Inquest into the death of Roberta Curry

CITATION: Inquest into the death of Roberta Judy Curry

[2022] NTLC 010 TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO(s): D0105/2019 DELIVERED ON: 10 June 2022 DELIVERED AT: Darwin HEARING DATE(s): 17,18 May 2022 FINDING OF: Judge Elisabeth Armitage CATCHWORDS: Intimate partner homicide; domestic violence; response by police; supervision by Community Corrections; 000 calls

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Police: Nick Papas Counsel for Corrections: Ian Read Counsel for Territory Families: Michael McCarthy Judgment category classification: B Judgement ID number: [2022] NTLC 010 Number of paragraphs: 67 Number of pages: 21

IN THE CORONERS COURT AT DARWIN IN THE NORTHERN TERRITORY OF AUSTRALIA No. D0105/2019 In the matter of an Inquest into the death of

ROBERTA CURRY ON: 18 June 2019 AT: 19 Holtze Crescent, Katherine.

FINDINGS Judge Elisabeth Armitage

1. The deceased’s family have requested that she be referred to by her first name, “Roberta”. Roberta was born in Timber Creek on 14 August 1990 to Joy Raymond and Christopher Curry. Roberta had two older sisters. Her mother and one of her sisters attended the inquest. I thank them for doing so and offer my sincere condolences for Roberta’s tragic and traumatic death.

2. Following her parents’ separation Roberta moved to Bulla Community with her mother.

There she went to primary school and later spent two terms at Kormilda College. She then went to live with an older sister in Timber Creek. She started drinking and was asked to move back to her mother’s at Bulla Community.

3. At 18 years of age she met Leonard. They had two children, Alexander was born in 2011 and Owen in 2012. However, Roberta was drinking heavily and Leonard moved to Queensland with the children.

4. Roberta moved to Katherine where she met Lance and became pregnant. Her third child, Jacob, was born in 2014. When she and Lance separated, Lance retained primary care of Jacob.

Relationship with Lorenzo Deegan

5. In March 2016 Roberta was living in Halls Creek in Western Australia. She commenced a relationship with Lorenzo Deegan. She had known Lorenzo from when she was younger, when they both lived in Timber Creek. Her family did not approve of the relationship because it was thought that they may have had the same father.

6. On 23 January 2017, while at Halls Creek, Lorenzo and Roberta were drinking alcohol together and Lorenzo accused Roberta of cheating on him. Lorenzo punched her in the chest. She fell to the ground and blacked out. He punched and kicked her to her head and face. She suffered a deep 4 centimetre laceration to her scalp, a deep 4 centimetre laceration to her left eye, multiple bruises and swelling to her face.

7. On 3 February 2017 Lorenzo was arrested and charged with aggravated unlawful wounding pursuant to s301(1)(b) of the Criminal Code Act 1902 (WA). In the Kununurra Magistrates Court the sentencing Magistrate found that it was a “jealous, drunken attack” and convicted and fined Lorenzo $2500.

8. On 3 March 2017 Roberta and Lorenzo were living in Timber Creek. At about 7.00pm Roberta went to “Clive’s Place”, a residence next to the BP garage. There was a high fence around the property with barbed wire. Clive was 72 years of age and was said to often have people over to drink alcohol. Roberta went with her cousin, Caroline, and they stayed until early the next morning.

9. At 3.00am Lorenzo arrived outside the fence. He said he wanted Roberta to go home with him. She refused. In sentencing Lorenzo for his attack on Clive, Justice Mildren said Lorenzo’s motives for the “home invasion” were “jealousy” and “to punish Mr Stone for keeping [his] partner away from [him]”. In the sentencing remarks in relation to Roberta’s death Justice Kelly said of Lorenzo that night: “You climbed a high fence, punched a glass panel in the front door, broke it and went inside, looking for Roberta. You also wandered around the place looking for alcohol and you were eventually escorted out of the gate and off the premises by three people.

Later on, after 4.00am you climbed the fence again, calling to Roberta. This time the occupant got a steel pole and used it to poke you through the gate.

You punched him in the face a number of times, forcefully knocking him down onto the bitumen road. While he was down, you kicked him twice in the head and the torso and abdomen, as he lay defenceless on the ground.”

