Inquest into the death of Ralph Donald

CITATION: Inquest into the death of Ralph Donald [2026 ] NTCC 04 TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO(s): D0209 of 2023 DELIVERED ON: 20 March 2026 DELIVERED AT: Darwin HEARING DATE(s): 18 - 22 August 2025 FINDING OF: Judge Elisabeth Armitage CATCHWORDS: Coronial proceedings; inquests; death of man in context of intimate partner violence; domestic and family violence; coercive control; attempted killing / completed suicide; intervention / prevention; consideration of systemic failings and systemic reforms; need for further urgent reform.

Coroners Act 1993 (NT) ss12, 14, 15, 34, 35, 40 Domestic and Family Violence Act 2007 (NT) s5B Firearms Act 1997 (NT) ss10, 39, 40, 42 Law Enforcement (Powers and Responsibilities) Act 2002 (NSW) Part 6 Police Administration Act 1978 (NT) ss126B, 126C Doomadgee v Clements (2006) 2 Qd R 352 at [24]-[25] Harmsworth [1989] VR 989 at 996 Findings in the Inquest into the death of Domestic violence victim (Jingili Water Gardens) 17.01.25 Inquest into the death of Anne Chantell Millar [2005] NTMC 056 Inquest into the death of Jodie Palipuaminni [2006] NTMC 083 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 Inquest into the death of Wayne Walker & Jacqueline Morrison [2008] NTMC Inquest into the deaths of Wendy Murphy and Natalie McCormack [2016] NTLC

REPRESENTATION Counsel assisting: Dr Peggy Dwyer SC Instructed by Maria Walz Legal For the Northern Territory Dr Ian Freckelton AO KC with Police Force: Ms Amanda Burnnard Instructed by Police Legal For the Department of Mr Tom Hutton Children and Families: Instructed by Hutton McCarthy Judgment category classification: B Judgment ID number: [2026] NTCC 04 Number of paragraphs: 300 Number of pages: 103

TABLE OF CONTENTS THIS WAS A DEATH THAT OCCURRED IN THE CONTEXT OF DOMESTIC VIOLENCE .... 8 Need for a multi-agency Domestic and Family Violence Death Review Team Recommendation 3: Inclusion of relevant information in SupportLink Police powers to seize firearms while investigating allegations of domestic

Recommendation 4: Legislative change to give police increased powers to seize firearms when investigating complaints of domestic and family Recommendation 5: System architecture changes to enhance ability to Recommendation 6: Embedding a specialist DFV Practitioner at DCF Central Support for people experiencing relationship problems or family separation: Accommodation for women experiencing, or at risk of experiencing violence 89 Recommendation 10: Outcome evaluation for NT Men’s Behavioural Change Recommendation 3: Inclusion of relevant information in SupportLink Recommendation 4: Legislative change to give police increased powers to seize firearms when investigating complaints of domestic and family Recommendation 5: System architecture changes to enhance ability to Recommendation 6: Embedding a specialist DFV Practitioner at DCF Central

Recommendation 10: Outcome evaluation for NT Men’s Behavioural Change

IN THE CORONERS COURT AT DARWIN IN THE NORTHERN TERRITORY OF AUSTRALIA No. D0209 of 2023 In the matter of an Inquest into the death of

RALPH DONALD ON: 3 OCTOBER 2023 AT: MILNER FINDINGS INTRODUCTION: THE PREVENTABLE DEATH OF RALPH DONALD

1. Ralph Donald was a much-loved son, brother and father. He was also a hard worker and a caring friend.

2. In 2019, he met Irish nurse Eileen Gibbons, and they started a relationship. On 24 October 2022 they had a daughter together, who they both loved very much.

3. After their daughter was born, the relationship between Eileen and Ralph deteriorated. Together they sought some relationship counselling, and Ralph sought help for a long-standing alcohol problem. After a separation, on several occasions Eileen also sought help from Police, mainly because Ralph would not give her back items of property that she needed for their baby. Ralph was not physically violent towards Eileen, and, perhaps because of this, the Police officers she spoke with did not recognise the seriousness of his escalating behaviour. They did not recognise it as coercive control. No one, neither Police, nor the people around Ralph (including Eileen) recognised the increasing red flags in his behaviour. Not enough was done to support Ralph or to protect Eileen, and on 3 October 2023 he shot Eileen, before turning the gun on himself. Eileen survived, but he did not. He was 35 years old.

4. People reading about what Ralph did may assume he was “just a monster”, but that is not how he was described by those closest to him.1 Eileen still describes him as a good man, who was caring and always there to help those around him. His family told me that he was generous, loyal and helpful. Although he had his struggles, they did not think that he was beyond help. He was family and they loved him.

5. As for Ralph’s heinous act, no one saw it coming. He had never been charged with an offence of violence, had never been subject to a Domestic Violence Order and had never previously used any physical violence toward Eileen,2 until the day he tried to kill her.

6. The purpose of this Inquest was not to apportion blame, but rather it was to try to better understand why Ralph tried to kill Eileen, the mother of his young child and then killed himself. What went wrong? What could have been done to prevent Ralph’s death? What can be done to prevent any more deaths like Ralph’s?

7. During his life, Ralph was supported by his family and friends, but no one knew how to get him the right help. He became sad, angry and despairing about the breakdown of his relationship and his separation from his child.

8. Had Ralph and Eileen both been able to access appropriate support, it is possible that Ralph’s death could have been prevented. The tragedy of Ralph’s story – his brutal attack on Eileen and his suicide – highlights the need to support people who are at risk of using violence in their intimate relationships, and of effective intervention before the risk is realised and more lives are lost.

9. Meeting this need requires a shift in our collective thinking. As explained by Dr Chay Brown, an expert in the prevention of domestic, family and sexual violence: 1 Evidence of Alissa Donald on 20 August 2025 at T79.

