Inquest into the death of Holly Davidson

ORDER: RESTRICTION OF PUBLICATION ORDER LIFTED 23 JUNE 2025 CITATION: Inquest into the death of Holly Anne Davidson [2021] NTLC 029 TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO(s): D34/2020 DELIVERED ON: 9 November 2021 DELIVERED AT: Darwin HEARING DATE(s): 27, 28 September 2021 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Domestic violence allegations made against serving police officer, inadequate investigations, coercive control ‘red flags’ not recognised

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Police Commissioner: Michael McCarthy Counsel for Police Officer: Ray Murphy Judgment category classification: B Judgement ID number: [2021] NTLC 029 Number of paragraphs: 99 Number of pages: 27

IN THE CORONERS COURT AT DARWIN IN THE NORTHERN TERRITORY OF AUSTRALIA No. D34/2020 In the matter of an Inquest into the death of

HOLLY ANNE DAVIDSON ON: 5 MARCH 2020 AT: PALMERSTON FINDINGS Judge Greg Cavanagh Introduction

1. At the commencement of the inquest I made a non-publication order in relation to the names of Holly Davidson, her partner (a serving police officer) and their children because the evidence involved sensitive personal matters that would inevitably have significant and negative impacts on the children. “Non Publication order lifted 23 June 2025”

2. Domestic violence perpetrated by serving police officers is considered to be a significant issue and police appear to struggle with investigating their own members. The Assistant Commissioner of Police, Michael White provided evidence in these terms: “Reports from other jurisdictions suggest that the rate of domestic violence involving police officers is higher than the population at large and the rate at which action is taken (in the form of a DVO or prosecution) is lower than that of the population at large.”

3. Holly Davidson was 38 years old when she died. She had been a police officer from the time she joined the force in Victoria in 2005. In 2009 she relocated and became a police officer in the Northern Territory. She commenced living with another officer (who had also relocated from

Victoria) in 2010. He had a daughter from a previous relationship and they planned to have a child together.

4. Holly Davidson became pregnant in 2011. On 21 June 2011, at twenty-one and a half week’s gestation and while at home alone, she went into labour.

She thought it was false contractions, but then gave birth. She rang ‘000’ and asked for an ambulance and rang police communications and asked that her partner be contacted. The operator contacted another member with a similar name, it delayed her partner getting to the hospital.

5. While waiting for the ambulance, her baby stopped breathing on several occasions and she performed cardiopulmonary resuscitation. She and the baby were taken to hospital. The baby was pronounced deceased at 4.16pm.

Her partner arrived about 5 minutes later. The circumstances of the birth and death of her baby left her traumatised and that trauma never resolved. She was diagnosed with post-traumatic stress disorder (PTSD).

6. Four months after the death of her baby she conceived again. However, after giving birth in July 2012, the effects of her trauma took hold and she turned to alcohol. She became dependent and struggled with the dependency for the rest of her life.

7. She returned to work as a police officer on 19 August 2013. However, between taking leave and being stood down, due to intoxication at work, she did not attend the workplace a great deal until she was dismissed from the police service three and a half years later on 3 March 2017.

8. The alcohol made her life difficult and impacted the relationship with her partner. There were seventeen complaints to the NT Police about domestic disturbances and violence over the period of 5 years between 8 February 2015 and 26 February 2020.

Reports of Domestic Violence Report 1

9. On 7 February 2015 the first report of domestic violence was made to police by a doctor. Holly Davidson told the doctor that her partner had assaulted her. She had bruising to her upper arms and chest. She said the violence had started in January 2015.

10. Police investigated and were told that Holly Davidson and her partner yelled at each other and that her partner had grabbed her by the upper arms, shook her and poked her in the chest. However she refused to give a statement or provide permission to take photographs of the bruising. She requested that no further action be taken. Police spoke to her partner, he provided a similar account, and said they were both still coming to terms with the death of their baby and were seeking counselling. Police determined it was not domestic violence.

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11. On 5 June 2015 a second incident of domestic violence was reported to police by a cousin. Holly Davidson’s partner had been trying to physically remove her from the house and it was said they were “trying to hit each other” and it had been going on for 15 minutes. When police arrived Holly Davidson was barricaded in her room. The children appeared fearful and were clinging to their father. Holly Davidson appeared intoxicated. Her partner said she was “intimidating” him and so he had taken hold of her by the arms and attempted to escort her out of the house. Holly Davidson was arrested and a s41 DVO issued for a period of 12 months with Holly Davidson as the defendant for the protection of her partner and the children.

One of the requirements was that she not be intoxicated when around them.1 1 There is a growing body of research on police misidentification of the primary perpetrator. See for instance: Policy Paper 1 “Officer she’s psychotic and I need

12. No DVO was taken out to protect Holly Davidson. In the opinion of Assistant Commissioner White, the failure “likely impacted [Holly Davidson’s] trust in the manner in which Police would handle reports of domestic violence and may have undermined her willingness to engage with the agency”.