10. Clive suffered a traumatic brain injury, seizures, fractures to both eye sockets, four fractured ribs and a lacerated spleen (which had to be removed). The following afternoon Lorenzo was found by police at Roberta’s residence hiding under a blanket in a cupboard. Lorenzo was arrested and charged with criminal damage, aggravated unlawful entry and causing serious harm. On 13 February 2018 he was sentenced to imprisonment for 4 years and 7 months (backdated to 4 March 2017), suspended after 2 years on condition he remain under the supervision of a Probation and Parole officer for 18 months from release. The conditions of his supervision included entering the Venndale drug and alcohol program for 3 months, residing in Katherine, not having any contact with Clive, not consuming alcohol, submitting to random breath testing, and that he wear an Electronic Monitoring Device (EMD) while at Venndale and for three months thereafter.

11. During the police investigation into the assault on Clive, Roberta reported a previous assault on her. She said that she and Lorenzo had been drinking VB cans in the creek bed at Timber Creek two days earlier and they had 10 or 11 cans each. At about 8.00pm they were in the park near the Roadhouse and were arguing over cigarettes. She said that Lorenzo punched her left eye and lip. She went to the shop to wash her face and get some ice. Lorenzo waited outside and they got a lift home with Night Patrol. She said she didn’t immediately report the assault to police because she thought that if she did Lorenzo would “bash her more”.

12. Lorenzo was charged with assaulting Roberta and, pursuant to s41 of the Domestic and Family Violence Act, the police issued a Police Domestic Violence Order (“DVO”) with Lorenzo as the defendant and Roberta as the protected person. The criminal charge was listed for hearing on two separate occasions but Roberta did not attend court and the charge was withdrawn. However, after several adjournments the DVO was confirmed

for a period of 12 months expiring on 2 November 2018. The DVO expired 4 months prior to Lorenzo’s release from gaol.

Venndale

13. Lorenzo was released from prison on 3 March 2019. He spent one night at his brother’s house in Katherine and on 4 March 2019 he entered the Venndale Rehabilitation Program. On entering Venndale he signed and agreed to follow the “Venndale Client Rules” which included rule 29, “no mobile phones and/or not to be in possession of a mobile phone”. He completed the program on 27 May 2019.

14. According to Venndale records Lorenzo participated “extremely well” in the rehabilitation programs. He attended a family violence program between 11 and 14 March 2019 and was described as a “quiet participant”. It was said, “He was able to participate well in group activities and group discussions … was able to identify strategies and use them when confronted with violence in the future. He also knows that there are different types of domestic abuses such as physical abuse, financial abuse, social abuse and verbal abuse.” Lorenzo also attended a weekly Catholic Care counselling session to address anger management issues. He said he found it to be beneficial. He was keen to ensure he received visits from his children.

15. On 28 March 2019 the Probation and Parole Officer (“PPO”) contacted Clive to let him know that Lorenzo was subject to a full non-contact condition and if he was approached he should call the police and let Corrections know. However, Roberta was not notified of his release because she was not listed as a victim in the offending for which he was serving a sentence. The DVO in which she was the nominated protected person had expired.

16. On 12 April 2019 Lorenzo’s children visited him at Venndale. Three days later Lorenzo asked his PPO if he could visit his children in Darwin. Travel restrictions were in place primarily to protect Clive, in Timber Creek, and there were no identified concerns about travel to Darwin.

17. His PPO spoke to Lorenzo on 7 March 2019 and he denied having any contact with his ex-partner, Roberta. However, unbeknownst to his PPO and against the Venndale rules, Lorenzo kept a secret mobile phone. He started trying to find out where Roberta was living. On 16 March 2019 he sent these texts, “Mum did you find Roberta?” and “She there eberywhere Mum night cliff and city, renae for daughter seen her there that nother day, if nothing mum I’m thinking to cut this ancle brayslib off and go up Darwin and find her myself”.

18. Throughout March and April Lorenzo sent similar messages to a number of family and friends requesting they find Roberta and bring her to Katherine. His messages became more threatening. For instance, on the same day he spoke to his PPO about travelling to Darwin to see his children (the 15 April 2019) he sent a message, “Roberta if you don’t come Katherine, I’m coming up there and I’m gona smash the fuck outta you, you motherfucker, keep hanging around Darwin you dog, you wait Roberta I’ll be there”.

On 26 April 2019 he sent this text, “Leaving Adelaide River, I’ll see you soon, you better wait la Loretta house, if not well fuck you, you will find me in Nightcliff flats 27 drinking”. On 27 April 2019 he sent another message. It read, “You wait you motherfucker you bin take off with someone from terry house, you motherfucker I gota smash you wait, you bin fuck someone you wait”.

