New South Wales Police Force (NSW Police Force) being connected to or given the opportunity to comment on recruitment and education at the NSW Police academy.

265 This inquest has been informed that fresh domestic violence complaints consume at least 60% of a police officer's daily shift. The potential impact of such a high level of DV complaints may anecdotally result in police officer burnout and affect job satisfaction.

266 A similar recommendation was proposed in the 2022 Commission of Inquiry into Queensland Police Service Responses to Domestic and Family Violence. It was designed as a police recruitment strategy to ensure that applicants from diverse backgrounds and experiences were attracted to the role of a police officer; as well as targeting applicants with an interest in social work and domestic violence policing.

267 In the conclave, Ms Butler and Ms Chaffey agreed that the recruitment of applicants with a social work background would be beneficial as they would be likely to have experience with trauma-informed and crisis response approaches. It was submitted that the DV Registry is ideally positioned to encourage recruitment and education and attempt to address disillusionment and burnout with police officers.

268 This recommendation is not supported by the NSW Police Force. It is submitted that "Officers serving within the NSWPF Academy undergo a rigorous recruitment and screening process facilitated by Police Recruitment Branch, People and Capability Command. The aptitude and

experience of the officers selected to serve as trainers is subject to extensive consideration as part of the process. Additionally, the DFVR already provides information to aid in the development of DV training material for inclusion in the Constable Education Program." 269 It should be noted that the recommendations from the Queensland Commission emerged after careful consultation and evidence from eminent experts in the domestic violence field. It is hoped that this recommendation is reviewed in a positive light.

Recommendations 4 and 5: Recommendation 4: That consideration is given to a pilot of a PACER style co-responder program involving the attendance of Women's Domestic Violence Court Advocacy Service (WDVCAS) officers at domestic violence call outs during daylight hours.

Recommendation 5: That a working party be formed including members of the DV Registry, Crime Prevention Command, WDVCAS and Legal Aid to develop the pilot co-responder program.

270 This recommendation proposes that WDVCAS attend domestic violence call outs with police officers to provide on-site assistance to police and victims, similar to the PACER pilot for mental health matters. The model would envisage WDVCAS officers either directly interviewing complainants or assisting responding police officers with appropriate and sensitive questioning options.

271 The conclave participants generally perceived the merit of such an approach, although noted that there were safety concerns relating to the protection of the WDVCAS officers attending incidents. Ms Stiles suggested that a co-responder pilot was a natural extension of the co location model.

272 The NSWPF have indicated that this "recommendation will be considered, however, it must be noted that the potential development and implementation of such a program will need to confront an extensive array of issues in relation to, among other things, the availability of funding and the management of safety risks to WDVCAS officers." Recommendation 6: That the working party also work on methods of improved information transfer and phone calls between police and

WDVCAS.

273 WDVCAS officers receive very limited information at the time they receive the electronic referral from police reporting a domestic violence matter. Ms Chaffey confirmed that the WDVCAS officers receive the web form DVSAT and not the separate sticker filled out by police or any other victim statements or police narratives. Ms Chaffey indicated that it would greatly assist if the WDVCAS workers could receive a phone call and be provided

with a more informed handover after receiving the computerised referral from police. This proposal was largely supported during the conclave, although it was noted by Superintendent Emerson and Ms Stiles that the WDVCAS officers worked during standard office hours and many domestic violence referrals occurred outside these hours. Ms Stiles noted that in many locations, WDVCAS and police officers already have strong working relationships and regularly phone or email each other about particular matters.

27 4 The NSW Police have indicated that this recommendation will be considered.

Recommendation 7: That urgent consideration is given to whether police officers are sufficiently trained in the professional judgment component of the current DVSAT and if further training is warranted prior to the introduction of the new DVSAT.

275 Constable Osborne and Constable Gilbody indicated in their oral evidence that in addition to completing a risk assessment score in the DVSAT, they were unaware that they could exercise their own professional judgment in the DVSAT to identify a person at "serious threat". It is noted that the Commissioner of Police submitted that Constable Osborne was not definitive as to his knowledge of the option at the relevant time in his oral evidence. It is apparent, however, that Constable Osborne was not aware of the professional judgment option.

276 During the conclave, Superintendent Emerson agreed that it was important that general duties officers are aware of the option to exercise their professional judgment and refer a complainant to a Safety Management Meeting, regardless of their score, as assessed during the administration of the DVSAT.