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13. On 10 June 2015 a friend of Holly Davidson’s called the police. She said that Holly Davidson was a victim of domestic violence and was staying with her and sleeping on her lounge. She said she had photographs of the bruising caused by the partner. She said the partner had visited her house and had been aggressive toward both of them. That report did not prompt police to take any action to revise their views of what should be done in relation to the complaint five days before, or to protect Holly Davidson.

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14. On 22 July 2015 a neighbour called police twice at about 8.30pm. She said she could hear yelling, screaming, swearing and children crying. She heard a male saying “Just get the fuck out, you’ve been drinking”. She said she saw the male push the woman outside. She said there had been ongoing incidents at the premises. By the time police arrived Holly Davidson had left. They spoke to her partner who told them Holly Davidson had been intoxicated and had refused to leave. He said they had an argument and he physically removed her from the premises. He said she had grabbed a knife and threatened to harm herself. He was asked to make a statement about her intoxication to breach her on the DVO. He refused. He was offered support but declined. The police looked but could not find Holly Davidson.

Statements from others were taken to the effect that during the altercation protection”: Police misidentification of the ‘primary aggressor’ in family violence incidents in Victoria. Women’s Legal Service Victoria/Monash University July 2018.

her partner, held her around the neck, knocked her to the ground with his fist, dragged her and kicked her while on the ground.

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15. The next day (23 July 2015), another neighbour rang police to report that Holly Davidson was outside her premises with a ripped shirt and blood on her. By the time police arrived she had left. Her partner said she was intoxicated, they had argued and she left. She returned the following morning and took a bag of clothes. Police were unable to find her.

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16. On 26 July 2015 she contacted police herself. She was in a park, looking as if she had been ‘living rough’. She was taken to the hospital for an assessment and provided short-term accommodation by police. She said she did not want her partner to know she was speaking to police. Holly Davidson said she had been assaulted on three occasions: the 5th and 6th of June and 22nd July 2015. She said she had been subjected to “manipulation and control” by her partner. She did not want the relationship to end but she wanted the violence to stop. She would not provide a statement for the prosecution of her partner but said she would provide one for a DVO application. She said that her friend had photographs of the injuries inflicted in June. An application was made for a DVO to protect her on 28 July 2015.

That was the only time an application was made for her protection.

17. However, by 14 August 2015, Holly Davidson said that she did not want the DVO application to proceed. The officer to whom she said that noted a “relatively recent bruise on her upper arm”.

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18. On 9 October 2015 a rehabilitation provider reported that Holly Davidson had presented with bruising to her arms and chest. She had said her partner

grabbed her by the upper arms and poked her in the chest. She asked that her partner be refused entry to the centre. She said they had been involved in a fight because she was drinking. The records of the rehabilitation provider note that on the previous two days they had taken her to hospital because of her attendance while intoxicated. Police tried to contact Holly Davidson over the next month but she refused to engage. Her partner refused to make a statement but told investigating police that he was acting in self-defence and had used some force but it was reasonable. He said he was unhappy with the way police were treating him like a suspect and his supervisors were not recognising that he was a victim.

19. On 5 January 2016 Holly Davidson made a statement to say that the allegations she made about both the 22 July 2015 and 9 October 2015 were not true. That was at a time when her health appeared to be improving. She appears to have abstained from alcohol for the following 9 months. On 27 January 2016 her partner made a statement indicating amongst other things that he only struck Holly Davidson in self-defence. Holly Davidson returned to work on 25 February 2016. The DVO taken out on 28 July 2015 for Holly Davidson’s protection was heard in the Local Court on 1 March 2016 and dismissed.

20. Holly Davidson stayed sober until they went on a holiday together on 9 August 2016. They both sought out advice that while on holidays it would be okay for her to drink socially. After their return, on 27 August 2016, Holly Davidson and her partner argued and she left home and was later arrested for high range drink driving. She said she had left home because of a “domestic”. She refused to elaborate and her partner refused to provide a statement.

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21. At 5.00pm on 1 September 2016 a neighbour rang Police and said that Holly Davidson and her partner were arguing in the driveway and he was calling her “names”. When police arrived she had already left. Her partner told police that she had problems with alcohol and he had asked her to leave the house. The police tried to find her and left messages on her phone. At 3.00am the following morning she rang police and said she had been at home “for ages”, and she had been unaware police were looking for her. She said the incident had been only “verbal”.

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22. On 10 September 2016 the police chaplain sought that police conduct a welfare check on Holly Davidson due to disclosures that she had been assaulted by her partner. Her partner told the police she had not come home the previous night. At 6.50pm that same day Holly Davidson called Police.

She said she did not wish to speak to anyone about the incident or allegations she had made to the chaplain. Police finally caught up with her on 23 September 2016 and she said that the incident had not taken place.