2 Evidence of Eileen Gibbons on 18 August 2025 at T23, 26.

“…we have developed a narrative in our society that men using violence are just monsters and [we should lock them up and] throw away the key. They're not monsters, they're men, they're everyday men. We all know them. We all know men who are using violence, who have used violence. People like those men. Those men are not irredeemable. Those men do, I have a very firm belief, they [do] have the capacity to change.

I’ve seen it happen. And I just think we need to wrap our support services around [them] better. Not as an excuse, not as a minimisation for the use of violence, but because supporting someone to change their use of violence, benefits all of us.”3

THIS WAS A DEATH THAT OCCURRED IN THE CONTEXT OF DOMESTIC VIOLENCE

10. Ralph Donald’s death by suicide immediately after attempting to kill his ex-partner was clearly a death that occurred in the context of domestic violence.4

PREVIOUS INQUESTS INTO DOMESTIC VIOLENCE DEATHS

11. Numerous inquests have been conducted into domestic violence deaths in the Territory.5 Twenty years ago, my predecessor, Coroner Cavanagh, said:6 “I think I am able to say that it is now recognised by the overwhelming majority of people in this community that there is a pressing need to recognise that domestic violence is an issue of the utmost seriousness, and it concerns every member of the community. No longer is it appropriate to view violence in the family or in a relationship as something 3 Evidence of Dr Chay Brown on 20 August 2025 at T33.

4 Throughout these Findings, the terms “domestic violence”, “domestic and family violence” and “DFV” are used interchangeably.

5 For example, Inquest into the death of Reba Lakuwanga [2002] NTMC 007, Inquest into the death of Anne Chantell Millar [2005] NTMC 056, Inquest into the death of Jodie Palipuaminni [2006] NTMC 083, Inquest into the death of Wayne Walker & Jacqueline Morrison [2008] NTMC 058, Inquest into the deaths of Wendy Murphy and Natalie McCormack [2016] NTLC 024.

6 Inquest into the death of Jodie Palipuaminni [2006] NTMC 083 per Territory Coroner Cavanagh at [70].

personal or private. Like any other crime it must be regarded as a threat to the strength and cohesion of community life. It has serious and long term consequences for the health and development of children who become exposed to it, and to avoid taking responsibility for the fact that is it occurring in our midst is to allow ourselves to become inured to violence.”

12. In November 2024, I delivered Findings in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood.7 That series of inquests examined the domestic violence deaths of four Aboriginal women who had been killed by their intimate partners. During those inquests, I received evidence about the extent and impact of domestic and family violence in the Territory,8 including: a. the untold grief and trauma caused to victims, witnesses, families, police, paramedics and other first responders, health professionals, Corrective Service officers, child protection practitioners, social, outreach and support workers;9 b. the loss experienced by communities as a result of domestic and family violence deaths;10 c. the effect of the unrelenting presence of violence in the lives of Territorians,11 particularly in our children and young people. I received evidence concerning the connection between a child being exposed to domestic and family violence and that child becoming involved in the criminal justice system, and often becoming domestic violence offenders themselves;12 7 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

8 See Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [101]-[120].

9 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [103]-[111].

10 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [106].

11 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [107].

12 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [115]-[117].

d. the economic cost of domestic and family violence in the Territory, previously estimated to be somewhere between $457.2 to $606.1 million per year;13 and e. the staggering number of domestic violence deaths in the Territory.

In 2021, the rate of domestic and family violence-related homicide in the Northern Territory was seven times the national average,14 and at the time of those Findings, the records held by my office showed that at least 86 women had been killed by their intimate partners since the year 2000.

13. Those inquests provided an important opportunity to closely examine evidence of real life experiences of domestic and family violence: I was able to hear from women who had experienced domestic violence, and from people working directly with men who used violence; to listen to the harrowing 000 calls of victims and their family members seeking help and to watch their interactions with attending Police, captured on body worn video; to review the records of the Department of Children and Families to understand the way that agency responded to reports of domestic violence; to hear about the supports and services available to people experiencing domestic violence and to analyse the availability and effectiveness of programs for users of violence, both in custody and in the community.

14. The inquests brought together experts from academia, government and the not-for-profit sector, as well as individuals working on the frontline of responding to domestic and family violence. I was able to hear about the work being done to better support both victims and perpetrators of domestic violence, and of initiatives being developed to improve responses to domestic violence. During the inquests, lines of communication were opened, or cemented, and I have been told that 13 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [113].

14 Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [89].

people were brought together in a way that has been very helpful to achieving reforms.15

15. Having examined the circumstances of each woman’s death, I was able to consider “common” issues relating to their deaths. This enabled me to identify systemic failings in the responses of our agencies to the epidemic of domestic and family violence in the Northern Territory, and to make 35 specific and practical recommendations aimed at saving lives. Those recommendations were based on the evidence I had received, and were developed with the benefit of detailed and helpful submissions from the interested parties, including government agencies.

16. I have been told that the evidence, Findings and recommendations from those inquests have informed the work being undertaken by the Domestic Family and Sexual Violence Prevention Division within the Department of Children and Families, which has responsibility for providing strategic policy advice, implementation and program design to the whole of government domestic violence response.16

17. As I said at the time, those recommendations were neither radical nor novel. I was not trying to discover some secret solution to the wicked problem that is domestic and family violence. All of the recommendations were built on and informed by the work that was already being done by our academic experts, managers and frontline staff working every day in the domestic violence sector, and executives and workers at agencies including NT Police, NT Health, the Department of Children and Families, and the Department of Corrections. Most importantly, they were informed by families who had lost a loved one in an act of domestic violence, and community members with lived experience.

18. Since delivering those Findings, I have been encouraged by the public discourse acknowledging the extent of the domestic and family violence 15 Evidence of Assistant Commissioner Michael White on 22 August 2025 at T37.