277 The Domestic Violence Death Review Team DVDRT 2023 annual report prepared by Ms Anna Butler noted that there is a clear correlation between a recent estrangement or separation between a couple and significant violence, including homicide. The report confirmed that almost two-thirds of women were killed by their ex-partner either after or at the point of separation. This factor alone, may well require a general duties officer to consider whether or not they should exercise their professional judgment, regardless of any other DVSAT scores.

278 In the newly developed DVSAT, the question relating to 'recent separation' of the parties in Part A, does not attract any weighting. On any view, the need for general duties police to be trained in the exercise of their professional judgment in those circumstances becomes more imperative.

279 The NSW Police Force has indicated that "as a consequence of the simplification of the DVSAT process as part of the current review [sic] is likely to reduce the information-gathering burden on officers and, in turn, allow them to focus their attention more on the exercise of professional

judgment by reference [sic] either matters disclosed during the DVSAT process of other features of the incident or investigation".

280 In addition, a "DV Insight" information sheet on exercising professional judgment when completing a DVSAT has been created and additional training "on the professional judgment element of the DVSAT is being scoped." Considerations 281 Women in Australia are being slaughtered at an unacceptable rate by persons known to them intimately.

282 Research has been able to identify risk factors which potentially signal behaviours which may result in serious injury or death. Women (and some men) can be the subject of coercive, financial, sexual, psychological and physical control. The nature of an intimate relationship may discourage a victim from reporting the behaviour and the associated offending to police or others.

283 In that context, it is vitally important that police are trained, informed, proactive and sensitive to a complainant presenting with a complaint; as well as undertaking the task of considering the availability and veracity of the available evidence to commence any prosecution.

284 The introduction of DVECs have preserved the version of events as provided by the complainant, as well as the demeanour of that person, in preparation for a criminal prosecution. The DVSAT should be undertaken by police with a similarly robust adoption to ensure that as many supports as possible are implemented to assist a complainant/victim.

285 These supports include a referral to the WDVCAS and SAM. In addition, other initiatives, including 'Staying Safe at Home' and housing referrals are available in certain areas. Unfortunately, housing support in terms of permanent or temporary support is always oversubscribed, particularly in regional areas, where it may well be non-existent. Additional funding for housing accommodation for DV victims would provide some safety and independence for women wanting to leave violent households.

286 The more junior police involved in this inquest have clearly been impacted by the events of 17 June, 21 June and 30 June 2021. They have candidly indicated that their policing role would be supported by understanding a more trauma-informed approach, as well as more 'on the job' training. It is clear from the available evidence that many general duties police are overwhelmed by the domestic violence epidemic. Training and support of police, as well as victims, would hopefully provide better outcomes.

287 The involvement of the WDVCAS, both at the initial stage when a DVSAT is forwarded, as well as the ongoing support at Court, appears to be positive to the victim and the police. The co-location trial of WDVCAS

officers has cemented positive and ongoing communication between the police and WDVCAS.

288 The involvement of the WDVCAS in attending scenes with police is the next obvious extension and would provide support for both victims and police. It is hoped that this would be trialled, much like the PACER trial in the future.

289 The evidence from the conclave indicated that the DVSAT would be streamlined to 11 questions. The evidence also suggests that police will use an 'app' on their Mobipol devices, rather than paper forms which are then required to be uploaded to the COPS system. It remains unclear as to how this new system will cater for an officer's professional judgment of the reported risks, and the weight given to them, as disclosed by a complainant during the administration of the DVSAT. - 290 Neville's family expressed their concerns as to whether the issues associated with the delay in authorising the triangulations would have resulted in locating him sooner. Forensic pathologists invariably decline to provide the kind of precise time estimates frequently referred to in television series or movies owing to variables such as heat, cold, situational occurrences or a person's idiosyncrasies. It will remain unclear whether Neville committed suicide shortly after he fled the scene of the attack and whether the delay in the triangulation made any difference. It will remain an insoluble question as to when Neville died.

291 The expert conclave were asked about the availability of, and efficacy of, male offender DV and mental health support programs. The conclave indicated that there are some programs, however, their efficacy is unknown. The clear indication from the conclave was that there is insufficient recurrent funding for female victims, which remains the immediate priority.

Conclusions 292 Michelle was killed by her husband, Neville, who also attempted to kill their daughter, Jennifer. There is no rational reason or excuse for his behaviour.

His actions were deliberate and pre-meditated.

293 This inquest sought to identify systemic shortcomings, rather than any deficiencies by an individual.

294 Multiagency co-operation, recurrent funding, resourcing and training must be considered in an attempt to address this domestic violence scourge than is inundating our society, both in cities and regional towns.