She was contacted again on 4 October 2016 and said she had been “dramatising the situation” and her partner had been supportive of her.

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23. On 23 December 2016 police received a report from the Quest Apartments that Holly Davidson’s partner had come looking for her and identified himself as a police officer. He took a room near hers and jumped from his balcony onto hers and escorted her from the building. Police attended at their residence. Her partner told police that she had been intoxicated and he believed she might self-harm. Police dealt with the matter through the disciplinary system providing Holly Davidson’s partner with a formal caution. They did not investigate as to whether Holly Davidson needed protection.

24. On 24 December 2016 Holly Davidson presented to the Emergency Department at 4.21am with her partner. She had been referred by her GP.

She was said to have been on an 8 day “bender” that had finished the previous morning. She had not had a drink since 11.00am and was in the tremors. There was said to be noticeable antagonism between Holly Davidson and her partner and she was offered a private review but declined.

25. On 3 March 2017 Holly Davidson was dismissed from the Police Force.

26. On 12 August 2017 Holly Davidson sent a message to her partner: I run away, yes I do. Because I know what follows if I don't, and I can't bear it anymore.

The screaming yelling arguments, the abuse u deny, and then the days of silence ....which u don't even recognise as abuse.

So I run. I want to put it off as long as possible… Many messages from her partner followed both cajoling and threatening, attempting to have her return home.

27. On 15 August 2017 (three days later) Holly Davidson was taken by her partner to the Emergency Department for alcohol withdrawal. She had the DT’s (delirium tremens) “bad”. The notes record: “Holly Davidson ‘ran away’ over the weekend and started drinking again”. Her partner had collected her from the hotel that morning. She said the relationship was safe, that there was no DV. But it was noticed that there was ‘lots of stress in the relationship’. Her partner said he was at his “wits end”.

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28. On 3 September 2017 Holly Davidson’s partner escorted her to the front counter of the Police Station. He demanded she be breached for being intoxicated. He said there had been no domestic violence and she had agreed to accompany him there. She agreed there had been no domestic violence.

To the police officers she appeared unwell. They called an ambulance and she was conveyed to RDH. The ambulance notes indicate that she had a ‘large argument with her partner’ who dropped her at the police station. She had a wound to the left side of her forehead above the eyebrow but would not say how that occurred. The incident was not identified by Police as involving domestic violence.

29. On 8 September 2017 at 3.30pm she attended the emergency department, with her partner, suffering symptoms of withdrawal. She said she had been on a drinking binge since last Friday (a week before). Her blood alcohol was

0.384. It was said she had been long-grassing for 5 days after being “displaced from home”. She had a right black eye and said she fell on her face. She denied her partner was physically or verbally abusive. She said she left home to drink. She was discharged three days later.

30. There were a number of further admissions to hospital for withdrawal from alcohol on 18 September 2017, 29 September 2017, 16 October 2017, and 30 October 2017. On the last of those occasions she had abrasions to both wrists and bruising under the right eye she claimed was due to falling out of bed when drunk. She said she hit her eye on the bedside table. She said she had felt suicidal over the weekend but that had passed. She had lacerations from cutting after the “fight with partner over breakup”. In another attendance on 26 November 2017, it was noted that there had been a relationship breakdown and she was in the process of leaving her partner.

Report 12

31. At 6.51pm on 1 December 2017 two neighbours called police and said that a male had chased a woman down and “dragged her back to the house”. The woman had asked one of them to call the police. Police did not attend until the following morning at 9.00am. Holly Davidson was not at home. Later that day at 3.00pm Police attended once more and spoke to Holly Davidson and her partner. Both confirmed the report. Holly Davidson said an

argument started because her partner thought she was leaving to get alcohol.

The incident was not identified by Police as involving domestic violence.

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32. At 5.35pm on 25 May 2018 police officers saw a vehicle enter the police station carpark. The front passenger door opened while the vehicle was still in motion and Holly Davidson tumbled out of the vehicle. The car did not stop and drove off. Police observers asked what had just happened, Holly Davidson said “no comment” and “I’m not telling you anything”. Later, when her partner was asked about the incident he said they were arguing and he was trying to prevent her relapsing. He said he was driving her to the police station to get assistance. The children were in the vehicle. As he turned the corner the door opened and she rolled onto the road. He said he stopped and asked her why she jumped out. She looked okay so he drove home. The Police notified Territory Families and appeared to recognise that it involved domestic violence, but took the matter no further.

33. On 14 June 2018 Holly Davidson presented at the RDH emergency department with an increasing haematoma on the left buttock. She said that she had jumped out of a moving vehicle and afterwards had no injuries but the bruise had continued to trouble her and the pain was worse when sitting.

It was determined that it was not for drainage. She was offered admission overnight but declined.