16 Evidence of Seranie Gamble on 21 August at T29, T37.

crisis in the Territory, and the need for urgent action. I applaud the NT Government’s commitment to increased funding for responding to domestic, family and sexual violence, which I am told is at the greatest level it has ever been in the Territory.17

19. In this Inquest, I received positive evidence concerning systemic and cultural changes that have been made within NT Police and the Department of Children and Families, the two agencies primarily responsible for the governmental response to domestic and family violence. This evidence also allowed consideration of what more needs to be done.

20. The records held by my office show that, in spite of some positives, since I delivered those Findings in November 2024 there have been at least ten more preventable domestic violence deaths in the Territory, of which eight were intimate partner deaths. These cold statistics reveal that more still urgently needs to be done to prevent further deaths, and further suffering. I adopt the words of Seranie Gamble, the Executive Director for the Domestic Family and Sexual Violence Prevention Division within the Department of Children and Families, who said that:18 “Every life lost is still preventable. I think there’s absolutely more we need to do every day to do everything we can to address these issues. There’s so much more. We’re still learning and applying to improve our practice across multiple agencies and services. And resourcing that is really important.”

LEGISLATIVE FRAMEWORK AND THIS INQUEST PROCESS

21. Ralph’s death was a reportable death, because it appeared to be a violent death, resulting from injury, pursuant to s12(1) of the Coroners Act 1993 (“the Act”). In accordance with s14 of the Act I investigated the death, with the assistance of a thorough police investigation. I have had the 17 Evidence of Seranie Gamble on 21 August 2025 at T31.

18 Evidence of Seranie Gamble on 21 August 2025 at T32.

benefit of a detailed coronial report and brief of evidence from Detective Senior Constable First Class Kellie Moir, and of ongoing assistance from Detective Senior Constable Tara Aikas. I am grateful for their efforts.

22. Section 34(1)(a) of the Act requires that I make findings, if possible, as to the identity, date, and place of death; the cause of death, and any relevant circumstances concerning the death.

23. The Act also provides that I may comment on a matter, including in relation to public health or safety or the administration of justice, connected with the death being investigated,19 and that I may report to the Attorney-General on a death20 and make recommendations to the Attorney-General on a matter, including public health or safety or the administration of justice connected with such a death.21 I accept that my “power to comment arises as a consequence of the obligation to make findings…It is not free ranging”22 and it must be “directed to specific ends.”23

24. Pursuant to my discretion under s15(2) of the Act, I held a public Inquest between 18 and 22 August 2025 at Darwin Local Court. I was assisted by the appearance of representatives for the Northern Territory Police Force and the Department of Children and Families.

25. Ralph’s family attended every day of the hearing, and Eileen Gibbons appeared by videolink from Ireland. I heard from Eileen, as well as Ralph’s mother Nerissa, his brothers Charles and Angus, and his sister Alissa. I am grateful for their involvement and contribution. They shared their memories of Ralph and helped me to understand who he was, what happened in the leadup to his death and what they think might have helped to prevent that tragic outcome.

19 Coroners Act 1993, s34(2).

20 Coroners Act 1993, s35(1).

21 Coroners Act 1993, s35(2).

22 Harmsworth [1989] VR 989 at 996. See also Doomadgee v Clements (2006) 2 Qd R 352 at [24]-[25].

23 Harmsworth v State Coroner [1989] VR 989 at 996.

26. I also heard evidence from a number of Police officers involved with Ralph and Eileen in the lead up to the shooting. I was particularly impressed by individual police witnesses who reflected on their interactions with Ralph and Eileen, on what could have improved their responses, and who told me about their experiences of the changes being implemented within NT Police. Consistent with my aim of identifying systemic failings rather than blaming or stigmatising individuals, I will refer to individual responding officers by rank or position, rather than by name.

27. Witnesses from Relationships Australia and Dawn House gave evidence about interactions with Ralph and Eileen, and about the services they provide more generally. Together with evidence from CatholicCare and Dr Chay Brown, these witnesses helped me understand the challenges and continuing unmet need in the sector’s ability to respond to domestic violence.

28. I received institutional responses from NT Police and the Department of Children and Families. These witnesses spoke frankly about how the agencies’ responses to Ralph and Eileen should have been better and helpfully updated me about the changes that have been made since Ralph’s death. I have also received and considered submissions on behalf of those agencies, which have helped shape the recommendations I make today.

29. Death prevention is a major part of my function and in these Findings I intend again to make practical and specific recommendations aimed at saving lives.

THE STORY OF RALPH DONALD Early life

30. Ralph Donald was born in Darwin on 6 August 1988 to Nerissa and John Donald. He is survived by an older brother, Charles, and two younger

siblings, Angus and Alissa. His father passed away in 2008, when Ralph was twenty years old.

31. There was some family stress while Ralph was growing up. His father suffered chronic pain and carried trauma from his childhood, including the loss of his own father by suicide. Ralph’s father had a short temper and his parents argued. Ralph and his siblings sometimes witnessed his dad being violent to his mum. When Ralph was growing up, two child protection notifications were made to the Department of Children and Families about the family, reporting concerns about John’s hoarding behaviour and associated unsafe living conditions. On one of these occasions, the family had to leave their housing, and the children, and their mother Nerissa (who was pregnant) stayed at Dawn House, because they had nowhere else to go.

32. Ralph lived in Darwin his whole life and after completing year 10 in 2004, he obtained a Certificate I in Plumbing, Draining and Gas Fitting.

He worked in various roles, including as a commercial fisherman and a tyre fitter. In 2020 he attended the Tertiary Enabling Program through Charles Darwin University and around the time of his death he was about to start an adult apprenticeship.

33. After his father passed away, Ralph shared a home with his mother and siblings and was responsible for the mortgage. It was a big responsibility, and a cause of significant stress for him.

