Inquest into the death of Ms K

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Ms K Hearing date: 3 April 2024 – 5 April 2024 Date of findings: 12 December 2024 Place of findings: NSW Coroners Court - Lidcombe Findings of: Magistrate Elizabeth Ryan, Deputy State Coroner Catchwords: CORONIAL LAW – mandatory inquest – death of a person by homicide – coercive control – was response of NSW Police Force to reports of domestic and family violence adequate – is risk assessment tool used by NSW Police Force adequate?

File number: 2017/71927 Representation: Counsel assisting the inquest: S McGee of Counsel instructed by the NSW Crown Solicitor’s Office.

The NSW Commissioner of Police and Senior Constable Valentina Latkich: S Love of Counsel instructed by NSW Police Force Office of the General Counsel.

The Secretary of the NSW Department of Communities and Justice, in respect of Department of Communities and Justice, Women, Family and Community Safety: G Lewer of Counsel instructed by Department of Communities and Justice, Legal.

Recommendations: 4. Pending implementation of Recommendation 3, that the revised DVSAT guide, and instruction and training material specifically direct police officers to consult all accessible incident and criminal history information from other states and territories, when assessing whether a matter should be upgraded to ‘at serious threat’ level in the exercise of professional judgment on the basis of:

• the total number of prior domestic violence incidents in the past two years including in other states and territories (‘Additional indicators on DVF history’); and

• the presence of any ‘trigger offences’ in the past two years including in other states and territories.

5. That the predictive accuracy of the revised DVSAT be reviewed at intervals of at least 12, 24 and 36 months post commencement.

6. That as part of the DVSAT reviews, consideration be given to the inclusion of an offence of coercive control (‘abusive behaviour towards current or former intimate partners: section 54D Crimes Act 1900) within the last two years as a ‘trigger offence’.

To the DVSAT Working Group, and the NSW Domestic, Family and Sexual Violence Board

7. That the DVSAT Working Group consult with the RACGP, RANZCP and the Australian Psychological Society as to how the DVSAT should operate for non police referrals in to the Safter Pathway system.

To the Secretary, Department of Communities and Justice, and to the NSW Commissioner of Police

8. That the Department of Communities and Justice and the NSW Police Force consult with the RACGP, RANZCP and the Australian Psychological Society to develop policy in the areas of perpetrator identification, engagement and service referrals.

To the Attorney General, NSW

9. That the Attorney General consider, as part of the statutory review undertaken into section 54D of the Crimes Act 1900, amending the definition of ‘abusive behaviour’ in section 54F(2) of the Crimes Act 1900 and the definition of Findings in the Inquest into the death of Ms K

‘domestic abuse’ in section 6A(2) of the Crimes (Domestic and Personal Violence) Act 2007 to include the following: ‘behaviour that uses coercion, threats, physical abuse or emotional or psychological abuse to demand or receive dowry, either before or after a marriage’.

Non-publication Orders prohibiting the publication of certain evidence pursuant orders to section 74(1)(b) of the Coroners Act 2009 (the Act) have been made in this inquest. A copy of these orders, and orders made pursuant to section 65(4) of the Act, can be found on the Registry file.

Findings in the Inquest into the death of Ms K

Section 81(1) of the Coroners Act 2009 (NSW) [the Act] requires that when an inquest is held, the Coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of Ms K.

Introduction

1. Ms K was 43 years old when she was killed by her husband, Mr S. For many years Ms K had been the victim of her husband’s abuse, and she had been making plans to leave their marriage. On 7 March 2017, Mr S used a knife to stab his wife before he then pushed her to the ground and suffocated her. He then left the house. Their younger son AS found his mother’s body some hours later, lying on the kitchen floor covered with a blanket.

2. After killing his wife Mr S tried unsuccessfully to hang himself, before being arrested and charged.

3. Mr S made admissions to police and was charged with the murder of his wife. He was refused bail and went into custody. There he took his own life sometime between 14 and 15 January 2018.

4. Pursuant to section 27 of the Act, an inquest is required into the circumstances of Ms K’s death, because she died as a result of homicide.

5. Because Mr S died in custody, an inquest into his death is also mandatory. This is the subject of a separate inquest, which was heard following that of Ms K.

The role of the Coroner

6. Pursuant to section 81 of the Act a Coroner must make findings as to the date and place of a person’s death, and the cause and manner of their death.

7. In addition, pursuant to section 82 of the Act the Coroner may make recommendations in relation to matters which have the capacity to improve public health and safety in the future, arising out of the death in question.

Ms K’s life

8. There was little dispute about the circumstances of Ms K’s life and her tragic death.

For this reason, much of the following background material is drawn from the closing submissions prepared by Counsel Assisting. I have indicated the few areas where there is a factual dispute.

9. Ms K emigrated to Australia from India in 1994, after her arranged marriage to Mr S took place. Ms K was twenty years old when she married. Mr S had emigrated to Australia ten years earlier and was fourteen years older than his wife.

Findings in the Inquest into the death of Ms K

10. Both Ms K and Mr S were of Sikh Indian background. Mr S had been born in Singapore to parents of Indian origin, but when he was a young boy his family sent him to India to work on a relative’s farm. There is evidence that as a result Mr S was denied the education which his siblings received, and that he came to resent this fact. Reportedly he taught himself to read, and as an adult he worked as a factory supervisor.

11. The couple’s two sons PS and AS were born in Australia, in 1996 and 1999 respectively. At the time of their mother’s death, PS was aged 20 and his brother AS was 17.

12. Ms K was a working mother with qualifications and experience as an assistant nurse working in aged care. Her friends and colleagues regarded her as a good friend and a selfless mother.

13. For many years Ms K’s marriage was an abusive one, and it appears that she remained in the family home mainly for the sake of her sons. At the inquest, her strong sense of commitment to her family was confirmed by two close friends and colleagues, Ms M and Ms H. They described her as ‘a very loving person, always smiling, always friendly and happy’ and ‘willing to help everyone and put the needs of others before her own’.

14. Ms K is survived by her mother who lives in India, and her two sons PS and AS.

They did not want to participate in this inquest, which is understandable. PS and AS witnessed domestic conflict and abuse while they were growing up. This culminated in the horrific murder of their mother by their father. This was followed by their father’s incarceration, and his suicide ten months later.

15. It is difficult to imagine a more traumatising family history for two young people. So it is very understandable that the boys, now young men, had no wish to relive the tragedy of their parents’ deaths by participating in these inquests.