19. On 3 May 2019 Territory Families sent an email to Venndale requesting permission for Lorenzo to travel to Darwin to see his children. It was proposed that he travel to Darwin on 9 May 2019 and return the following day. His PPO said they would approve the travel if Venndale did. Venndale replied to the PPO, “If you are able to get someone to check on him while in Darwin then I’m happy to approve. I want him to [finish] the program.”

20. Territory Families arranged and paid for Lorenzo’s transport to and accommodation while in Darwin. His NAAJA Throughcare Officer offered to drive Lorenzo to and from appointments with the children.

21. He saw the children (and his mother who was also visiting the children) on 9 and 10 May 2019. Although he had messaged a woman in Darwin who he believed was with Roberta saying, “I’m coming up now look for Roberta now”, it is unlikely that he found her before he returned to Katherine. On 16 May 2019 a PPO visited Lorenzo at Venndale. Lorenzo spoke of “how fantastic it was to see his kids”.

22. On completing the Venndale program on 27 May 2019 he was permitted to live with his siblings in Holtze Crescent, Katherine. Although the property was designated a “restricted premise” under the Liquor Act and alcohol should not have been consumed there, the neighbours referred to it as a “party house” as there were often drinking and loud parties there which disturbed them.

Trip to Darwin

23. On 4 June 2019 his PPO gave permission for travel to Darwin to see his children. The plan was that he go to Darwin on 5 June 2019 and return on 7 June 2019. Territory Families once more booked accommodation for him at a motel. The NAAJA Throughcare officer was again providing transport. However, when Lorenzo did not attend the arranged 3pm access visit the Throughcare officer and Territory Families worker made several attempts to reach him on the phone. When Lorenzo eventually responded he said he was not feeling well and couldn’t see the children.

24. This excuse was a lie. Instead of visiting his children as arranged, Lorenzo picked up another female relative to assist in his search for Roberta. When she was found all three went back to the motel and consumed alcohol together. There was an argument and Roberta tried to leave but Lorenzo took her by the arms, forced her on to the bed and said, “You’re not going anywhere”. He then jumped on the bed and punched her with force twice to her ribs. Roberta began to cry and the other family member intervened.

Roberta asked the family member to call the police but she said the phone battery was flat.

25. They went to the residence of a relative the next day where they drank more alcohol in a flat and in a park across the road. Lorenzo became angry with Roberta about perceived

infidelity with two other men while he was in gaol. He chased her into the flat. She was then seen to run out and plead with a family member to stop Lorenzo from hitting her.

Return to Katherine

26. The next day Lorenzo was required to return to Katherine. Lorenzo collected his belongings from the motel but he refused to let Roberta collect her belongings from the place where she had been staying. Family members purchased a bottle of rum and a 10 pack of premix cans and Lorenzo started drinking again. It was observed that Lorenzo seemed to be acting “weird funny”, it was said that “he thought Roberta was going to run away from him”. When Roberta started to load items into the vehicle for the trip Lorenzo approached her saying, “where do you think you’re going”. He punched her in the chest knocking her backwards. A family member intervened. Roberta and Lorenzo left Darwin at 4.00pm on 7 June 2019, headed for Katherine in a vehicle with four other people.

27. On the way alcohol was purchased at Adelaide River and Lorenzo punched Roberta in the chest once more. They stopped at Kybrook Station to drop off two of the passengers.

Lorenzo followed Roberta into a house when she went to go to the toilet. She said to the other female passenger, “I don’t trust going to Katherine I might get hiding or bashed”.

Lorenzo, Roberta and the other 2 remaining passengers continued on to Katherine and arrived at Holtze Crescent, where Lorenzo was living, at 9.30pm. None of the assaults by Lorenzo on Roberta over those two days were reported to police at the time.

28. Over the following days Roberta often left Holtze Crescent and stayed with other family and friends in Katherine. On 10 June 2019 Lorenzo sent a number of texts to a female member of Roberta’s family looking for Roberta. He texted, “Renae where Roberta?”, “Renae you better answer the phone you dog you gona make Roberta get in big trouble, where you mob?”, “You better ring back renae dog motherfucker you better tell me where Roberta that dog you mob wait Roberta you motherfucker you wait”, and “Keep hanging up you motherfucker I’ll catch you mob”.