295 Women of all ages and circumstances are victims. Ms Bulter opined that "despite the significant cohort of women aged 50 years and older who are killed in a IPV homicides, older women can be forgotten or overlooked in primary prevention work and reports of their homicides often do not attract

media attention." In rural and regional NSW resources are limited and often temporary and would benefit from recurrent funding from government.

296 In hindsight, Ms Michelle Michel's death was predictable. Her death leaves her close family members with unfathomable grief, and ongoing questions as to how this abuse could have occurred over so many years.

297 The family statements prepared by her sister, daughter and daughter-in law, all attest to her devoted love and support for her children and her grandchildren. Her sister, Lindylee, said, "We all miss talking and seeing her everyday, her quirky laugh that was only unique to her, watching her favourite movies, listening to her favourite music and looking at Fords. We miss her everyday, she was sadly taken from us too soon, left a big hole in our life without her. She will always be our hero and our angel." 298 Her daughter Jennifer, said, she was dedicated to "her children and grandchildren. She loved them more than anything else in this world and would do anything to keep them safe. And she did. She is a person that can never be replaced no matter who you meet or how many years pass." 299 Her daughter-in-law, Christina, commented that Michelle "showed how compassionate, strong, brave, attentive, protective, caring and loving she was. She was always a mum first, the family's rock, she made all of us feel so loved, she was completely selfless and she was just trying to enjoy life with her family".

300 I am of the view that it is appropriate to make the proposed Recommendations to the Commissioner of Police, pursuant to section 82 of the Coroners Act 2009 (NSW).

Closing Observations 301 Before turning to the findings that I am required to make, I would like to acknowledge my gratitude to Ms Kirsten Edwards of senior counsel and Ms Kathleen Zielinski, solicitor, for their significant assistance, commitment, support and preparation of this case.

302 I would also like to acknowledge and thank the Office in Charge of this investigation, Detective Senior Constable Samantha Prescott for her assistance and commitment.

303 Finally, I would like to again record my most sincere condolences to Michelle's family.

Findings pursuant to section 81 (1) of the Coroners Act 2009 (NSW) 304 I make the following findings pursuant to section 81 (1) of the Coroners Act

2009 (NSW):

Findings The identity of the deceased 305 The person who died was Michelle Daphne Michell.

Date of Death 306 Michelle died on 30 June 2021.

Place of Death 307 Michelle died at 187 Glenn Innes Road, lnverell.

Cause of death 308 The cause of Michelle's death was multiple stab wounds to the abdomen and chest.

Manner of Death 309 The stab wounds were deliberately inflicted by Neville Michell.

Recommendations 310 I make the following recommendations pursuant to section 82 of the Coroners Act 2009 (NSW), To the Commissioner of Police

1. That a requirement be introduced to ensure that police officers completing a DVSA T review any prior DVSAT 's completed by the complainant, including any available narrative (Facts Sheets and/or DVO applications) for incidents in the last 12 months.

2. That the DV Registry create a bespoke training model whereby: a) police officers observe (remotely, where appropriate) WDVCAS officers administer DVSAT tools and WDVCAS officers observe police officers administer DVSAT tools; and b) Police officers and WDVCAS officers subsequently attend an in person seminar to share reflections, commentary and feedback about administering those tools.

3. That consideration is given to the Domestic and Family Violence Registry (DV Registry) within the New South Wales Police Force (NSW Police Force) being connected to or given the opportunity to comment on recruitment and education at the NSW Police academy.

4. That consideration is given to a pilot of a PACER style co-responder program involving the attendance of Women's Domestic Violence Court Advocacy Service (WDVCAS) officers at domestic violence call outs during daylight hours.

5. That a working party be formed including members of the DV Registry, Crime Prevention Command, WDVCAS and Legal Aid to develop the pilot co-responder program.

6. That the working party also work on methods of improved information transfer and phone calls between police and WDVCAS.

7. That urgent consideration is given to whether police officers are sufficiently trained in the professional judgment component of the current DVSAT and if further training is warranted prior to the introduction of the newDVSAT.