The issues at the inquest

16. The inquest into Ms K’s death examined four issues, as follows:

1. the nature of Ms K’s relationship with Mr S at the time that he killed her;

2. Mr S’s mental state at the time of killing Ms K;

3. the adequacy of the response by officers of the NSW Police Force to a report made by Ms K on 17 August 2016, and whether this response complied with NSW Police Force’s policies and procedures; and

4. the adequacy of the risk assessment tool used by NSW Police Force officers when responding to incidents of domestic violence.

Findings in the Inquest into the death of Ms K

The nature of Ms K’s relationship with Mr S

17. The coronial brief contained extensive material about the marriage between Ms K and Mr S, principally over the period 2003 to 2016. During this period the family had numerous interactions with police, which are summarised below.

18. Statements were also obtained from friends and colleagues of Ms K, and from a relative of Mr S.

19. The evidence about Ms K’s marriage also included records obtained from medical professionals whom Ms K and Mr S consulted over this period.

The period 2003 to 2007

20. In December 2003, Ms K attended St George Police Station to report that her husband had slapped her face and threatened to hit her with a cricket bat. She told police that Mr S had been physically and mentally abusive to her for many years.

21. Police charged Mr S with assault and commenced proceedings to obtain an Apprehended Violence Order [an AVO]. However, at court Ms K sought to withdraw the AVO, and it and the assault charge were withdrawn and dismissed.

22. In 2004, Mr S made reports to his sons’ school and to police that Ms K had physically abused their older son PS, that she had a mental illness and would not take her medication, that she had tried to flush the head of their other son AS down the toilet, and that she had then verbally abused AS.

23. After speaking with the children, police determined not to take action as they considered Mr S had influenced the boys’ accounts. To child protection officers, Ms K said that there was long term domestic violence in her relationship with her husband.

24. A year later Mr S was charged with assault occasioning actual bodily harm. Two neighbours had called police after hearing Mr S yelling the words: ‘Why do I have to kill you, why are you making me do this, I am going to have to kill you now’.

When police arrived, Ms K told them that Mr S had hit her in the pelvis and the head, and had slapped one of their sons when he asked his father to stop. She said Mr S had then struck herself and her son with a wooden chair and a stick.

25. In court in October 2005, Mr S pleaded guilty to the charge in relation to his wife.

He was convicted and received a suspended sentence of 12 months, together with an AVO. The charge in relation to their son was dismissed.

Findings in the Inquest into the death of Ms K

26. In February 2007, Mr S made another report to the boys’ school, claiming that Ms K had twisted their younger boy’s hand because he had left his homework at school. Mr S did not wish the police to be notified.

The incident in August 2007

27. One night in August 2007, Ms K rang police to report that she was scared. She provided her address, and then hung up.

28. When police attended the home, she told them that Mr S had been drinking alcohol and they had an argument about her cooking. He had then grabbed her by the hair, dragged her around, and slapped her. According to Ms K, her husband then told PS to bring him a kitchen knife, which he did. Mr S then threatened Ms K with the knife while holding her head. Their younger son began to cry and Mr S was distracted, causing him to cut her on the left side of her chin. Mr S then went into the bedroom and fell asleep.

29. Police attended the home and photographed Ms K’s injuries. While they were there Mr S awoke, and police observed that he was intoxicated. He was arrested and charged with assault occasioning bodily harm. Police also imposed an AVO which included the condition that he not reside where Ms K lived, and that he not approach her within 12 hours of consuming alcohol or other drugs.

30. Notably, Ms K’s older son was argumentative with the attending police, who assessed that he had not told them the truth about the incident in order to protect his father.

31. Mr S pleaded not guilty to the criminal charge, and there was a contested Local Court hearing in January 2008. In her evidence Ms K told the court that if she had really told the police about her husband ‘he will be in the gaol a long time ago honestly’. Previously she had not done so because: ‘ … he’s my husband … he’s the father of my children. He said he wants to have a family together. This – I’m not that nasty. I want him to get help, to get better, or leave me’.

32. Ms K told the court that while her husband was threatening her with the knife, he had said to her: ‘You are a bitch. I’ll kill your family. I do this one. You think you go to the work as you do this kind of thing’. All rubbish the things that he go to my character, and children. … I don’t want to use these words what he saying to the children to tell me’.

33. When Mr S gave evidence at the Local Court hearing, he denied having assaulted Ms K and claimed that she had inflicted her injuries upon herself. Their older son Findings in the Inquest into the death of Ms K

PS was called as a witness in his father’s case and said that he had not seen their father touch Ms K in any way.

34. Ultimately the Local Court magistrate found Mr S guilty, observing that it was most unlikely that Ms K had inflicted on herself the injuries that had been observed and photographed by police. Mr S was convicted and sentenced to 8 months imprisonment, with a final AVO. He lodged an appeal and was granted bail pending its hearing.

35. In May 2008, Mr S’s appeal was successful, and the conviction and AVO were set aside.

Events between 2007 and 2012

36. Thereafter, Ms K did not report to police any incidents of physical violence.

However, there were numerous interactions with police, as follows:

• in February 2009, Ms K reported to police that she was scared to go home and wanted advice on how to leave her relationship. She was given written information about services available for victims of domestic violence and advised to contact a solicitor.

• in December 2009, Mr S contacted police and reported that Ms K was threatening self harm, had attempted to hurt herself with a knife, and wanted to get a gun. When police attended, Ms K told them she had threatened self harm in order to make Mr S get work, as she was tired of him gambling their savings.

• in December 2012, the couple’s younger son AS rang police to report that Mr S had slapped his face. He also told police that his father regularly assaulted him. When police attended the home, Mr S agreed there had been an argument but denied slapping his son. His older son PS confirmed this version. Police assessed that there was no basis for any charges.

Reports made to medical professionals

37. Mr S attended his GP on a number of occasions in 2012 and 2013, expressing concern about his consumption of alcohol. He told his GP that his wife was angry and paranoid. He and the GP discussed counselling, but no referrals were made.

Mr S had further attendances on his GP between October and November 2013, in which he said he was drinking extra alcohol, had family problems, was separating from his wife, and was having difficulties with his mother in law from India who was staying with them.

38. For her part, Ms K reported to her GP stress, poor sleep, low mood and issues with her husband. Between March and October 2013 she had several sessions with a Findings in the Inquest into the death of Ms K

clinical psychologist who diagnosed her with severe depression, severe anxiety, and an adjustment disorder.

39. According to her psychologist’s records, Ms K disclosed that Mr S had been physically and verbally abusive to her, had injured her, and had falsely accused her of having relationships with other men. In addition, he had made it difficult for her to spend time with her sons. Ms K also reported that her husband had a history of gambling and alcohol addiction, was cheating on her, and was saying indecent things about her to his family and friends.