29. At 9.30am on 11 June 2019 Lorenzo found Roberta with family outside the Katherine Centrelink office. Lorenzo said, “where the fuck have you been, you leave me back at home”. Roberta hid behind another family member. Lorenzo raised his fists and said, “come here you cunt”. He then hit Roberta to her face and head with his fist three or four times. She fell to the ground and he kicked her with his boots twice before a family member pulled him away. Lorenzo then got a block of concrete and raised it above his head saying, “you better tell me the truth or I’ll hit you with a rock”. A family member took the concrete from him. Lorenzo then hit Roberta another two or three times saying, “tell me the truth where have you been”. Lorenzo then walked with Roberta into the shopping centre and she then went home with him. None of those assaults were reported to the police at the time.

Roberta calls the police

30. In the following days Roberta was again staying away from Holtze Crescent. On 13 June 2019 she was staying at Bernhard Street. At 9.00pm Lorenzo went to Bernhard Street and demanded that Roberta leave and go with him. At 9.16pm Roberta called 000 and said that Lorenzo, her “partner”, had been drinking contrary to the conditions of his parole and she wanted police to attend and arrest him. She said he had an ankle brace(let) and asked if police could track him. She said he had hit her with his fist and she just wanted him to go back to prison. She asked if police were going to look for him.

31. Two police attended at 9.31pm and stayed for 6 minutes. One of the police officers had his body worn video activated. She said, “can you guys look for Lorenzo Deegan, he has been drinking, he done this to me (showing her top lip) … he is not here”. When asked where he had gone she pointed and said, “come on, you guys should know”, “he is on parole”. When asked where else he lived she said she wasn’t with him anymore.

The police left saying they would look for him. For about 10 minutes the police conducted some unsuccessful street patrols before being called to another job. Data from his EMD confirmed that Lorenzo was in the vicinity of Bernhard Street when Roberta rang 000.

32. At 9.53pm Roberta rang 000 again and said, “there is a bloke here threatening us, Lorenzo Deegan, he is threatening us”, “he’s drinking, he’s intoxicated and he’s threatening..” She then hung up. The operator called back and Roberta wanted to know if police had caught Lorenzo. The operator marked the status as a “Reassurance patrol”.

The police who had attended earlier responded to police communications, “Matter already attended to on previous job. Complainant making several phone calls for original incident. No new incident had occurred by time of members’ arrival”.

33. At 10.37pm Roberta rang 000 a final time. She said, “He keeps coming around and threatening … he’s drinking … and he’s intoxicated and he’s threatening us … Lorenzo Deegan and they’re all fighting out there … seriously! Come on!” The operator noted Roberta as saying, “oh just come please otherwise they’ll be dead”.

34. The same police officers were at that moment on a “child welfare job”. They said they could attend after that. They arrived at 11.02pm and remained for 6 minutes. When they arrived there was no fighting outside. They spoke to a male resident who came to the door while Roberta remained inside. A Probationary Constable yelled at the occupants, “It’s police again, do you not listen, I’ve said this to you like five times, if you don’t want us to come back stop calling us ... If you are getting angry at us coming, stop calling, easy as that…I’m gonna go now, ok, stop calling, you obviously don’t want us here”. The police officers reported back to police communications, “We’ve attended once again, Roberta is very intoxicated, it’s the same thing as before, he’s not here, we’re going mobile and clear, nil offences.” Roberta made no further calls to police.

Random breath testing

35. It was a condition of his suspended sentence that he was subject to random breath testing to ensure he didn’t start drinking again. He was first tested two days after being released from Venndale, on 29 May 2019 at 9.06pm. He tested negative.

36. Prior to Roberta’s death he tested negative on two more occasions, 10 June 2019 at 10.09am and the next day, 11 June, when he visited the Probation and Parole Office (the same day he assaulted Roberta in front of Katherine Centrelink). Further attempts to random breath test him were made on 31 May at 9.55am, 13 June at 9.06pm (the day Roberta called the police), 18 June at 9.07pm (the day of Roberta’s death, Lorenzo’s brother answered the door and told the PPO he had gone for a walk) and 3 July at 9.08pm, but on each of those occasions he was absent from his premises and the two times a phone call to him was attempted, they went to voicemail. On 29 June 2019 at 9.42am he tested negative at home and prior to his arrest on 9 July 2019 he tested negative when he reported at the Community Corrections office.

Last day

37. On 17 June 2019 Lorenzo found Roberta near Woolworths. He took her back to Holtze Crescent. Roberta stayed mainly in the bedroom while Lorenzo and other family partied and shared a 30 pack of VB and a bottle of Rum. At about 11pm she was asked for and gave away a cigarette. During the night neighbours heard loud music, beer cans being thrown around, fighting and arguing. At 4.30am the following morning, police were called to a disturbance. Lorenzo and others involved walked away down the street.