34. Ralph was a heavy drinker and he struggled with alcohol abuse. He experienced alcohol related seizures in 2012 and 2014. In 2017 he was referred to the Top End Mental Health Alcohol and other Drug Service for his alcohol use, and in January 2018 he attended an alcohol detoxification and rehabilitation program.

35. Ralph enjoyed hunting and fishing, and he obtained his shooters licence in 2018. Ralph owned three registered firearms, including a Marlin 3030 rifle.

Ralph meets Eileen

36. In 2019, he again sought help at a rehabilitation centre. It was there that he met Eileen Gibbons, who was working as a nurse. Eileen had emigrated from Ireland in 2012 and had no family in Darwin. They started a relationship.

37. During their time together, Eileen noticed that Ralph was quite stressed and had some anger issues, and she hoped they could work through the issues together.

38. In 2022, when Eileen was pregnant, Ralph agreed to attend counselling.

Eileen contacted Relationships Australia and undertook an initial intake process. A couple of weeks later, a second intake was completed with Ralph. Both were interested in couples counselling, but a brief risk assessment indicated some concerns, so initially they were offered individual sessions.

39. In her individual sessions on 29 March and 11 May 2022, Eileen disclosed that she believed Ralph had problems with abusive behaviours and drinking, and she wanted to support him to address these behaviours.

The counsellor’s note includes:24 “[Eileen] explored concerns related to her FDV in her current relationship with Ralph and named: emotional abuse, verbal abuse, gaslighting, feeling scared due to abuse in an argument that occurred 4 months ago, that she had meant to leave him but while he did not follow her or pursue her, he did say things to her in a way that made her feel guilty and shame and so chose not to leave.”

40. Ralph attended two sessions, on 12 April and on 31 May 2022. He was noted to be very new to counselling, and the majority of his first session was spent building understanding, trust and rapport. At the second session, he told the counsellor that he was attending because he knew it 24 Relationships Australia NT Case Profile Report [8-2A] at p6.

was important for Eileen, and he hoped counselling would help them to argue less.

41. A plan was made for them to attend counselling together on 20 June 2022, but Ralph told Eileen that he didn’t feel like he had got anything out of counselling, and, after they argued about it, she cancelled the scheduled appointment. Eileen felt that Ralph was closed off to help.

She felt that when she tried to work on their relationship problems, Ralph thought she was attacking him or blaming him. She felt that more needed to come from Ralph to be able to make things work.

42. Ralph and Eileen’s daughter was born on 24 October 2022. Although they both loved their daughter, their relationship deteriorated and the arguments increased. They mainly lived in accommodation that Eileen had rented, but they had periods of separation. In early 2023, Ralph moved back to his family’s home.

43. Ralph did not have a history of violence towards Eileen, or any other person. He had a record for driving offences only, mainly drink driving.

Between June 2005 (when he was a juvenile) and April 2020, he was charged with 5 drink driving offences, from low to high range.

Police involvements

44. Between 26 March 2023 and 21 September 2023, police received seven reports about the relationship between Eileen and Ralph. Eileen made five reports; Ralph called the police once, and on one occasion his brother, Angus, called the police. However, no domestic violence order (DVO) was made or sought and the couple were not referred to the Family Safety Framework.

Ralph takes the baby capsule and pram

45. On or around 21 March, Ralph and Eileen had an argument. She picked up her phone and was about to call police, but Ralph left, taking the baby’s capsule and pram with him in his car.25 Eileen calls Police the first time (26 March 2023)

46. On 26 March 2023 at 2:09pm, Eileen called the Police Assistance Line and reported that her partner was following her around Kmart and would not leave her alone, but that if he left, she would not need police to attend. The call ended abruptly after 37 seconds, before the call taker had taken Eileen’s name, or that of her partner. The event was finalised without police being dispatched and no alerts were recorded.

Ralph seeks assistance for Family Dispute Resolution

47. On 29 March 2023, Ralph contacted Relationships Australia and completed an intake for Family Dispute Resolution (FDR), a process for parents who are separating and need to mediate and develop a parenting plan for their children. There is no record of further contact between Ralph and Relationships Australia about this.

Eileen again seeks help from Police (31 March 2023)

48. By 31 March 2023, Eileen and her daughter had moved to a friend’s home, but Ralph had kept the capsule and pram that she needed for the baby. On this date, she went to the Noonamah address where she had been living with Ralph to try to retrieve these items. She thought he 25 Statutory declaration of Senior Constable O dated 13 August 2025 [2-6A] at [9].

would be at work, but he showed up while Eileen was at the property.

He verbally abused her and she ran away.

49. At 12:03pm Eileen called police from the Noonamah Hotel. She said she was trying to pack up her car to leave the Noonamah home where she lived with Ralph, but he was refusing to allow her to take the car. She told police that she had walked to the Noonamah Hotel to call police as she had no phone.

50. Ralph followed her to the Hotel and they had a verbal argument. Eileen told him that she didn’t want to talk to him and didn’t want to be in a relationship with him anymore. He said to her “Wherever you go, I will follow you.” She became upset and left.

51. At 1:46pm Eileen attended Casuarina Police Station and reported ongoing verbal, emotional and psychological abuse by Ralph. She described the events at Noonamah and told Police she would wait for them at an address in Moil as she wanted a DVO. This report was created as a domestic disturbance event, requiring a Priority 1 police dispatch (the highest priority). At 1:48pm this was downgraded to a Priority 2, noting that the parties were at different locations from each other. At 2:46pm, it was noted that no police units were available to respond.

52. At 3:07pm a unit was dispatched in response to Eileen’s call from the Hotel, but Eileen had already left that location, and those officers were unaware that she had attended at Casuarina Police Station to make a report there, or that she had given them the Moil address. The officers attended the Noonamah residential address but did not find Ralph or Eileen there.