40. In July 2013, police attended the family home after Ms K rang them to seek advice on how to leave home. To these officers Ms K repeated her claims that her husband had been abusive for many years, was spending all their money, slept with other women, and insulted her reputation to others. She said that she had decided to leave the marriage. Police advised both Ms K and Mr S to seek legal advice. The police report did not make any reference to Mr S’s 2005 conviction for assault occasioning bodily harm.

41. The following year Ms K reported to police that her husband had taken some of her clothing and her gold jewellery, much of which had been gifts to her on her wedding. When police attended, Mr S denied having done so. They were both advised that it would probably be best for them to move forward with a separation.

Again, the police report did not make any reference to Mr S’s previous conviction, but only to ‘previously recorded domestic violence incidents, verbal arguments’.

The visit of Ms K’s mother

42. During 2013 and 2014, Ms K’s mother made a lengthy visit to Australia and stayed with the family.

43. Ms K told her psychologist that with the benefit of her mother’s presence, she had started to feel more relaxed and was becoming more assertive with Mr S. Notably, in March 2014 she opened a bank account in her own name and instructed her employer to deposit her wages into it. She also started driving lessons. A friend later confirmed with police that while her mother was there, Ms K had ‘got a lot stronger and decided that, when the boys had finished their schooling, she would leave [Mr S]’.

44. After Ms K’s death, her older son PS told police that over the past few years his mother had ‘started to defend herself more during arguments’ and was not as frightened of his father, because she knew she could call the police for help.

45. However, again according to the psychologist’s records, Ms K considered that around this time Mr S was becoming increasingly controlling and was checking on her whereabouts.

Findings in the Inquest into the death of Ms K

46. After Ms K’s death, her mother described to police what she had observed while she was staying with the family. She had encouraged her daughter to separate from Mr S because he was not supporting her. Mr S had taken her daughter’s wedding jewellery and some of her more expensive clothing, which Ms K’s mother believed he was selling to support his gambling addiction. He would not let Ms K become close to her sons, or allow them to speak to herself.

The years 2015 to 2017

47. During 2015 and 2016, Mr S continued to report to his GP that his relationship with his wife was difficult and that he was drinking a lot. He described his wife as ‘very disrespectful and verbally abusive’. Ms K told friends that she still wanted to separate from him, as he was gambling their money, and their mortgage was in arrears.

48. Ms K’s friend and colleague Ms H gave evidence at the inquest. According to Ms H, Mr S did not like his wife to invite her friends to their home. Nor did he want her to visit people without him. Ms K had told Ms H about her husband’s drinking and gambling, and that he had sold some of her clothes and jewellery. Ms H had urged her to be careful, and to think about leaving her marriage. She also warned Ms K that her husband might physically harm her, but Ms K did not think this was likely.

49. Mr GS, whose father was a relative of Mr S, also gave evidence at the inquest. Mr GS had come to Australia in 1993 and had settled in Melbourne. From 2015 onwards Mr S began phoning Mr GS, complaining that his wife was not looking after himself and their sons. Mr GS urged Mr S to sort out his marriage problems, as their sons were getting older and it wasn’t good for them to see their parents arguing. He also advised Mr S that if he and his wife couldn’t work out their problems, they should separate.

50. According to Mr GS there were times when these conversations with Mr S were very frequent, but he said he had never had any concerns for Ms K’s safety. He had regarded Mr S’s complaints as ‘whingeing’ and not indicating anything very serious. Mr GS continued not to be concerned, even when on 7 March 2017 Mr S rang while he (Mr GS) was at work and told him that he was going to kill himself and his wife.

Ms K’s final contact with police: 17 August 2016

51. On 17 August 2016, Ms K phoned police from her workplace, to report that her husband had damaged her car the previous day after a verbal argument. Mr S had been angry that she had parked her car in their driveway, which he considered to be his parking space. Ms K had said she would move her car if he asked nicely, to which Mr S had replied: ‘Don’t worry, I’ll move it, watch me how I do it’.

Findings in the Inquest into the death of Ms K

52. When Ms K saw her car the next morning, it had been ‘keyed’ with scratches at the rear and the passenger side panels.

53. Police attended and spoke with Mr S, who denied any involvement. As there was no available CCTV, police did not consider there was enough evidence to charge anyone in relation to the damage to Ms K’s car.

54. Nor did the attending police officers consider there was sufficient evidence to seek an AVO for Ms K’s protection.

55. The appropriateness of this response is considered later in these findings.

The months leading up to Ms K’s death

56. In September 2016 and again in November 2016, Mr S told his GP that he was very stressed about his wife, and about his older son PS, who he did not feel was doing well at university.

57. During 2017, Mr S’s hostility towards his wife appears to have escalated, based on the observations of people who were interviewed after Ms K’s death.

58. A male neighbour overheard an argument between the couple, after which Mr S said to the neighbour: ‘Sorry but the fucking bitches. The fucking bitch, I brought her over here, gave her everything. She fucking had nothing and this is the fucking thanks I get for it’.

59. According to PS, his mother accused his father of stealing her necklace, after which the couple stopped speaking with each other. PS also said that his father spoke to him in threatening terms about Ms K, saying things like: ‘I think she’s having an affair, that’s what women do, they do secretive things’; and ‘If she doesn’t stop this I’m going to kill her and then kill myself’. Reportedly he also told PS: ‘She needs to start behaving otherwise I’m going to lose it’; and ‘I’m fifty seven years old and I have diabetes, I have nothing to lose’.

60. Mr S appears to have become convinced that his wife was having an affair (there is in fact no evidence that this was the case) and that she had, as he put it, ‘destroyed’ and ‘broken’ their family. About two weeks before Ms K was killed, Mr S took AS with him and drove to Ms K’s workplace, to see what she was doing.

Ms K finished her shift at about 8.35pm. Mr S and AS remained in Mr S’s car observing her while she sat in her car for about two hours.

61. Over these months Ms K was making enquiries about leaving the family home. By now both her sons had finished secondary school. She made internet searches for TAFE and university courses, and for new jobs. Just one day before her death, she asked her friend and colleague Ms H if she had a spare bedroom, as she wanted to move out of her home. Ms H did not have a spare room, but she told Ms K that Findings in the Inquest into the death of Ms K

she could arrange one for her. She also offered to call a domestic violence service, but Ms K asked her not to as she didn’t want to make her husband angry.

62. At this time Ms K was working two jobs, and over the period 6-10 March 2017 she took leave from one of them. Mr S also took leave at that time, telling police afterwards that he wanted ‘to catch her’ in an affair. He spent much of 6 March 2017 trying to track her movements.

The events of 7 March 2017

63. On the morning of 7 March 2017, Mr S attended the nearby Kings Park Tavern, then went to a supermarket and purchased a knife. He returned home shortly before 11.30am, to confront his wife.