When the police attended the disturbance was over.

38. Lorenzo got back to the residence at about 4.55am. At an unknown time Lorenzo punched Roberta to the lower left side of her abdomen causing a lateral fracture of the 11th rib and lacerating her spleen. At about 7.00am Roberta was seen to walk into the kitchen to take a bottle of water from the fridge. At 7.45am neighbours heard what sounded like groaning coming from the house. At 8.50am Lorenzo called his mother (aunty) telling her to call an ambulance because “she has stopped breathing”. Police arrived at 9.07am followed by paramedics. Roberta could not be revived.

39. An autopsy found a number of acute injuries including a bruise to the lower lip, 1.7 litres of fresh blood in the peritoneal cavity, large blood clots around the spleen and the

spleen laceration, fracture of the 11th rib, deep bruising over the right hand, bruising to the right thigh and a bruise to the top of the head. She had no alcohol in her blood.

Arrest and sentence

40. Lorenzo was arrested on 9 July 2019. On 5 May 2020 he pleaded guilty to four assaults on 5, 6 ,7 and 11 June 2019 and negligent manslaughter on 18 June 2019. In her sentencing remarks Justice Kelly said: “Police initially obtained a statement from you as a witness to the death. In that statement you claimed RC had drunk a large quantity of alcohol on the night before her death, that you had seen her wake up in the morning and drink water and that she had choked on the water. You said that you had tried to revive her but you could not.

That was a lie. Analysis of RC’s body revealed that she had zero blood alcohol content. The cause of death was the application of blunt force to her torso, causing a fracture of her rib, which perforated her spleen. Her spleen bled over several hours.

The forensic pathologist said that RC would have displayed symptoms of significant discomfort and pain during the time that she was bleeding to death. Had she been provided with medical attention in a timely fashion, the injury to her spleen would not have been fatal. You admit negligently causing RC’s death by punching her forcefully to the torso, and thereafter, failing to seek medical treatment while her condition deteriorated due to internal blood loss.”

41. For the assaults and negligent manslaughter, Lorenzo was sentenced to a head sentence of 9 years imprisonment. The unserved portion of his sentence for causing serious harm to Clive was restored and made partially cumulative by 1 year. The total effective sentence was 10 years imprisonment backdated to 9 July 2019 with a non-parole period of 6 years.

Autopsy

42. Dr Marianne Tiemensma, Forensic Pathologist, conducted an autopsy on 20 June 2019.

She commented:

• This was the sudden and unexpected death of a young adult female, with a reported history of ethanol and methamphetamine abuse.

• According to the provided information, the decedent reportedly consumed “a large amount of home distilled alcohol” the evening, night and morning of her death, however toxicological analysis did not show the presence of alcohol(ethanol), methanol, or drugs, thereby contradicting this information.

• Autopsy revealed a number of acute injuries, supportive of injury due to assault, including: A bruise to the right lower lip – unlikely the result of a fall in a o conscious, non-intoxicated adult.

Diffuse bruising over the dorso-medial aspect of the right hand – o suggestive of an “offensive” injury, such as the decedent delivering a blow to another party.

Bruises to the head and right thigh.

o Fracture of the left 11th rib laterally, with underlying soft tissue o haemorrhage and a large spleen laceration.

The decedent was reportedly resuscitated, however none of the injuries o to the torso are typical of resuscitation injuries.

• Histological examination did not show any underlying spleen pathology, and there was no evidence of an inflammatory response, organisation or healing of the injuries to the lip, left chest wall, mesentery or spleen, to suggest these were anything other than recent injuries.

43. The forensic pathologist’s conclusions, that Roberta died from hypovolaemia due to spleen laceration due to blunt force trauma (in the setting of reports of domestic violence in the residence; and other blunt force injuries present to the body), were supported by Dr Johan Duflou who conducted a review of the autopsy. Dr Duflou concurred with the opinions of the forensic pathologist that there was no evidence of a healing response to any of the injuries and it was his opinion that all the documented

injuries occurred “around the time of death”. In addition, having considered the records of the emergency personnel who attended at Holtze Crescent, Dr Duflou considered that she was deceased at the time of their arrival on the scene and had likely been dead for a period of time. Dr Duflou opined that “there was a shorter rather than longer time period between splenic laceration and death”, and “it is very unlikely that the deceased sustained the lethal injuries (rib fracture, lacerated spleen and mesenteric bruising) more than 8 hours prior to death, and likely sustained the injuries some considerable hours less than 8 hours prior to death”.