34. On 18 June 2018 she attended the emergency department at 10.04am. Her general practitioner had referred her back to the hospital as the lump was not improving. The collection was drained by the surgeons and she was sent home with antibiotics.

35. On 21 January 2019 her partner took her to hospital at 1.00pm. She said her last drink was at 4.00am. She had booked into a hotel to be away from her family but her partner picked her up and took her to hospital. She said she

usually drank 2 – 3 bottles of wine a day. She said when she is drinking heavily a large part of the compulsion to drink was to avoid the tremors. She said she was terrified of the potential for having a seizure. She said she did not want her husband or daughter at her bedside. It was said in the hospital notes, “Does not describe relationship with husband as supportive. Has had issues with DV. She did not want to engage with rehabilitation services and left against medical advice at 7.30pm”.

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36. On 4 May 2019 Holly Davidson contacted Police. She said she had been in a physical fight with her partner and had managed to get away. Her partner went to the police station. He said that Holly Davidson had sent him a text saying she would catch the bus home from work. He responded by saying he would pick her up. He took the children to pick her up and saw her getting on the bus. He followed the bus to the exchange and escorted her to the car.

He said when he questioned her about drinking alcohol she became aggressive and got out of the car. He attempted to get her back into the vehicle and she “lashed out aggressively and head-butted him in the face”.

The officers then attended on Holly Davidson. She said she no longer needed them and had called her mother to collect her. Holly Davidson refused to engage with police and the only action taken by police was submitting an application to the Department of Health for making a banned drinker order in relation to Holly Davidson.

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37. On 12 July 2019 a rehabilitation service made a report to police that Holly Davidson had been subjected to verbal and physical abuse and she suspected her partner was “stalking her again via her phone”. Four days later the police contacted Holly Davidson. She refused to comment or make a statement. Police asked if they could look at her phone. She refused. Police then spoke to her partner. He said he hadn’t seen her for two days and found

her intoxicated at the shops. He said she was a chronic alcoholic and hated him for stopping her drinking. He said the family had the “find my iPhone app”. No action was taken.

38. On 30 August 2019 Holly Davidson appears to have written in her diary about domestic violence the evening before. She said she had refused to show her bank account to her partner. She wrote that he “absolutely lost his shit” and hit her about the head and shoulders and tried to drag her out of the house. She said he knocked her contact lens out and caused bruising to her neck, shoulders, arms and jaw. She did not call the police.

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39. On 19 December 2019 a doctor from the hospital made a report to police.

Holly Davidson’s partner had taken her to the hospital at 5.42pm the day before. He told the hospital he found her in a shopping centre toilet using his “find my phone”. She said she had started drinking three days before and had been having two to three bottles of wine each day after work. That day she had felt tired and gone to the toilets. She did not wish to discuss the potential triggers for her drinking although said she had been “banged in head by partner”.

40. The next day she was reviewed by the consultant. The consultant wrote: “Revisited history. Holly Davidson reports DV between herself and partner on Saturday which occasionally occurs … does not want to elaborate”. The report to police indicated that Holly Davidson had said that her partner had punched her in the face on Saturday 14 December 2019 and she had punched him back.

41. That day Holly Davidson sent a message to her partner, in effect setting out her plan for her recovery and added:

“U may have had a visit from police today but it’s not going to go anywhere bcoz I kno I told them nothing. If I had, if u were worried, ud b angry. But I didn’t.”

42. Attempts were made to contact Holly Davidson without success and the following day police attended her residence. She was not at home but they spoke to her partner. He said he had found her intoxicated and had to “physically lift her into the car”. He took her to the hospital and the doctor asked him to leave the room. He said it was a common occurrence for Holly Davidson to make allegations while intoxicated and then withdraw them when sober. He said they were sleeping in separate rooms but there was no violence. Police were unable to make contact with Holly Davidson and the matter was finalised on 16 January 2020.

43. Holly Davidson wrote an email to her mother on 23 December 2019 stating: “today when he hit me I yelled for him to stop … so they knew I wasn’t making shit up… I have been hit about 4-5 times today… threatened me with a broom. Jabbed it into my chest, used it to bar me leaving”.

44. On 6 January 2020 she recorded herself stating, “remember how he hit you once again around about the head because you had reported it to the police that he had done it before, so what did he do he set right back into doing friggin again in front of [one of the children]”.

45. By that time Holly Davidson was planning to leave her partner. She was storing items for her new residence at her mother’s place and at work. She obtained work as an administrative assistant with Territory Families and was well regarded at her workplace. However at the beginning of February her father was sick and about to have a heart operation. She started drinking again and arranged travel to Brisbane from Darwin on 8 February 2020.

46. On 8 February 2020 while waiting for the flight at the airport, her partner contacted her. He said he was driving to the airport. She told him she was

going to see her father and to turn around. He arrived at the airport. She walked away from him and asked one of the staff at a kiosk if they could call security as her partner wouldn’t stop stalking her. He then left. However he continued to try and contact her while in Brisbane multiple times a day.