64. Two neighbours heard screams between 11.30am and 12.30pm. Later, one of the neighbours told police that she had not reported this because ‘fights and yelling were so frequent’.

65. Mr S’s phone records indicate that he then made phone calls to an Indian number and a Singaporean number, before having a phone conversation with Mr GS (referred to in paragraph 50 above). After this he left the house.

66. At about 4.20pm, Ms K’s younger son AS came home and found his mother dead, lying on the floor under some blankets. He told police ‘my dad did it’. Soon afterwards his brother AS also arrived home and told police that as soon as he had seen police at the house, he knew his father had killed his mother.

67. Police found Mr S at about 6.00pm, sitting in his car nearby. He immediately admitted to having killed his wife. He also told police that after killing Ms K he had tried to hang himself in the outside area of their house, but the rope he was using kept slipping.

68. Soon afterwards Mr S participated in a formal interview at the police station, in which he said that he had killed Ms K because he believed she was having an affair. Her ‘whole attitude’ had changed since she had learned to drive, and she had been ‘putting me under thumb like this’. As far as he was concerned: ‘Enough is enough. You’re going to carry on like that, you die, I die, that’s it’. He had intended to kill himself because, he said, he did not want to spend time in gaol.

69. Mr S was charged with murder and remained in custody until 15 January 2018, when he committed suicide.

The cause and manner of Ms K’s death Findings in the Inquest into the death of Ms K

70. An autopsy was performed on 9 March 2017 by forensic pathologist Dr Elsie Burger.

71. Dr Burger recorded the cause of Ms K’s death as ‘unascertained’. She found that:

• Ms K had received stab wounds to her neck/chin and shoulder. These were unlikely to have brought about her death, although ‘they could certainly have contributed to her death’

• Injuries on Ms K’s face were consistent with injuries associated with smothering. However this could not be certain, as typically, smothering did not leave any features which can be detected on post mortem examination.

72. I accept the submission of Counsel Assisting that on the balance of probabilities, the cause of Ms K’s death can be found to be suffocation. I base this finding upon:

• Dr Burger’s conclusion that the post mortem findings are in keeping with suffocation

• Mr S’s multiple admissions to police that he had put a covering over Ms K’s face. He variously described the covering as his hand, a pillow, and a towel.

73. The evidence is therefore sufficient to establish that the cause of Ms K’s death is suffocation, and that the manner is homicide.

74. I now turn to the issues examined at the inquest.

The nature and circumstances of Ms K’s relationship with Mr S

75. In closing submissions Counsel Assisting submitted that taken together, the evidence would permit the court: ‘ … to be satisfied to the Briginshaw standard as to the veracity of [Ms K’s] reports of a lengthy history of emotional and psychological abuse by [her husband].’

76. In support of this submission Counsel Assisting pointed to the multiplicity of different sources which had reported that for many years Mr S had behaved towards his wife in a manner which was controlling, and was physically, emotionally and psychologically abusive.

77. This submission was not disputed by any of the parties of sufficient interest.

78. That Mr S had been physically violent towards Ms K is evidenced by his criminal conviction in 2005 of assault occasioning bodily harm. In addition, Ms K told police that she had underreported the extent of her husband’s physical abuse.

79. As regards Mr S’s emotional and psychological abuse of his wife, a wide range of sources attest that this occurred over a number of years. The sources include: Findings in the Inquest into the death of Ms K

• eye witnesses of such behaviour, including Ms K’s sons and her mother.

• Ms K’s reports of such behaviour to her friends, her treating psychologist, and police.

• comments made by Mr S himself which are indicative of a controlling and abusive attitude towards his wife (refer to paragraphs 49, 50, 58 and 59).

80. The evidence supports the conclusion that Mr S’s relationship with his wife was characterised by physical, emotional and psychological abuse over many years.

81. I accept the additional submission of Counsel Assisting that Mr S’s behaviour over these years would accurately be described as ‘controlling’. His conduct included:

• attempts to isolate Ms K’s sons from her and from her mother, and to manipulate them to think badly of both women.

• attempts to isolate Ms K from her friends and colleagues by discouraging them from visiting their family home.

• insulting her reputation to their sons, to other family members, and to people outside their home.

• taking and spending her earnings and possessions.

• checking where she was going and what she was doing.

82. The evidence also supports the conclusion that Mr S’s controlling and threatening behaviour escalated in the months leading up to his fatal attack upon Ms K in March

83. This period coincides with the formation of a serious intention on Ms K’s part to leave her marriage, as described in paragraph 61 to 62 above.

Coercive control and cultural considerations

83. The inquest was assisted by the evidence of two experts, who offered contextual evidence about the domestic violence environment within which Ms K lived, and the risk factors for lethal violence that were present. The court also heard of initiatives undertaken within Riverstone Police Area Command, to raise awareness within the local Sikh community about the new coercive control offence and the kinds of behaviour it prohibits.

84. The experts were:

• Professor Heather Douglas, Melbourne Law School, whose primary research focus is intimate partner violence.

• Dr Manjula O’Connor, clinical psychiatrist, whose research focus is family violence and the experience of migrant women.

The evidence of Professor Douglas Findings in the Inquest into the death of Ms K

85. Professor Douglas described the phenomenon of coercive control within intimate partner relationships as: ‘ … a strategic course of gender-based abuse in which some combination of physical and sexual violence, intimidation, degradation, isolation, control and arbitrary violations of liberty are used to subjugate a partner and deprive her of basic rights and resources’.

86. Having reviewed the evidence in Ms K’s case, Professor Douglas concluded that Mr S’s behaviours demonstrated many of the tactics of coercive control, including those recognised in the new NSW criminal offence of coercive control, pursuant to section 54D of the Crimes Act 1900. This offence, which came into effect on 1 July 2024, criminalises behaviour which is used towards a current or former intimate partner with the intention to hurt, intimidate, scare, threaten or control them.

87. In Professor Douglas’ further opinion, within Ms K’s marriage at the time of her death there existed a number of factors which are associated with a risk of lethality.

88. These included acts of coercive control (heightened when Mr S became aware that Ms K was making plans to leave their marriage); monitoring of her movements (likewise increasing in response to Ms K’s attempts to withdraw from her husband’s control); threats to kill her; misuse of alcohol; and financial strain potentially as a result of his gambling.

The evidence of Dr O’Connor

89. Dr Manjula O’Connor was asked to provide the court with information about beliefs, customs and practices within Indian communities in Australia regarding gender roles, marriage, separation and family violence. She was also asked to identify if these cultural factors manifested in Ms K’s marriage.