Formal Findings

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

(i) The identity of the deceased is Roberta Judy Curry (@ Currie) (ii) The time of death was between 5am and 9am on 18 June 2019. The place of death was 19 Holtze Crescent, Katherine.

(iii) The cause of death was hypovolaemia due to spleen laceration due to blunt force trauma to the torso.

Issues 000 calls and police response

45. Concerning the 000 phone calls made on 13 June 2019, the institutional response provided by Assistant Commissioner Martin Dole identified that they were incorrectly classified as “Disturbance General” when there was sufficient information for the calls to have been properly classified as a “Disturbance Domestic”. The incorrect classification permitted the complaint to be “auto finalised” after the results of “no offence detected” were provided by the attending members. Had the calls been correctly classified as a “Disturbance Domestic” the complaint could not be “auto finalised” because the Police PROMIS system would generate tasks which would require the attending members to input information and take action relevant to a domestic violence complaint, and the shift Supervisor would be tasked to audit the attending members’

response to ensure the General Orders and the legislation had been complied with. In response to this classification error, the Standard Operating Procedures (“SOP”) for Call Takers has been updated and Call Takers are now prompted to ask questions to determine whether the parties are related and, if so, to consider whether the matter should be classified as a Domestic Disturbance.

46. Although there was sufficient information in the call-out information and on the information provided by Roberta to the attending police, the police members failed to identify and rectify the incorrect classification of the Call Taker and thereafter failed to follow the General Orders and Police Practice and Procedure applicable to domestic and family violence complaints. They failed to access Lorenzo’s criminal history, failed to appreciate the seriousness of his offending and the likely risk that he posed, and ought to have conducted a more comprehensive investigation of the complaints. Both members were internally charged with breaches of discipline including: negligent, inefficient and careless discharge of their duties; failures to follow lawful direction, instruction or order; contravention of the body worn video instruction; and contravention of the code of conduct. Each member admitted the breaches and was formally cautioned.

47. As a partial explanation for their poor performance, both officers pointed to personal stressors in their lives affecting their performance. At the time, neither officer raised the issue of stress with their supervisors nor did they access psychological support services offered through their employment. In his evidence one officer noted that “there’s always the stigma of reporting your own stress and mental health”. He identified that the current voluntary regime of mental health checks was easy to avoid and considered that “there should be some kind of mandatory well checks…forcing people to do it I think is better than just not doing it at all”.

48. Assistant Commissioner Martin Dole advised that a review into the police welfare system has commenced. While there is currently training at the Police College on selfcare methods, he was not aware of any arrangement whereby trainees were required, as part of their training, to experience one or more sessions with a psychologist. However,

he considered that such an opportunity “before injury and without stigma” was an “attractive idea” and a “worthwhile suggestion”. It may be that such a practical self – care component, engaged in by all recruits as part of their training program, would decrease the hesitation of members to access such services throughout their careers.

49. Had police investigated the complaint further and accessed Lorenzo’s history they would have discovered his history of domestic violence against a previous partner, his conviction for assaulting Roberta in February 2017, and the expired DVO which named him as the defendant and Roberta as the protected person. In addition, they would have discovered that he was on a suspended sentence for a serious violence offence with nil alcohol and EMD conditions.

50. Had those matters been properly considered Roberta would likely have been identified as being at serious risk of domestic violence and further steps could and should have been taken with a view to increasing her safety including by referring her to the Family Safety Framework. Had there been such a referral it is likely that a police issued DVO would have been taken out to protect Roberta. Police may have allocated more resources to locating, arresting, and potentially remanding Lorenzo for breach of his conditional sentence. In addition, as participants in the Family Safety Framework, Community Corrections would have been informed of Roberta’s complaints about Lorenzo and would likely have increased their surveillance and collateral checks on him.

51. One of the police Call Takers gave evidence and explained the process of obtaining relevant information during a 000 call. From her evidence I understand that it is very important for the Call Taker to obtain the location and nature of the incident so the job can be “accepted” and sent through to “dispatch”. She explained “location became the important thing because too many times people were hanging up and [we] didn’t have a location to be able to send the police”. On listening to many 000 calls including the calls made in this matter, Call Takers seemingly often interrupt a call maker’s narrative to obtain location information and these interruptions can appear rude and abrupt. This may, at least in part, explain why Roberta hung up on two calls.