53. At 5:46pm one of the officers spoke with Eileen by phone. She said that Ralph had taken the capsule and pram, there had been a verbal argument, but that Ralph had not threatened her or physically hurt her. She said that she did not want to be in a relationship with him anymore. The officer explained to Eileen that if Police attended and could see injuries, they could initiate an interim DVO but otherwise, she would need to

apply to the court herself if she wanted a DVO. The police officer offered and she accepted a referral to get help applying for a domestic violence order.

54. The following night, the same officer spoke with Ralph by phone about Eileen’s allegations. Ralph said he had gone to the Hotel to speak with Eileen, but she would not speak to him. He said he had not been violent.

It appeared to the officer that this was the breakdown of a relationship, rather than domestic violence and he offered Ralph referrals for counselling and legal advice, which he accepted. The second officer reflected that Ralph:26 “…sounded like a man struggling with the separation and being separated from his child.”

55. Two SupportLink referrals were submitted; one for Eileen for “DV related legal issue and Court support” and “s28 D & FVO – advice and support”, which noted that the DV indicators were listed as “verbal” and “emotional”, and one for Ralph for “Relationship counselling” and “Family law (law relating to relationships and children)”.

56. The PROMIS job was finalised with “no further police action required”.

The officers did not have concerns for Eileen’s safety, or that of her child.27

57. The next day, 2 April 2023, a JESCC operator unsuccessfully attempted to call Eileen in relation to the report she had made at the Casuarina Police Station two days earlier. The job was dispatched at 9:24pm and just after midnight, two officers attended the Moil address where Eileen had been when she called police two days earlier. Unsurprisingly, she was no longer there. The officers unsuccessfully tried to contact her by phone, before discovering that other officers had already spoken to her, on 1 April. The job was finalised as a duplicate entry. These efforts were 26 Statutory declaration of Senior Constable R dated 10 August 2025 [2-7] at [12].

27 Statutory declaration of Senior Constable R dated 10 August 2025 [2-7] at [17].

an inefficient use of Police resources, due to a failure to link the two jobs.

Significance of Ralph taking the capsule and pram

58. I note the significance of Ralph’s actions in taking items of property that Eileen needed for their daughter. I recognise this as coercive control.

Ralph took the baby capsule which meant that Eileen couldn’t safely take their daughter in a car. Ralph took the pram which made it difficult for her to take the baby on foot. Ralph was trying to control Eileen, by removing her capacity to move around with the baby. Eileen told me that at different times, Ralph took the capsule, the pram, the baby’s blanket and cups:28 “There was taking a lot of the stuff, but it was always to do with the child, and it would always make my life difficult.”

59. Ralph spoke to his brothers. He told Charlie about the incident in Noonamah and when he couldn’t recall why Eileen was so upset, Charlie attributed this to one of Ralph’s alcohol blackouts.29 Ralph told Angus that he needed help and was trying to get it. He said he had called a service for support30 but had not received a return call. Ralph was frustrated and told Charlie:31 “They’re meant to be there for you…and they don’t even answer the phone.”

60. The SupportLink referral made by police to Relationships Australia NT for Ralph on 1 April 2023 was received, but it appears that either he did not answer when that service tried to call him, or he declined their service.

28 Evidence of Eileen Gibbons on 18 August 2025 at T25.

29 Evidence of Charles Donald on 20 August 2025 at T76.

30 Not Relationships Australia.

31 Evidence of Charles Donald on 20 August 2025 at T72.

Eileen again seeks Police help (4 April 2023)

61. On 4 April 2023 at 12.49pm, Eileen called police to report multiple incidents that had occurred during the previous two weeks. She said that Ralph had been intimidating her, and had taken the baby’s belongings, which he had locked in a container at his home. She described mental and emotional abuse but confirmed that there had not been any physical violence. She referred to Ralph’s intoxication and said she was trying to “get out”. She said that his behaviour had been “really escalating”.

62. The event was created with a Priority 1 grading, but no units were available to dispatch. At 2:04pm the event was downgraded to Priority

63. I have received evidence from NT Police that by 11:05pm there were still 53 other jobs outstanding and 28 remained outstanding by 6:43am the next day. I accept the enormous pressure and strain that Police are under, and the stress for those officers when they cannot attend to many critical jobs within the prioritised timeframes.

64. Eileen attended Casuarina Police Station with her daughter at 2:50pm on 5 April 2023. She spoke with two police officers and the meeting was recorded on their body worn video. Eileen described multiple incidents of verbal abuse, intimidation, control of property and disputes about the custody of their daughter. The officers confirmed that there was no physical violence, and that Eileen’s concern was32 “…more of the escalating in verbal and controlling behaviour.”

65. Police explained to Eileen that they can initiate “emergency” DVOs (pursuant to s41 of the Domestic and Family Violence Act 2007 (NT), as it then read) when a certain threshold had been met, but that didn’t apply here and there were other services available that could help her take out a s28 DVO (s28 of the Domestic and Family Violence Act 2007 (NT)).

32 Statutory declaration of Cst H dated 12 August 2025 [2-4A] at [14].

In relation to the property that Ralph was keeping from her, the police officers told Eileen that they would have problems charging Ralph with stealing as the items were the joint property of the relationship.

65. Eileen said that she did not wish to have a DVO, but she wanted the property returned. She told Police that she felt she could protect herself from Ralph.33 The officers identified that Ralph’s behaviour was escalating, but they did not have immediate concerns for her safety, or that of her child. They did not believe that they had a sufficient basis to initiate a s41 DVO for her protection.

66. I accept that these attending Police officers were genuinely trying to help Eileen. They took time to listen to her concerns, and to elicit further information from her about what had been happening. The senior attending officer, a Senior Constable with about fifteen years of operational experience, was “wracking his brain” and he sought the advice of his supervisor, the Shift Sergeant, about what could be done to help her.