90. Dr O’Connor provided an expert report and gave oral evidence at the inquest. She identified a number of cultural beliefs and practices which in her opinion were present within Ms K’s marriage, and which were detrimental to her safety and wellbeing. These included:

• Male gender norms which emphasise the need to be in control of wife and children. Dr O’Connor commented that these norms are universal, but are particularly present in Indian culture. They were reflected in Mr S’s behaviour of isolating Ms K from her support networks including her mother and her friends; expressing hostility to the fact that she had a job and was learning to drive; and monitoring her movements when she was outside the family home.

• The patrilinear nature of Indian culture, whereby children are seen to belong to the husband and his family. This feature was manifest in Mr S’s tactic of isolating his sons from their mother.

Findings in the Inquest into the death of Ms K

• The belief that marriage is central to women’s lives, making it more difficult for a woman to leave her marriage and her children.

• Gender-based power imbalances imposed by the age gap between Ms K and her husband, and the advantage he possessed in having lived in Australia for some years before she arrived.

91. Dr O’Connor emphasised that the above beliefs and customs were not held or practiced by all members of the Indian community in Australia.

92. She also commented that cultural and gender norms are changing. This was reflected in the encouragement which Ms K’s friends and her mother gave her to leave her abusive marriage, and by Mr GS’s evidence that separation was acceptable within his extended family.

The evidence of Detective Inspector Meaghan Finlay

93. Detective Inspector Finlay is the Crime Manager at Riverstone Police Area Command. She gave evidence at the inquest about work she has done engaging with members of the local Sikh community through their temple at Blacktown.

According to Detective Finlay, this is one of the largest Sikh temples in NSW, with between 10,000 and 12,000 devotees.

94. Detective Finlay works alongside the NGO Harman Foundation and the Australian Sikh Association Council, to raise awareness within the Sikh community about domestic and family violence. Detective Finlay told the court that the practice of dowry abuse is an important focus of their work. Her information sessions are informal in nature, and provide information to men in particular about a range of matters. These include what is permitted and not permitted within an AVO; and the unacceptability of the more common controlling behaviours such as prohibiting a wife from working or from operating a bank account.

Mr S’s mental state when he killed Ms K

92. When Mr S entered custody on 7 March 2017 his legal representatives commenced preparations for a possible defence to his murder charge, based on mental illness. Ultimately however, Mr S took his own life before the commencement of his trial in the NSW Supreme Court.

93. As part of these preparations, Mr S was psychiatrically assessed on three occasions in 2017. The assessing psychiatrists concluded that at the time he killed Ms K, Mr S was experiencing a major depressive episode with psychotic features, the latter characterised by a delusional belief of her infidelity. The psychiatrists also considered that Mr S met the diagnostic criteria for alcohol use Findings in the Inquest into the death of Ms K

disorder. They adhered to these diagnoses after having been provided with the evidence that over a lengthy period, Mr S had inflicted physical, emotional and psychological abuse upon Ms K.

94. Ultimately, whether Mr S’s mental condition would have enabled a defence of mental illness is not a matter this inquest needs to determine. I accept the conclusion drawn by Counsel Assisting in her closing submissions: ‘Plainly Mr S’s mental state at the time of [Ms K’s] death included the active symptoms of at least a significant depressive illness, together with an alcohol abuse disorder and possible alcohol related brain damage, which impaired his judgement and impulse control’.

The response of NSW Police on 17 August 2016

95. The inquest examined the adequacy of the police response to Ms K’s last call for assistance on 17 August 2016. This issue was also examined within the wider context of whether a risk assessment tool used by police when attending domestic violence incidents is adequate.

96. The NSW police response to domestic violence is guided by two fundamental programs and procedures. These are:

• The NSW Government’s Safer Pathways Program and its risk assessment tool; and

• the NSW Police Force’s Domestic Violence Standard Operating Procedures [DVSOPs].

97. Both were in operation when Ms K made her call to police on 17 August 2016.

Safer Pathways and the Domestic Violence Safety Assessment Tool [DVSAT]

98. The Safer Pathways Program was introduced by the NSW Government in 2015, as part of its response to domestic violence. It is an integrated referral service, whereby government and non government agencies work together to provide victim-survivors of domestic violence with support and safety plans.

99. Typically, police are the first responders to an incident of domestic violence. When police are called to an incident they administer a risk assessment tool, known as a Domestic Violence Safety Assessment Tool, or ‘DVSAT’. The DVSAT is a key component of the Safer Pathway system, as it aims to identify the level of threat to the victim’s safety. This in turn will determine the service response.

100. The DVSAT consists of two parts. The first is a series of questions for the victimsurvivor, about behaviours and signs that are recognised as indicators of threat.

Findings in the Inquest into the death of Ms K

The second part is a section for the attending police officer to complete, in which she or he applies their professional judgement to determine the level of threat, taking into account police data about the perpetrator’s history of family violence.

101. If the attending officer assesses that the person is ‘at threat’, the person will be referred to an external Central Referral Point, which delivers support through Women’s Domestic Violence Court Advocacy Services.

102. If the person is assessed as ‘at serious threat’ they will be referred to a Safety Action Meeting, at which agencies will prepare a safety plan for the person.

The DVSAT completed for Ms K

103. On 17 August 2016, Senior Constable Valentina Latkich attended Ms K’s home in response to her report about the damage to her car. SC Latkich interviewed Ms K and administered the DVSAT. Prior to attending, SC Latkich had not reviewed the many COPS reports about the family, but she did so after her return to the police station.

104. At this time SC Latkich was stationed at Quakers Hill Police Station, an area whose population has a diverse range of language, cultural and ethnic communities.

105. SC Latkich had attended numerous incidents of domestic violence. At the inquest she said that in her experience, it can take time for victims of domestic violence to accept that they are able to call police for assistance. This is especially the case within some immigrant communities, where there is often a traditional preference for family conflict to be managed within the community itself.

106. On 17 August 2016, SC Latkich recorded that Ms K answered ‘yes’ to many of the questions in the first part of the DVSAT, including the following:

• Has your partner ever threatened to harm or kill you?

• Has your partner ever used physical violence against you?

• Has your partner ever choked, strangled, suffocated you or attempted to do any of these things?

• Has your partner ever threatened or assaulted you with any object (including knives and/or other objects)?

• Is your partner jealous or controlling of you?

• Does your partner have a problem with substance abuse such as alcohol or other drugs?

• Is/has your partner currently on bail, parole, served a time of imprisonment or has recently been released from custody in relation to offences of violence?

Findings in the Inquest into the death of Ms K

107. To the question ‘How fearful is the victim of their partner?’, SC Latkich recorded Ms K’s answer as ‘Not afraid’. Ms K had told SC Latkich that she believed her husband had ‘learnt his lesson’ in the last ten years.