He sent many messages and made many phone calls that went unanswered.

On 19 February 2020 alone he sent 21 unanswered messages saying that if she didn’t answer the phone she didn’t have a home to come back to and not to come back. He was jealous, thinking she was seeing or talking to another man in Queensland.

47. In the early hours of Saturday 22 February 2020 she returned from Brisbane.

She arrived in Darwin at 12.15am. Her partner picked her up at the airport.

He said she was intoxicated. She slept on the lounge and then went to the dentist later that day. There is no information as to what she did on Sunday, 23 February 2020.

48. However on Monday 24 February 2020 she caught a bus to work. The next day, Tuesday 25 February 2020 her partner came into town with the girls to pick her up and go out to dinner. He said she was intoxicated and they had an argument. They went home and Holly Davidson is said to have gone straight to bed.

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49. On Wednesday, 26 February 2020 at 7.10pm a manager at her work contacted Police. He said she was intoxicated and had bruising to her arms that looked like “grab marks”. She also had bruising under her left eye. She was thought to be intoxicated and when questioned about the bruises said her partner had hit her and she didn’t want to go home. She did not want to speak with police. Her managers also said they were told that her partner had threatened to kill her with a knife 3 days prior.

50. She told her partner she would catch a taxi home. He said he would pick her up. She didn’t reply and he went home. That night one of the staff members at work offered her a bed.

51. The next day, Thursday 27 February 2020 the staff at work thought she was intoxicated. She was falling asleep in a workshop she was attending. Police called about the report the previous day, but she refused to speak to them.

She spoke to the managers and when they asked why she didn’t go to police she held up both her arms showing the bruises and said that they know but they don’t do anything because her partner is a police officer. When pressed she said that if he was charged he would lose his job.

52. At 3.34pm police were contacted saying a woman had passed out on a bench in the Smith Street Mall. Police and paramedics attended. Holly Davidson was woken and said it had been a long day and she had “too many to drink” and had sat down and fallen asleep. She was put in a taxi to take her home.

When her managers found out one of them called police to say that her intoxication might be a “trigger for her partner to commit domestic violence”. The manager requested that police check on her. The police did not check on her that evening.

53. On Friday, 28 February 2020, police called her work to see if she had attended. She had not. At 10.40am they attended her residence. There was no answer when they knocked on the door and no answer when they rang her mobile. In speaking to her managers they ascertained that she was having a meeting with Territory Families on 2 March 2020 to discuss her employment. That was later changed to 3 March 2020. The police arranged to talk to her at the Territory Family offices after the meeting.

54. There is no information as to what Holly Davidson did, or what happened to her, on Saturday and Sunday, that is, 29 February 2020 and 1 March 2020 apart from her bank transaction records showing a purchase at Coles at about midday on the Sunday.

55. Monday, 2 March 2020 – Holly Davidson did not attend work but made arrangement to attend a meeting with her managers that afternoon and then changed the time to 9.30am the following day because of the unavailability of her support person. Her partner said she was sober that day.

56. Tuesday, 3 March 2020 – She met with her support person for coffee. She said she had a headache. Holly Davidson and her support person attended a meeting with her managers at 9.30am. She was told not to attend the following day until they had made a decision as to her employment (the following day it was decided to continue her employment). One of her managers said she looked refreshed. At 10.00am she met with police. They noticed bruising on her upper right arm and upper right chest. She said she got the bruises running into a door and would not talk further about it. She said she did not want to discuss domestic violence and was planning on placing herself back on the banned drinkers register and getting medication to help her abstain.

57. At 5.30pm Holly Davidson went to her GP in relation to her headache. She said she had the headache for 4 days mainly at the back of her head and had been taking Panadol and Nurofen. She said she had migraine type headaches in the past. Her doctor prescribed Mersyndol. She was sober on that day.

58. Wednesday, 4 March 2020 – Holly Davidson’s daughter was sick and spent the day at home. Holly Davidson had a headache. She made her daughter hot chocolate and then spent the day on the couch with an ice pack on her head, sleeping.

59. Police spoke to her partner while he was at work that morning. He said there had been no violence between them. He said he had assisted her into the shower on the evening of 22 February 2020 and she may have got the bruises then. He said she bruised easily. He was unaware how the bruise on the chest was occasioned but said that when intoxicated she bumped into things a lot. He said he thought she was seeing another man she met at AA.

60. Her partner went home at about 1.00pm. He found Holly Davidson asleep on the couch and could not rouse her, she just mumbled. She did not smell of alcohol. He asked their daughter if she had seen Holly Davidson drinking.