67. Ultimately, these officers finalised the report as a “civil matter only”. A DV audit was undertaken by a supervising sergeant who noted that the officers had acted in accordance with the General Order, the matter was “not a dv as reported” but rather was a “civil matter only over property”.

68. This is an example of NT Police not recognising Ralph’s behaviour as coercive control. They did not identify the seriousness of Eileen’s complaint, or the red flags in Ralph’s behaviour. As conceded by NT Police in its institutional response, this matter should have been categorised as domestic violence. The failure to do so is indicative of an inadequate appreciation (at that time) of the dynamics of domestic violence, especially of coercive control. I note that this was in April 2023 and I am told that since then much has been done to address this (see below).

33 Statutory declaration of Senior Constable O dated 13 August 2025 [2-6A] at [21].

69. In her evidence, Eileen told me that she went to Police because she needed help, but at the same time she was reluctant to cause a problem for Ralph. When police asked her if she wanted a DVO, she said no because it would affect his gun licence. She knew that his behaviour – the emotional and mental abuse – was wrong, but she did not believe that he would physically assault her, as that had never happened:34 “I took Ralph for his word that he would never physically hurt me, and I believed that because he had never laid a hand on me.

And I knew that his behaviour was a bit emotional and mental abuse was wrong, but I didn’t believe that he would physically touch me.”

70. She said that she was exhausted and in “survival mode”:35 “[I was] not thinking from the proper mindset, not able to make decisions. Everything I tried to do was difficult. There would be arguments for no reason…I had to defend myself all of the time. There was never peace and quiet, it was just getting through each day.”

71. Following Eileen’s report, one of the Police officers submitted a SupportLink referral. As a result, Legal Aid contacted her and asked her if she wanted to seek a DVO. She declined, and explained in her evidence in Court that:36 “…for me it was a very difficult thing to do, because of the coercive control…I would have rathered if somebody else would do that on my behalf, you know, to make…that call.”

72. Without blaming the police who were trying to help her, Eileen told me that she really wanted the Police to get a DVO on her behalf, even though she told them that it wasn’t necessary. Her calls to police, attendances at the police station, and participation in a recorded interview process were all real cries for help to keep her and her daughter safe.

34 Evidence of Eileen Gibbons on 18 August 2025 at T26.

35 Evidence of Eileen Gibbons on 18 August 2025 at T26.

36 Evidence of Eileen Gibbons on 18 August 2025 at T26.

Ralph seeks further help for his alcohol abuse

73. Between 28 April and 21 June 2023, Ralph attended an alcohol detoxification and rehabilitation program. During this time, he also attended two Relationship Education group sessions provided by Relationships Australia.

Trip to Ireland

74. By 2023, Eileen had not been home to Ireland for two years and she wanted to introduce her daughter to her family. Ralph refused to allow them to travel without him. The three of them travelled to Ireland in July/August 2023 and stayed for six weeks. Eileen recalls that Ralph was difficult and the freely available alcohol on the flight made things worse.

They argued a lot during the trip. Eileen said it was the worst six weeks of her life. By the time they arrived home in Darwin, the relationship was over.

75. To add to the strain she was under, after they returned to Australia, Eileen’s accommodation arrangements fell through and she was effectively homeless. She and her daughter were moving between the home of the Donald family, hotels, and Air BnB accommodation. She told me that when she stayed at Ralph’s home:37 “…things would escalate. It was all out of control… I never wanted to leave my daughter there. Every time I wanted to leave with her, that’s when Ralph would take an issue. I never was going to leave her there alone, and that was where the issue [was]. He said, “You can go, she can’t go.” So it was control.

And…sometimes we would leave [the baby] with [Ralph’s mother], and we might go out somewhere, but it would all descend into an argument. So it [was] really, really escalating and getting out of control. And there was a day when he drove round a roundabout and round and round. When I tried to get 37 Evidence of Eileen Gibbons on 18 August 2025 at T29.

out of the car, he…he took my phone and threw it into the bushes. Things [were] really getting out of hand.”

76. Eileen was trying to find safe accommodation for herself and her daughter, but she had to keep returning to Ralph because she had nowhere else to go.

Eileen calls Police because Ralph won’t let her leave (26 August 2023)

77. On the night of 25 August, Eileen wanted to leave Ralph’s home with her daughter, but Ralph would not let her. On 26 August 2023 at 1.15pm, she called police. She said she wanted to leave the property with her daughter, but that Ralph had locked the house and the front gate and would not let them leave. She told the call taker that she felt like she was being held against her will and she wanted a DVO. She also told them that Ralph had a gun licence. The Police call centre (JESCC) correctly created a Domestic Disturbance event with a Priority 1 grading and the Computer Aided Dispatch (CAD) log reflected that the incident was happening at the time, and in the presence of a 10 month old child.

78. No police units were available to be dispatched.

79. The JESCC operator conducted relevant checks, including on Ralph’s criminal history. These checks showed that there had been no Family Safety Framework notification, nor history of offences of violence.

80. At 1:35pm the event was downgraded to Priority 2 noting “no violence”, but marked as “High P2 dispatch”, noting “intimidating/controlling behaviour. POI on scene.” A further check showed that Ralph held a firearms licence and that three weapons were registered to him.

81. At around this time, Ralph’s older brother Charles came home for lunch and told Ralph he had to let Eileen leave, and Ralph acquiesced.

82. At 1:57pm Ralph called police and reported that his ex-partner had just left with his child, without his permission. He said she had called police

for an unrelated issue, and he wanted to see police. The two calls were cross referenced.