108. SC Latkich then returned to the police station and completed the DVSAT. She noted that Ms K had answered ‘yes’ to a number of the DVSAT questions. After reviewing the COPS events about the family, SC Latkich also recorded: ‘Prior history of violence including stalking and intimidation … 2 x AOABH, 1 x common assault with the POI as the defendant .. AVO’s in place from 2003 – 2008, nil current. Last ordered expired 2008’.

109. SC Latkich determined that Ms K was not ‘in harm’s way, or unsafe or at risk’, and that there was therefore insufficient basis to seek an AVO. At the inquest she explained this was because of ‘the length of time between incidents (verbal and physical) and the fact that on this occasion there were no reports of threats, intimidation or violence’.

110. SC Latkich then entered Ms K’s DVSAT into the NSW police system, which generated a referral to the Women’s Domestic Violence Court Advocacy Service at Blacktown. This Service made a number of attempts to contact Ms K, but there is no evidence that she responded to these.

111. At the inquest SC Latkich was asked about her decision not to seek an AVO on 17 August 2016. She explained that she had placed considerable reliance on Ms K’s response that she did not hold any current fears of violence, and also on the fact that there were no recent records of physical abuse.

The DV Standard Operating Procedures

112. The NSW Police Force’s Domestic and Family Violence Standard Operating Procedures [DVSOPs] came into operation in 2012. The DVSOPs outline the policy and practices which police are expected to apply when they respond to domestic and family violence incidents.

113. In 2015 and again in 2018 the DVSOPs were amended, to ensure that the new DVSAT procedures are included when police respond to a domestic violence incident.

114. The DVSOPs applicable in August 2016 required SC Latkich to provide Ms K with a document known as a ‘white card’. SC Latkich did so. This card sets out information and referral options for domestic violence victims. It also invites the victim to contact the attending police officer with any further information or enquiries.

Findings in the Inquest into the death of Ms K

115. The applicable DVSOPs also required SC Latkich to make a follow up contact with Ms K seven days later, which SC Latkich attempted to do. However, there is no record of what happened when she made this attempt.

Did the police response on 17 August 2016 comply with applicable policies and procedures?

116. Having examined the policies and procedures which applied in August 2016, I accept the submission of Counsel Assisting that in the context of what was required of responding police officers at the time, the response of SC Latkich on 17 August 2016 complied with applicable NSW Police Force policies and procedures.

117. In reaching this conclusion, I have taken into account that Ms K’s report to police did not involve a clear indication that she was at serious threat of physical harm. I also take into account significant developments that have taken place in NSW policing of domestic violence since that time. At the inquest SC Latkich spoke about the impact which these developments have had on the approach she now brings to domestic violence incidents.

118. SC Latkich said that she has reflected on the decisions she made on 17 August

119. She told the inquest that since that time she has developed a stronger understanding of domestic violence, and in particular that the absence of physical violence is not definitive. She said further that she now understood that controlling behaviour is often an indicator of a relationship which can become physically violent. Her deeper understanding was in part due to the recent introduction of the coercive control criminal offence, and the mandatory training which police have received in relation to it.

120. SC Latkich said that in hindsight, she believed that Mr S’s conduct in telling his wife that she could not park in the driveway, and his response ‘Don’t worry, I’ll move it, watch me how I do it’, were potentially examples of controlling behaviour, and would now cause her to make further investigations.

121. SC Latkich explained further that when administering the DVSAT she now saw her role as one of attempting to clarify the nature of the couple’s relationship, rather than simply to ask questions to determine if a criminal offence had taken place. She agreed this was especially important, now that the new offence of coercive and controlling conduct has been introduced.

122. It is much to the credit of SC Latkich that she is able to reflect on her approach to her work as a police officer, and in particular how she can respond in the most effective way to the very difficult work of policing domestic and family violence.

Her evidence was in many ways reflective of a shift in the approach to domestic violence policing which has taken place within the NSW Police Force, and which is now described in general terms.

Findings in the Inquest into the death of Ms K

Developments in NSW Police Force domestic violence policing

122. In the seven years since Ms K’s tragic death, there have been significant changes in the approach of the NSW Police Force to domestic and family violence.

123. Some of these changes have been guided by the NSW Police Force’s Domestic and Family Violence Registry [the DFV Registry]. This Registry was formed in January 2023, with the aim of modernising the policing of domestic violence. The DFV Registry is currently managed by Detective Inspector Jane Prior, who gave evidence at the inquest. She described a number of reforms, many of which are relevant to this inquest.

124. One of these reforms is a project to completely revise the police DVSOPs. The intention is to transform these from operating procedures to a guideline document, to be known as the ‘Domestic Violence Code of Practice’. The new Code of Practice, which is not yet complete, will incorporate information about the new s54D offence, and guidance as to the classes of abusive behaviour set out in s54C of the Crimes Act 1900 (NSW).

125. Another important reform project is the ongoing revision of the DVSAT tool.

Revision of the DVSAT

126. In 2019, there was an independent evaluation of Safer Pathway. This resulted in a recommendation that the DVSAT administered by police be revised to enhance its ability to predict the likelihood of further episodes of aggression or violence. In 2022 the NSW Bureau of Crime Statistics and Research [BOCSAR] released its research into this issue.

127. The BOCSAR research identified limitations in the DVSAT. These included the following:

• overall it has poor predictive accuracy when it comes to repeat episodes of domestic violence; and

• the questionnaire’s individual items are not weighted to reflect differences in the severity of the perpetrator’s conduct captured by each item.

128. According to the research, only five of the DVSAT indicators were of significance in accurately predicting future violence. These were:

• two measures of previous family and domestic violence

• the number of prior proven DV offences

• pregnancy and new birth

• the victim’s self-perception of the risk of future violence Findings in the Inquest into the death of Ms K

• misuse of drugs or alcohol.

129. In response, significant work commenced to revise the DVSAT. A DVSAT Working Group was established in 2022. Its aim is to develop a risk assessment tool which better predicts risk of serious DV threat, and thereby provides targeted protection to those victims who are most at risk. The Working Group involves the primary agencies of NSW Police Force, Legal Aid NSW and the Department of Communities and Justice [DCJ], as well as BOCSAR.

130. At the inquest, evidence about the Working Group’s reforms to the DVSAT was given by Ms Phillipa Hetherton. Ms Hetherton is the Director of the Interventions Branch, within Family and Communities Services at the Department of Communities and Justice.

131. First, Part A of the DVSAT, being the questionnaire, has been revised to improve its predictive accuracy. The revisions reflect BOCSAR research and modelling.