52. I suspect the general public does not understand that when making a 000 call certain information (location and nature of the problem) is crucial so that appropriate responders can be dispatched. Perhaps NT Police, Fire and Emergency Services could provide a public education program on how and when to make a 000 call.

EMD

53. Although Roberta told police that Lorenzo was “on parole” and wearing an ankle brace(let) (which the Call Taker correctly identified as a reference to EMD) police made no attempt to access the EMD data when they briefly unsuccessfully looked for Lorenzo on 13 June 2019 or thereafter. The police could have called an on-call PPO to access the EMD data. However, this avenue of enquiry does not appear to have been well understood by police. The updated Call Taker SOP now prompts Call Takers to ask whether the offender is wearing an EMD. If so, the Call Taker must now notify the Supervisor and the Supervisor/Watch Commander must “consider requesting location data”.

54. In addition a new SOP, “Urgent location data for people subject to EM”, commenced on 28 April 2022. For persons on police issued EMD, the EMD provider will, on request, immediately release location data to police. For persons on EMD fitted by Probation and Parole, the EMD provider will immediately release location data to police if a breach has been initiated or there is a warrant for the person’s arrest. In other circumstances PPO approval is required before the information will be released to police. Probation and Parole now provide a 24 hour EMD hotline so approval can be obtained without delay. A Memorandum of Understanding between NT Police, Department of the Attorney General and Justice and Territory Families is currently being finalised to address information sharing of EMD data.

Community Corrections

55. So far as the PPO was concerned, Lorenzo had successfully completed Venndale, was attending counselling, had breath tested negative, was complying with the conditions of

his EMD, and engaged in appointments with his PPO. He seemed to the PPO to be compliant with the conditions of his release. In reality this was not the case. To the contrary, he was accessing and drinking alcohol with his family and friends, he was threatening Roberta and her family members, and he was repeatedly assaulting her.

Even with the benefit of hindsight, Community Corrections were unable to identify what more they could have done to protect the community from the risks posed by Lorenzo’s behaviour.

56. Although he had not participated in each attempted random breath test and had not answered his phone on occasion, this was not in breach of his conditions and the PPO did not consider that a pattern of avoidance had been established sufficient to warrant further directions supporting breath testing. There were no arrangements made to breath test him in Darwin because each of the visits was of short duration. The PPO maintained that random breath testing once every 7-14 days was sufficient to identify and manage the risk of relapse. However, the Community Corrections Offender Management Framework provides that “failed attempts by compliance officers to locate and test an offender should be taken seriously and discussed with the offender”. The IOMS records provided concerning the management of Lorenzo on his order did not reference any such discussions as having taken place with Lorenzo following the failed RBT attempts.

57. Lorenzo’s PPO happened to be away when Lorenzo attended Darwin in June and was not notified of the failed access visit. In addition, Lorenzo’s PPO was not informed of Roberta’s complaints to police on 13 June 2019. These were identified as two missed opportunities for the PPO to increase her surveillance on Lorenzo and to conduct additional collateral checks, including with Roberta.

58. The institutional response on behalf of Territory Families was provided by the Executive Director for the Big Rivers region, Ms Kathryn Freeman. Concerning his failure to attend the access visit with his children, Territory Families did not notify the PPO until 8 July 2019, after Roberta’s death. Territory Families acknowledged that, as a matter of best practice, the children’s Case Worker should have notified the PPO of

the missed access visit. However, at that time Territory Families had no active policy or procedure concerning parents on supervised court orders. In response to the issues raised by this inquest, Territory Families are developing a policy to ensure that in future, in similar circumstances, Case Managers will notify Community Corrections in a timely fashion.

59. The NAAJA Throughcare worker was also aware that Lorenzo had failed to attend his access appointment. Although he claimed to have sent an email to Community Corrections informing them of this, the email could not be located. Noting that he did not have access to his written records when he prepared his statement, I consider it likely that the NAAJA Throughcare worker was mistaken. The NAAJA Throughcare worker was not completely frank with the PPO when concerns were raised with him about what had happened during the failed access visit in Darwin. Under a Memorandum of Understanding between NAAJA and Northern Territory Correctional Services dated July 2018 it is expected that “the parties will share information promptly and openly” subject to privacy issues governed by the Information Act.

Comment

60. What happened to Roberta was tantamount to kidnapping. Shortly before completing Venndale, Roberta and her family were the victims of repeated threats from Lorenzo, designed to frighten her into joining him in Katherine. When those threats failed, Lorenzo subverted an opportunity to see his children in Darwin, into an opportunity to track down Roberta. When he found her he coerced her through alcohol and violence to stay with him. The first night they were together in Darwin Lorenzo assaulted Roberta.