83. An attempted dispatch at 2:02pm was cancelled as a higher priority job took precedence.

84. No unit was available to dispatch until 5:29pm, some four hours after Eileen had left.

85. Police attended the address in response to Eileen’s call, but those attending officers did not know about Ralph’s subsequent call. They had to climb over the front gate, as it was locked and no one had responded when they knocked. They spoke with Ralph about Eileen’s complaint and asked him where she was. He repeatedly told them that he didn’t know where she was, then told them that she “had lost her fucking mind” and gone “mental”. He told police that she had post-natal depression and was unstable. Ralph told police that there was a verbal argument and Eileen had scratched him on the arm. Police observed minor small scratch marks on his arm. They asked if she had mental health problems or was intoxicated. He said no. They then checked the premises and confirmed that Eileen was not there. They did not ask Charles about what had happened. They asked Ralph whether he wanted a DVO, or to make a complaint about the scratch to his arm but he did not.

86. I find Ralph’s behaviour at that time to be consistent with an attempt to shift police attention away from investigating Eileen’s serious complaint – that he had detained her – by alleging that she had mental health issues and that she had assaulted him. He was enticing them to collude with him.38

87. Those same officers then attended upon Ms Gibbons, who had secured a hotel room for the night. She told Police that Ralph had been drunk, they argued, he was “roaring and shouting” and she knew that their daughter 38 See a discussion of “collusion” in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [487]-[489].

should be protected from that. She wanted to leave but needed to get her phone from inside the house. She admitted scratching Ralph as she tried to get past him to get into the house to get her phone. Once she was inside, he had then locked the door behind her. He would not let her leave and he kept her there against her will. She said she wanted a DVO, that he had firearms, he had taken the baby’s passport and was using their daughter to control her. She also described the verbal abuse that Ralph subjected her to, including “calling her names like cunt, piece of shit and every other name, you’re not a woman and you’re not this”.39

88. Eileen was not physically injured and Ralph had not been physically violent towards her. Because she had removed herself and secured a hotel room, the attending officers did not believe that Eileen was in any immediate harm or danger and did not consider that they had a basis to initiate a s41 DVO. The officers offered her a SupportLink referral, which she accepted.

89. The officers finalised the job by noting that there was “nil requirement for a s41 DVO” and “nil threats of violence”. They noted that there was no formal complaint from either Ralph or Eileen, and no CCTV or witnesses, but did refer to there having been “two DV incidents within the last year”.

90. One of the officers submitted a SupportLink referral for Eileen for advice and support in relation to seeking a DVO application, which was the practice of police at the time.40

91. A DV audit was undertaken by a supervising sergeant, who found that the police response appeared appropriate.

92. In contrast, the NT Police institutional response identifies this interaction as a clear example of missed opportunities. I agree that attending Police should have investigated Eileen’s serious complaint of 39 Statement of Cst J dated 18 August 2025 [2-5A] at [42].

40 Evidence of Cst J on 19 August 2025 at T19.

being detained in the house, they should have taken a statement from her and from Charles, sought a DVO for her protection and, as a result of the DVO, seized Ralph’s firearms. The supervising sergeant should have identified that further investigation was required.

93. One of the attending officers made a mandatory report to the Department of Children and Families, not about Ralph detaining Eileen, but as follows: “Parents of child are having a relationship break down. Verbal arguments however today mother Eileen has scratched ex partner Ralph Donald as she has removed him from the doorway to access the property to collect her belongings. She was holding [the child] at the time of the incident. Eileen has checked into the Travelodge for a few nights and will try and secure accom else where”.

94. The Department was not told that Ralph had locked Eileen inside the house, or that there were firearms present in his home, both of which were critical pieces of information.41

95. The Department decided to progress the report to intake assessment. The reason recorded for this was “Mother was holding the child while having a verbal arguments [sic] with and scratched the father”. This description gives rise to the possibility of victim/perpetrator misidentification. DCF requested police history and upon reviewing that screened the report out as: “…the police history doesn’t show an ongoing pattern of domestic violence concerns, it shows 3 incidents in 12 months.

In this incident the mother has scratched the father as she went past him after a verbal argument. There is no mention of the child being physically harmed and no information as to how the child was after the incident.

The parents are separating and the mother is currently staying in a hotel and looking for alternative accommodation.” 41 Evidence of Joanne Green on 19 August 2025 at T35.

96. Eileen and the baby stayed with friends until 20 September, but when that accommodation was no longer available, they moved back into the Donald family home, as they again had nowhere else to stay.

Ralph’s brother calls police (21 September 2023)

97. On the night of 20 September 2023 Eileen tried to leave the home, but Ralph wouldn’t let her leave with their child. They had a verbal argument.

98. At 8.29am the following morning, Ralph’s brother Angus called police.

He said that Ralph and Eileen were arguing; that she wanted to leave with their baby, and his brother would not let her take the baby. He confirmed that there were firearms at the home.

99. A Priority 1 Domestic Disturbance was created and eight minutes later, at 8.37am, police arrived. Angus told police that Eileen and the baby were at the property and were distressed because of verbal arguing that was ongoing since the previous night. Police could hear a man inside the house swearing and sounding aggressive.

100. Eileen came to the door, visibly distressed and carrying her daughter.

She said, “I need to get out of here, I've been asking people to ring the cops since last night”. Ralph followed her out of the house, saying “she has nowhere to go”.

101. The female attending officer took Eileen into the yard to speak with her.

Eileen told the officer that she and Ralph had argued the previous day, he had thrown her phone out of the car window, she stopped to get it, but he grabbed it first, and then drove off without her. She said that Ralph’s mother had allowed her to stay at the Donald family home but that she and Ralph had argued all night until police arrived. She said that Ralph had told her she could leave, but could not take their daughter with her, and Eileen was not prepared to do that.