Some of the individual items have also been given weightings.

132. Secondly, the scope of information to be captured has been expanded. The DVSAT will now take into account NSW Police Force records of reported (and not just charged/convicted) incidents of domestic and family violence. This reflects that the issue of risk may well go beyond the existence or non existence of charged conduct.

133. Thirdly, the threshold of ‘at serious risk’ will be automatically reached if the perpetrator has in the previous two years been charged with a ‘trigger offence’.

These include offences of assault occasioning actual bodily harm, intentionally choking, and predatory driving.

134. At the time of the inquest, the revised DVSAT was awaiting IT readiness before being implemented.

135. In light of this evidence, I accept the submission of Counsel Assisting, that substantial work has been undertaken to address deficiencies in the DVSAT. The changes reflect targeted review and research. As noted by Counsel Assisting, police officers have a very difficult job in responding to the multitude of reports they receive of domestic and family violence. Officers need all possible assistance in reliably assessing risk: ‘ .. to ensure that those matters where the risk is more pronounced can be delivered more intensive services, without overwhelming those services’.

136. The work done in this area reflects a serious commitment on the part of the partner agencies, including NSW Police Force, to addressing domestic and family violence within NSW.

Findings in the Inquest into the death of Ms K

Does the evidence support the need for any further changes?

137. It was rightly acknowledged by Professor Douglas that police face many challenges in predicting fatal outcomes, from the multitude of domestic and family violence reports to which they must respond. Tragically there will always be the risk that victims who are in fact at risk of serious threat will not be identified and will not receive the support that they need to escape their situation.

138. In the interests of reducing this risk so far as is possible, Professor Douglas and Dr O’Connor identified specific areas which in their opinion would further enhance the effectiveness of the DVSAT. These are now described.

Should non police referrals be included?

139. It is known that a significant proportion of domestic violence victims do not report to police. In her evidence Dr O’Connor commented that for this reason, the Victorian equivalent of Safer Pathway enables a range of non-police agencies, including psychologists and psychiatrists, to make referrals.

140. As has been seen, both Ms K and Mr S disclosed to health professionals information that would have been relevant to an assessment of the risk to Ms K.

141. At the inquest Ms Hetherton advised that this limitation has been recognised by the DVSAT Working Group, and that the Working Group acknowledged the potential of health practitioners as referrers of victims into Safer Pathway.

142. The court also received evidence from the Royal Australia College of General Practitioners about the work the College is doing to enhance its members’ response to disclosures of family violence by both victims and perpetrators.

Similarly, the court heard evidence about the need for funding for men’s behaviour change programs.

143. I accept the submission of Counsel Assisting, that the above evidence supports the following two recommendations: That the DVSAT Working Group consult with the RACGP, RANZCP and the Australian Psychological Society as to how the DVSAT should operate for non police referrals into the Safter Pathway system.

That the Department of Communities and Justice and the NSW Police Force consult with the RACGP, RANZCP and the Australian Psychological Society to develop policy in the areas of perpetrator identification, engagement and service referrals.

Should out of state incidents be included in the risk assessment?

Findings in the Inquest into the death of Ms K

144. The inquest heard evidence about the importance of enabling police to identify relevant incidents which have taken place in other Australian states and territories, when administering the DVSAT. The current DVSOPs do not instruct police to do this.

145. The court further heard that police are already able to access such information via the National Crime Intelligence System and National Police Reference System platforms. Detective Inspector Prior accepted that such information should be consulted by attending police when assessing risk.

146. This evidence supports the following two recommendations.

That consideration be given to whether and how incident and criminal history information from other state and territory jurisdictions can be directly incorporated into the revised DVSAT criminal history indicators (‘Additional indicators on DVF history’ and ‘Trigger Offences’) and built into the NSW Police Force IT system supporting the DVSAT.

Pending implementation of the above recommendation, that the revised DVSAT guide, and instruction and training material specifically direct police officers to consult all accessible incident and criminal history information from other states and territories, when assessing whether a matter should be upgraded to ‘at serious threat’ level in the exercise of professional judgment on the basis of:

• the total number of prior domestic violence incidents in the past two years including in other states and territories (‘Additional indicators on DVF history’); and

• the presence of any ‘trigger offences’ in the past two years including in other states and territories.

147. Counsel for the NSW Commissioner stated that the Commissioner acknowledged and would consider these recommendations.

Should there be additional review periods?

148. At present, it is contemplated there be a review of the revised DVSAT’s effectiveness at 12 months after its implementation.

149. However, this interval raises concern due to the current significant lag in time between the laying of criminal charges, and their finalisation at court. I accept the submission of Counsel Assisting that this reality supports the need for a lengthier timeframe of review. I will therefore make the following recommendation: Findings in the Inquest into the death of Ms K

That the predictive accuracy of the revised DVSAT be reviewed at intervals of at least 12, 24 and 36 months post commencement.

150. This recommendation will be considered by the NSW Commissioner.

Should offences of stalking and coercive control be included?

151. The court heard that the proposed list of ‘trigger offences’ for the DVSAT does not include the offences of stalking or of coercive control. This was of concern to Professor Douglas. She noted that both classes of behaviour often escalate when perpetrators realise they are losing control, commonly when they become aware of plans by the victim to separate. This behaviour was seen in Ms K’s case.

152. The Department of Communities and Justice [DCJ] responded to this proposal.

153. Regarding inclusion of the stalking offence, DCJ submitted that according to BOCSAR modelling, this would lead to a substantial increase to the volume of referrals to a Safety Action Meeting, at a level beyond its current resourcing capacity. The BOCSAR research additionally found that inclusion of the stalking offence reduced the revised DVSAT’s predictive accuracy.

154. So far as the offence of coercive control is concerned, DCJ submitted that it was as yet unknown what impact that inclusion of this offence as a trigger offence would have on the volume of referrals, or the predictive accuracy of the DVSAT.

155. Taking into account these submissions, Counsel Assisting proposed that it would be reasonable to not recommend immediate inclusion of these two offences as trigger offences. Counsel submitted however, that the prevalence of coercive control in fatal domestic violence cases strongly indicated that its inclusion should be considered in the planned reviews of the DVSAT’s effectiveness.

156. I accept this submission, and will make the following recommendation: That as part of the DVSAT reviews, consideration be given to the inclusion of an offence of coercive control (‘abusive behaviour towards current or former intimate partners: section 54D Crimes Act 1900) within the last two years as a ‘trigger offence’.

Police training in the ‘coercive control’ offence

157. Detective Inspector Prior also gave evidence about mandatory training which has been delivered to NSW police officers, to prepare them for the introduction of the new coercive control offence. She added that the DFV Registry recognised that police training in domestic violence will be enhanced by input from external agencies as well as external subject matter experts.