She had not. Hollly Davidson woke at about 4.00pm and appeared to be hallucinating. She said she had to go to work, she didn’t know what day or time of day it was, she was trying to plug her phone cord into open sockets and was incoherent. She walked into a wall and her feet and legs just kept walking. She was in the hallway and thought she was in the shower and was making gestures as if to turn taps on and was undressing.

61. Her partner said he took her to the shower and then put her to bed. An hour or so later there was a loud thump and it appeared that Holly Davidson had got out of bed. Her partner put her back to bed. Twenty minutes later there was another thump and when her partner checked on her he said she was snoring. He checked on her in the early hours of the next morning and found her to be unresponsive.

62. He called the ambulance at 2.58am (5 March 2020). The ambulance arrived at 3.03am. He told the paramedics he had seen her take 8 Mersyndol tablets.

He repeated that to police officers on their arrival. At about 3.32am she had a return of spontaneous circulation and was put on an auto pulse machine and taken to the ambulance. However, she shortly after became unresponsive once more. The ambulance arrived at Royal Darwin Hospital at 4.03am. She was declared deceased at 4.16am, due to an assumed drug overdose. The hospital notes indicated that she had multiple bruises of varying ages over her body including her arms, legs, hands, chest, right breast and the periorbital area.

63. A crime scene was not set up by police as is usual in such cases.

Autopsy

64. An autopsy was performed by the Forensic Pathologist, Doctor Marianne Tiemensma. Holly Davidson was found to have:

• “Multiple healing bruises of varying ages, and a few fresh abrasions on the body: o A pale brown bruise (20mm x 14mm) was present on the left lateral aspect of the forehead.

o A very superficial bright red abrasion (8mm x 3mm) was present on the medial aspect of the right upper eyelid.

o Two healing purple-brown bruises (respectively measuring 50mm x 35mm and 25mm x 25mm) were present on the lateral aspect of the right shoulder and upper arm.

o A purple/yellow/green bruise (65mm x 70mm) was present on the supero-medial aspect of the right breast.

o A yellow/green bruise (90mm x 70mm) was present on the infero-lateral aspect of the right breast. In the centre of this bruise, a linear purple bruise was visible.

o A very superficial linear abrasion (32mm in length) was present on the right lateral aspect of the abdomen.

o A fresh patterned "L"-shaped abrasion (60mm x 35mm) with two adjacent abrasions (14mm x 4mm and 40mm x 15mm) were present on the left lateral aspect of the abdomen. Bruising was seen in the surrounding skin.

o A pale brown bruise (30mm x 20mm) was present on the lateral aspect of the left buttock.

o Pale green/brown bruises were present on the dorsal aspects of the left 3rd, 4th, and 5th fingers (proximal).

o A pale brown bruise (38mm x 22mm) was present on the posterior aspect of the left upper leg, distal.

o Two small pale brown/blue bruises were present on the anterior aspect of the right leg, just above and below the right knee.

o A healing abrasion with scab formation (18mm x 4mm) was present on the anterior aspect of the right knee.

o A pale blue bruise (15mm x 2mm) was present on the antero-medial aspect of the left knee.

o A pale green bruise (40mm x 22mm) was present on the anterior aspect of the left shin.

o Two pale green bruises (respectively measuring 12mm x 10mm and 15mm x 10mm) were present on the medial aspect of the right ankle.

• From internal examination there were noted to be “superficial scalp contusions in both frontal regions measuring 50mm x 42mm on the right and 25mm x 25mm on the left.

• Approximately 70ml of fresh blood was present in the right subdural space. The brain was swollen, with flattening of the gyri and fullness of the sulci, and a midline shift from right to left. A right parahippocampal gyrus herniation, central herniation, and tonsillar herniation, were evident. No focal cortical contusions were seen, and no intraventricular haemorrhage was evident.”

65. The Forensic Pathologist indicated that the subdural haemorrhage had commenced to bleed three to five days prior to her death: “a right subdural haemorrhage was present over the right cerebral hemisphere; subsequent histological examination showed an early tissue response, in keeping with an estimated age of approximately 3 – 5 days old. Brain swelling and herniations were present that usually take hours to days to develop”.

66. The cause of her death was determined to be the subdural haemorrhage.

Doctor Tiemensma indicated that while chronic alcoholism made the blood vessels more fragile a subdural haemorrhage would not happen spontaneously. It required some form of trauma, likely a hit to the head, either due to falling or from another person.

67. Possible evidence of the trauma were the bruises to the head. The external bruise and the scalp contusions on both the right and left frontal regions. In the opinion of the Forensic Pathologist, from the dating of the external bruise, they were likely a few days old.

68. The evidence is that Holly Davidson was sober on the Monday, Tuesday and Wednesday (2 – 4 March 2020). The days for which the investigation was unable to provide much evidence were the Saturday and Sunday (29 February 2020 and 1 March 2020). There were some messages between HOLLY DAVIDSON (green) and her partner (blue) on the Sunday that indicated unhappiness:

69. She complained of having a headache to her support person on 3 March 2020 and that afternoon went to the doctor about it. She told him she had had the headache for 4 days. The doctor believed it to be a migraine type of headache (although, understood that a migraine would last a maximum of three days). He said that because it was her initial presentation in relation to the headache he prescribed Mersyndol.