311 I now close this inquest ~ agistrate Joan Baptie Deputy State Coroner 28 March 2025

Annexure to the findings in the inquest into the death of Michelle Michell New South Wales Police Force

DOMESTIC VIOLENCE SAFETY ASSESSMENT Event Number: 82777380 CNI: 835926784 LAC Name: NEW ENGLAND PD Threat Level: Threat Relationship Type: INTIMATE Event Summary

INCIDENT TIME: 12:00:00 INCIDENT DATE: 17/06/2021 LOCATION: 187 WARIALDA RD INVERELL NSW 2360 INCIDENT TYPE: ASSAULT - ACTUAL BODILY HARM VICTIM: NAME: MICHELLE DAPHNE MICHELL ADDRESS: 187 GLEN INNES RD INVERELL NSW 2360 PHONE NUMBER: CONT ACT NOTE: DOB or DATE RANGE: 30/01/1971

ATSI: UNKNOWN INTERPRETER: NO LANGUAGE: INTERPRETOR SERVICE: THREAT LEVEL: Threat

INJURIES: PERSON NAMED: NAME: NEVILLE KEITH MICHELL Domestic Violence Event Part A: Threat Identification Checklist Violence towards the Victim Threat Level Relationship type? INTIMATE Threat Status Victim Deceased/ Incapacitated NO NSW Police I DVSAT Form . .

1022

Event Number: 82777380 CNI: 835926784 Source of Threat Indicator Answer information if not from victim

1. Has your partner ever threatened to harm or kill you? No V 2'. Has your partner ever used physical violence aqainst you? No V

2. Has your partner ever choked, strangled, suffocated you or attempted to do any of these No V things?

3. Has your partner ever threatened or assaulted you with any weapon (including knives and/or objects)? No V

4. Has your partner ever harmed or killed a family pet or threatened to do so? No V

5. Has your partner ever been charged with breaching an apprehended domestic violence order? No V Relationship with the Victim Source of Threat Indicator Answer information if not from victim

7. Is your partner jealous towards or controlling of you? Yes V

8. Is the violence or controlling behaviour becoming worse or more frequent? Yes V

9. Has your partner stalked or constantly harassed or V texted/e-mailed you? Yes

10. Does your partner control your access to money? No V

11. Has there been a recent separation (in last 12 months) or is one imminent? Yes V - Background of Partner Source of Threat Indicator Answer information if not from victim NSW Police I DVSAT Form - 1023

Event Number: 82777380 CNI: 835926784

12. Does your partner or the relationship have financial difficulties? Unknown V

13. Is your partner unemployed?

No V

14. Does your partner have mental health problems (including undiagnosed conditions) and/or Yes V depression?

15. Does your partner have a problem with substance abuse such as alcohol or other drugs? Yes V Source of Threat Indicator Answer information if not from victim

16. Has your partner ever threatened or attempted suicide? Yes V

17. ls/has your partner currently on bail, parole, served a time of imprisonment or has recently been released from custody in relation to offences of No V violence?

18. Does your partner have access to firearms or prohibited weapons? No V Children - Source of Threat Indicator Answer information if not from victim Only ask if victim is female

19. Are you pregnant and/or do you have children No V who are less than 12 months apart in age?

Only ask if victim is female

20. Has your partner ever threatened or used physical violence towards you while you were No V preqnant?

21. Has your partner ever harmed or threatened to harm your children? No V

22. Is there any conflict between you and your partner regarding child contact or residency issues No V and/or current Family Court proceedings?

NSW Police I DVSAT Form 1024

Event Number: 82777380 CNI: 835926784

23. Are there children from a previous relationship present in the household? No V Sexual Assault Questions II Source of Threat Indicator Answer information if not from victim

24. Has your partner ever done things to you, of a sexual nature, that made you feel bad or physically No V hurt you?

25. Has your partner ever been arrested for sexual assault? No V

TOTAL NO. OF INDICATORS ---------<'- Yes 7 No 17 Unknown 1 Refused to Answer 0 Part B: Other Identification/Professional Judgement Has the victim been recorded on COPS as a victim in any 3 or more occasions within a 6 month period in any DV related No matter?

How fearful is the victim of their partner?

Afraid What concerns did the victim express?

(What the victim think FEAR THAT HER PARTNER WOULD ATTEND THE H the partner might do OUSE AND HURT HER and to whom?) I NSW Police DVSAT Form , 1025

Event Number: 82777380 CNI: 835926784 Were there children present or witness to the incident?

Yes If yes to previous Question, did you sight them and check on their welfare? Yes Are there any other additional factors, circumstances or details that you are aware of, which make you believe overall there is a No serious threat to the safety of the victim or children?

What are those additional factors?

End of Assessment

• Please, note that victims of domestic violence may be assessed as being at 'Serious Threat' if they reach one or more of a number of thresholds: 1. Police tick 'yes' to a set number of the pre formatted 25 risk identification questions within the DVSAT and/or 2. The victim is recorded as being a 'victim' three or more times in a DV event in the last 6 months and/or 3. Police have used their professional judgement to determine the victim is at serious threat.

I NSW Police DVSAT Form 1026