Sadly when she asked a family member to call the police she was told the phone was “out of charge”. She was assaulted again the next day and again when the car was being packed for the return trip to Katherine. She was not permitted to collect any of her belongings. She was assaulted again on the drive to Katherine. During one stop, Lorenzo watched her when she went to the toilet but she managed to secretly voice her fears of being bashed by Lorenzo to another passenger. When she tried to escape Lorenzo in Katherine, he repeatedly found her and took her back to his home. When he

violently assaulted her in the presence of family members on a main street in Katherine, no one reported it to police.

61. When Roberta finally called the police, they did nothing to help her. To the contrary, the police members were rude to her and dismissed her complaints. They failed to follow any of their procedures concerning domestic violence complaints. In addition, they failed to use available EMD information to assist them to locate and arrest Lorenzo.

62. The police told her not to call again and she did not. Two weeks after he found her and 5 days after she reported him to police, Roberta was killed by Lorenzo. She was killed in the “party house” where he had been approved to live. She was killed after he had participated in an alcohol fuelled night, while she remained largely hidden in a bedroom and sober. Lorenzo’s 7th known assault on Roberta resulted in her death.

63. Although he was under court ordered supervision, his experienced and diligent PPO remained oblivious to Lorenzo’s repeated breaches of his order. He was drinking regularly and was perpetrating acts of violence on his ex-partner. The drinking and violence was occurring on some of the very same days Community Corrections were unsuccessfully attempting to conduct RBT and on a day when he attended a supervision appointment. Had there been better communication by Police and Territory Families with Community Corrections, there would likely have been further enquiries and additional collateral checks conducted by his PPO. However, Community Corrections did not think there was much more that they could have done to discover his noncompliance.

64. While, Police, Territory Families and Community Corrections have committed to changes in policy and procedure and a Memorandum of Understanding to address failures in information sharing concerning EMD data and possible breaches of supervised orders, my concerns with the efficacy of the Community Corrections supervision and RBT regime remain. Firstly, I was concerned that the RBT testing in Katherine did not appear to be very random. It was all attempted close to 10am and

9pm. It would be easy for persons under supervision to be absent from home or simply not answer the door when testing was attempted. Secondly, there was no consequence if the supervised person failed to answer or return an RBT phone call. Finally, it was only expected that a supervised person would be tested about once every 7-14 days. Under that regime it was easy for Lorenzo to avoid detection. I consider that a more rigorous supervision and testing regime was called for, at least for the potentially high risk period immediately following the release of a supervised person from a controlled environment such as gaol or a residential rehabilitation program.

65. Justice Kelly, who sentenced Lorenzo for the negligent manslaughter of Roberta, recently spoke to The Australian1 to raise national awareness about the scourge of domestic violence blighting the lives of many Aboriginal women and their families. She said, “It is genuinely tragic that there are vast numbers of Aboriginal men in prison…The mirror image of that is the vast numbers of Aboriginal women in the morgue and in hospitals. It’s a total epidemic of domestic violence”. Justice Kelly remarked that some men thought they had “ownership of a woman- she has no right to say no, and she has no right to leave when she wants”. I wonder whether she recalled Roberta when she gave that interview. Justice Kelly said that since 2000 “52 Aboriginal women have been the victims of homicide”. However, on records maintained by the Coroner’s Office from August 2000 through to August 2019, there were 65 Aboriginal woman killed by a current or former intimate partner2. Roberta was number 65. In spite of detailed considerations and recommendations made by Territory Coroner Greg Cavanagh in the Inquest into the deaths of Wendy Murphy and Natalie McCormack [2016] NTLC 024, the contagion of domestic violence rages unabated.

1 The Australian, “’Epidemic of violence’ plagues women says judge Judith Kelly”, by Aimos Aikman 3 June 2022.

2 Not all matters proceed to the Supreme Court and there may be unfinalised matters before the Supreme Court.

Recommendations

66. That the Memorandum of Understanding between the Police Force, Corrections and Territory Families concerning the sharing of information, specifically relating to EMD data so that police can access location data be finalised as soon as possible.

67. Community Corrections provide more comprehensive supervision to violent offenders in the first month of their release in to the community.

Dated this 10 day of June 2022.

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ELISABETH ARMITAGE TERRITORY CORONER