Coercive control

70. Holly Davidson’s partner was from time to time said to be manipulative and controlling. When questioned about his controlling ways he generally indicated that Holly Davidson was an alcoholic and he needed to know where she was to either stop her drinking or so as to assist her when she was intoxicated. It appeared to explain his tracking her phone. Her alcoholism

was provided as the reason he removed her from the house or used force to keep her there. The same might be said when he escorted her to the police station and asked that her bail be breached for drinking. Perhaps it might be seen in his insistence that he pick her up from work or when he intercepted her at the bus stop.

71. It is difficult however to see her alcoholism as the reason for him reading her texts and having access to her social media accounts. There are instances where he attempted to warn off a person he thought she was having an affair with using her own Messenger account. It also doesn’t explain the constant messaging and telephone calls when she was with her father in Queensland.

It appears they were more to do with his belief that she may be talking to another male.

72. The supportive explanation also does not fit with the tone of the vast majority of messages from him to Holly Davidson when she was drinking or not complying with his wishes. Many are too foul and abusive to print here.

Many appeared designed to make her feel guilt over her drinking and to trade on that guilt to get her to comply with his wishes, including sexual wishes. Others threatening what would happen if she didn’t. A message on 16 October 2019 gives some of the tone: “Fuck all this. I have fucking had it. My life is so fucking shit.

Physically, mentally, professionally and personally. All of it is shit.

All of it. I have fucking had enough. I’m sick of this pain. I have been miserable for so fucking long. I should have just grabbed the girls, packed up and fucked off interstate. Left you and all this shit behind.”

73. Another on 6 January 2020 said in part: “Don’t Fuck Up or I promise you that I will take the girls away from you”.

74. On 8 February 2020 after she left for Brisbane he sent a message saying: “As you don’t particularly care about me you can get the fuck out of my life you lying, cheating, deceiving, lying, miserable drunk. Don’t

come back here again … You are the biggest mistake of my life. I should have gotten rid of you years ago … Goodbye you miserable piece of shit.”

75. The Police Assistant Commissioner, Michael White provided two affidavits and gave evidence during the inquest. I thank the Assistant Commissioner for the careful analysis and solutions offered.

76. Amongst other things he said that police and community understanding of coercive control had improved in recent years and there were a number of “red flags” that should have led to further investigation. Those included many of those mentioned above but also Holly Davidson making clear statements of domestic violence to police and then reneging on those statements.

The Partner

77. Holly Davidson’s partner provided a Statutory Declaration to the investigating police. However there are parts of that declaration that are contradicted by other evidence in the investigation brief. There were also questions about what happened during those last five days that needed answers. However, when Counsel Assisting called upon the partner to provide evidence, his lawyer sought that he not be compelled to do so on the grounds that it might incriminate him in an offence or offences in relation to her death.

78. In my 25 years as the Territory Coroner that is the only occasion that a serving police officer has refused to answer questions because the answers might incriminate him or her in an offence relating to the death.

79. There was a significant amount of evidence that Holly Davidson’s partner had a quick temper. In 2015 a superintendent in the police force wrote: “From time to time, when he is under stress, he has acted aggressively and abusively towards others at work where he has lost

control. It concerns me because in front of me and other managers he is this calm, very helpful bloke, yet there is this volatility”.

80. Some of the incidents reported to police suggest that what was being observed were not the actions of a rational person in control of his emotions.

Another witness and relative of Holly Davidson said “He just loses control, just all clarity”.

81. During the course of the evidence, a Mental Health Nurse who was treating Holly Davidson told how she had said her partner was easily angered and would say some very degrading things in the presence of their young daughter. However she remained very protective of him. She said that his concern for her safety was “overplayed” with him tracking her every movement.

82. On Sunday, 4 September 2019 when she attended for an appointment with the Mental Health Nurse, her partner was with her. He was described by the Mental Health Nurse as “distraught and very angry”. The Mental Health Nurse said he was “extremely aggressive” and just “barged in, very threatening, almost shouting” and said: “Get this woman out of my life – out of our life, out of my children’s lives”. According to the Mental Health Nurse it was very intimidating. He went on to say, “I did feel that this was a controlled environment, how would he be in an uncontrolled environment at home?”