Findings in the Inquest into the death of Ms K

158. On the question of police training, at the inquest Professor Douglas referred to research conducted in the United Kingdom, where the coercive control offence has been in place for eight years. This research suggested that refresher courses, preferably conducted face to face, were needed to enhance police’s response to domestic and family violence.

159. This evidence prompted Counsel Assisting to propose the following recommendations: That the NSW Police Force develop a framework for the period 1 January 2025 to 31 December 2027, to guide police training in domestic and family violence policing that identifies intervals for refresher training, modes for course delivery, and protocols for integrating course evaluations and workforce capability assessments into the training design.

That the NSW Police Force continue to consult with external subject matter experts, and government and non government stake holders, in the development of any policy and training content related to domestic and family violence.

160. Counsel for the NSW Commissioner of Police stated that these recommendations would be considered by the NSW Commissioner.

The question of dowry abuse

161. At the inquest Dr O’Connor told the court that within Victorian legislation, the practice of ‘dowry abuse’ has been included as a form of abusive behaviour.

162. Dr O’Connor explained that the term ‘dowry abuse’ referred to the practice of using coercion, violence or harassment to demand money, property or gifts which are typically transferred by a woman’s family to her husband upon marriage, and not uncommonly for many years thereafter.

163. According to Dr O’Connor, the process of migration can facilitate this particular kind of abuse, because in many cases the Indian bridegroom has become a resident of the new country, and for this reason is considered by a bride’s family to merit a large dowry. Within Indian families it was sometimes the case that the husband’s coercive demands upon his wife’s family for further gifts or money continued for many years after the wedding.

164. In Dr O’Connor’s opinion, Mr S’s behaviour towards his wife manifested some of these features, including his taking of her gold jewellery which she had received as gifts upon her marriage.

165. Dr O’Connor commented further that in Australia, the phenomenon of ongoing dowry abuse was not well understood. In her opinion it was a form of abuse which Findings in the Inquest into the death of Ms K

was distinct from ‘financial abuse’, which is included in the current NSW legislation as one of the forms of abusive behaviour. For this reason, she advocated that dowry abuse be specifically listed as an example of the types of behaviour that could meet the definition of abusive behaviour.

166. This evidence prompted Counsel Assisting to propose the following recommendation: That the Attorney General consider, as part of the statutory review undertaken into section 54D of the Crimes Act 1900, amending the definition of ‘abusive behaviour’ in section 54F(2) of the Crimes Act 1900 and the definition of ‘domestic abuse’ in section 6A(2) of the Crimes (Domestic and Personal Violence) Act 2007 to include the following: ‘behaviour that uses coercion, threats, physical abuse or emotional or psychological abuse to demand or receive dowry, either before or after a marriage’.

167. The court did not receive submissions on behalf of interested parties in relation to this recommendation.

Conclusion

168. I express to the sons of Ms K and Mr S my sincere sympathy for the loss of both their parents in such tragic circumstances.

169. I thank Counsel Assisting Ms McGee and the Assisting team for their work in the preparation and conduct of this inquest. I thank also the Officer in Charge of the coronial investigation, Detective Inspector Meagan Finlay and the previous Officer in Charge Detective Senior Constable Rebecca Gibson for the preparation of the brief of evidence.

Findings required by s81(1)

170. As a result of considering all of the documentary evidence and the oral evidence heard at the inquest, I am able to confirm that the death occurred and make the following findings in relation to it.

Identity The person who died is Ms K.

Date of death: Ms K died on 7 March 2017.

Place of death: Ms K died at , Glenwood NSW.

Findings in the Inquest into the death of Ms K

Cause of death: Ms K died as a result of suffocation.

Manner of death: The manner of Ms K’s death was homicide by a known person.

Recommendations pursuant to s82 To the NSW Commissioner of Police:

1. That the NSW Police Force develop a framework for the period 1 January 2025 to 31 December 2027, to guide police training in domestic and family violence policing that identifies intervals for refresher training, modes for course delivery, and protocols for integrating course evaluations and workforce capability assessments into the training design.

2. That the NSW Police Force continue to consult with external subject matter experts, and government and non government stake holders, in the development of any policy and training content related to domestic and family violence.

To the DVSAT Working Group, the NSW Domestic, Family and Sexual Violence Board, and the NSW Commissioner of Police

3. That consideration be given to whether and how incident and criminal history information from other state and territory jurisdictions can be directly incorporated into the revised DVSAT criminal history indicators (‘Additional indicators on DVF history’ and ‘Trigger Offences’) and built into the NSW Police Force IT system supporting the DVSAT.

4. Pending implementation of Recommendation 3, that the revised DVSAT guide, and instruction and training material specifically direct police officers to consult all accessible incident and criminal history information from other states and territories, when assessing whether a matter should be upgraded to ‘at serious threat’ level in the exercise of professional judgment on the basis of:

• the total number of prior domestic violence incidents in the past two years including in other states and territories (‘Additional indicators on DVF history’) and

• the presence of any ‘trigger offences’ in the past two years including in other states and territories.

5. That the predictive accuracy of the revised DVSAT be reviewed at intervals of at least 12, 24 and 36 months post commencement.

6. That as part of the DVSAT reviews, consideration be given to the inclusion of an offence of coercive control (‘abusive behaviour towards current or former intimate Findings in the Inquest into the death of Ms K

partners: section 54D Crimes Act 1900) within the last two years as a ‘trigger offence’.

To the DVSAT Working Group, and the NSW Domestic, Family and Sexual Violence Board

7. That the DVSAT Working Group consult with the RACGP, RANZCP and the Australian Psychological Society as to how the DVSAT should operate for non police referrals in to the Safter Pathway system.

To the Secretary, Department of Communities and Justice, and to the NSW Commissioner of Police

8. That the Department of Communities and Justice and the NSW Police Force consult with the RACGP, RANZCP and the Australian Psychological Society to develop policy in the areas of perpetrator identification, engagement and service referrals.

To the Attorney General, NSW

9. That the Attorney General consider, as part of the statutory review undertaken into section 54D of the Crimes Act 1900, amending the definition of ‘abusive behaviour’ in section 54F(2) of the Crimes Act 1900 and the definition of ‘domestic abuse’ in section 6A(2) of the Crimes (Domestic and Personal Violence) Act 2007 to include the following: ‘behaviour that uses coercion, threats, physical abuse or emotional or psychological abuse to demand or receive dowry, either before or after a marriage’.

I close this inquest.

Magistrate E Ryan Deputy State Coroner, Lidcombe 12 December 2024 Findings in the Inquest into the death of Ms K