83. After her death her partner once more went to the rooms of the Mental Health Nurse. He didn’t have an appointment but walked in and showed a video on his mobile phone. The Mental Health Nurse said it affected him profoundly. Indeed, remembering the video during his evidence, it took him some time to compose himself. He said: “I think that video more or less reflected the type of person [the partner] was that I did not see … he almost laughed and smiled while showing me the video … you could hear laughter in the background (on the video) as well … It was Holly Davidson trying to make her

way to the shower … and she was marching on one spot with her hands on the wall and [her partner] said “What are you doing? And she said “I’m trying to turn the shower on … I did tell him then he should have taken her directly to the hospital but he didn’t.” At the time the video was taken the deceased was sober and her confusion was likely the result of the haemorrhaging blood in the subdural space of her skull.

Comment

84. The reasons victims of domestic violence don’t report the violence and if they do, seek to retract their reports are today well known. It is the reason police are enabled to make and seek Domestic Violence Orders for the protection of victims without their cooperation. They could have made or sought orders on many occasions in relation to the deceased, in addition to the one time in 2015.

85. The reasons why a victim might not wish to report are magnified when the perpetrator is also a police officer. The Assistant Commissioner noted some of those additional barriers: a. Difficulty of knowing to whom to report and fear of disclosure to the perpetrator (he noted that was compounded in rural or remote areas); b. Fear that the disclosure may result in further and escalated violence (and noting police have access to firearms); c. Fear that the perpetrator will have access to inside information and manipulate the system; d. Fear that other police will minimise the reports and protect the perpetrator.

86. Those fears were from time to time expressed by Holly Davidson. She said there was “no point”, she “knew how the system works”, that her partner

was a police officer and “he would be informed of the complaint” and she would have to “deal with the consequences”. She also said that she had spoken to the police and “nothing was done”.

87. What is more, those fears appear to have been realised. The Assistant Commissioner was of the view that there were a number of failures in the way police dealt with the complaints. The head of the Domestic Violence Unit at the time provided the opinion that “throughout these incidents, we have failed”.

88. There were also procedural difficulties for investigators. The main one was that because it involved a serving police officer many of the previous incidents were locked down. Even the head of the Domestic Violence Unit could not access all recorded incidents. That prevented a holistic view of the incidents and may have impeded the recognition of patterns of behaviour and coercive control.

89. A possible way around that aspect was the potential early involvement of the Professional Standards Command. However, they were not involved in the investigation and did not oversee it as it unfolded. They were involved only retrospectively when approving the investigation.

90. It is obvious that there needs to be better coordination of information and better oversight. The Assistant Commissioner proposed that a way to ensure both was for the Assistant Commissioner with responsibility for the Domestic and Family Violence Unit, to oversee the conduct of all domestic violence complaints involving police officers from complaint to finalisation.

91. I was told that the Police were also utilising better software to track Human Resource issues and other aspects of an officer’s career such that if there were to be workplace issues that were relevant to an investigation they would be captured and made available to investigators. He also indicated that the General Order would be updated to better reflect “current

understandings and practices with respect to domestic violence”. That would include coercive control.

Crime Scene

92. A crime scene wasn’t declared. It is likely that declaring it was affected by similar considerations to the failure to protect Holly Davidson after complaints were made. In effect, the word of a fellow police officer weighed more heavily than it should, and her death was believed to be an overdose.

In this case there was also the history of domestic violence including the recent reports that were at that very time being investigated. That should have made the police more cautious. The Assistant Commissioner indicated that a crime scene should have been declared, saying all unexpected deaths should be treated as suspicious until proven otherwise.

93. I commend Police and in particular the Assistant Commissioner on the willingness to objectively and critically analyse the evidence in this inquest and show a desire to improve practices and procedure. I also commend the staff at Territory Families who showed great concern, empathy and understanding.

Formal Findings

94. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased is Holly Anne Davidson.

(ii) The time of death was 4.16am on 5 March 2020. The place of death was Royal Darwin Hospital.

(iii) The cause of death was subdural haemorrhage in the context of chronic alcoholism due to post traumatic stress disorder after the death of her first-born child.

Recommendations

95. I recommend that the Commissioner of Police establish a process where all complaints of domestic violence involving police officers are overseen by the Assistant Commissioner responsible for the Domestic and Family Violence Unit.

96. I recommend that the Commissioner of Police ensure that the processes and procedures for the investigation of domestic violence involving police officers permit access by the investigating officers to all relevant history and prior matters including any relevant information in the workplace.

97. I recommend that the Commissioner of Police ensure that the General Order is updated so as to convey a contemporary understanding of domestic and family violence (including coercive control) and that all police officers have training in the identification of ‘red flags’ for coercive control.

98. I recommend that the Commissioner of Police give consideration to developing a risk assessment process/tool to support police in identifying both the physical and non-physical aspects of domestic and family violence.

Referral

99. I believe that offences may have been committed in connection with the death of Holly Davidson and in accordance with section 35(3) Coroners Act I report my belief to the Commissioner of Police and the Director of Public Prosecutions.

Dated this 9 day of November 2021.

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GREG CAVANAGH TERRITORY CORONER