102. While Eileen was speaking with this officer, the male officer spoke to Ralph. Although the officers did their best to speak with Eileen and Ralph individually and to separate them, this was difficult to achieve in the limited space and in circumstances where the officers had been trained to remain in each other’s line of sight (to be “situationally aware”).42

103. Ralph was aggressive and refused to speak with the male officer. He was “clenching [his] fists, eyeballing and attempting to size up to members and take control of the situation”.43 That officer could smell alcohol on Ralph. While the female officer tried to speak with Eileen, Ralph called out that “she’s not taking my daughter”, “she has nowhere to go”, “she has no fixed address”, “she has nothing”, and “where’s the safest place for the child”. Ralph said that Eileen wanted a DVO and one officer replied: “we’re not taking out a DVO, there’s no emergency”.

104. Eileen reported that as Ralph had taken her phone, she had no way to contact anyone. She said she had nowhere to live and she would be applying for a DVO.

105. Police facilitated Eileen packing some belongings to be able to leave, and contacted Dawn House, a women’s refuge, to confirm whether there was space for Eileen and her baby.

106. Ralph told police about the prior incident, when Eileen had scratched his arm. They gave him information about seeking a DVO. Ralph was upset and asked, “when can I see my fucking daughter?”, and Police suggested he could arrange parenting orders through Relationships Australia.

Ralph said that he had contacted them but hadn’t heard back. I pause to note that this is consistent with the records held by Relationships Australia (referred to above at [47]).

42 Evidence of Cst S on 20 August 2025 at T15.

43 PROMIS 10462767 Summary [6-24] at p3.

107. A second unit was requested to assist and that unit arrived as the first officers were taking Eileen and the baby to their car. As the female officer helped Eileen into the car, the male officer told the second unit that: a. Ralph might come out of the property, b. he had firearms in the house, and c. he looked mentally unwell.

108. I accept that the female officer did not hear this exchange. She also did not know that her partner had smelt alcohol on Ralph.

109. The first attending unit took Eileen and her daughter to Dawn House.

Eileen told them that she wanted a DVO that day, but those officers formed the view that they did not have a basis to initiate a s41 DVO.

110. Upon arriving at Dawn House, the manager advised the officers that she would help Eileen apply for a DVO. To assist with that application, the female officer provided the PROMIS references for the previous police attendances, and was satisfied that Dawn House would help Eileen to seek a s28 DVO.

111. Ultimately, a DVO was not sought. Eileen told me that she thinks maybe she didn’t press for it. She said she really wished that someone had taken that out of her hands and taken out a DVO for her protection.

112. In its institutional response, NT Police conceded that the attending members should have taken out a “Police DVO”. While I am mindful that these officers had to quickly go on to the next job, I agree and consider that this was a significant missed opportunity. A police initiated DVO was appropriate in the serious circumstances that police encountered, and would have led to a suspension of Ralph’s firearms licence and the seizure of his firearms.

113. One of the attending officers made a mandatory report to the Department of Children and Families in relation to the “verbal argument” between Ralph and Eileen, and about Ralph not wanting Eileen to leave the property with the child. The report included information about Ralph’s aggression towards police, but did not indicate that Eileen had previously been detained in the house, that there were firearms present, or that an attending officer thought that Ralph appeared mentally unwell.

114. DCF obtained the police history and determined that no further action should be taken, as the relevant threshold had not been met.44 The assessment was: “While the current concerns are worrisome, police history received for the parents does not show an on-going pattern of significant FDV occurring in the household that the children are being exposed to. The current report is recommended to screen out as there is insufficient information that [the child’]s wellbeing and safety have suffered (or is at risk of) significant or detrimental harm due to the actions or inactions of her parents.”

115. The report did not proceed to an investigation. It appears that if the Department had received all of the relevant information in the mandatory notification from police, the outcome of this assessment may have been different.45

116. Eileen and her baby stayed at Dawn House for 13 days. She told me that it was the first time that she really felt that someone was helping her.

117. On 21 September, Dawn House staff completed a CRAT with Eileen.

This is the Common Risk Assessment Tool, which is used to determine a person’s level of risk of experiencing domestic violence . A score over 28 is considered high risk. Eileen’s score was 39 and suggested physical 44 Evidence of Joanne Green on 19 August 2026 at T36.

45 Evidence of Joanne Green on 19 August 2025 at T37.

and verbal abuse.46 A Safety plan was prepared, but no mandatory report was made. The CRAT was not provided to Police or to DCF.

118. One issue that Dawn House discussed with Eileen was that it may offer her some additional protection if she got a new phone number; however, Eileen did not want to do this because she did not want to lose contact with people, particularly Ralph’s mother who was a support, and she wanted to stay in contact with her so she could continue to see her granddaughter.

Coercive control

119. Coercive control is understood to be “a range of strategies used to manipulate, dominate and control the actions of another with the aim of achieving and maintaining personal power, particularly over an intimate partner.”47

120. I find that Ralph’s behaviour set out above was escalating coercive control. The red flags in his behaviour included: a. verbal abuse towards Eileen, including calling her demeaning names like “cunt, piece of shit” and saying things to undermine her selfworth, like “you’re not a woman”, b. taking the capsule and pram and locking them away so Eileen could not access them, c. taking their child’s passport, d. demanding that if Eileen wanted to travel to Ireland, she had to take him with her, 46 Eileen Gibbon’s CRAT dated 21 September 2023 [8-4].

47 NT Domestic Sexual Violence Reduction Framework (2018-2028), referred to in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [374].

e. throwing Eileen’s phone away, f. telling her that while she could leave his family home, she could not take their daughter with her, and g. detaining/locking her inside his home.

121. At the time of Ralph’s death, the definition of domestic violence in the Domestic and Family Violence Act 2007 included conduct causing harm, damaging property, intimidation, stalking and economic abuse. It did not include coercive control or emotional and psychological abuse. That legislation was amended in 2023 and since March 2024 both of those terms have been included in the definition of domestic violence.

Relevantly, coercive control is now defined in the legislation as follows:

DOMESTIC AND FAMILY VIOLENCE ACT 2007 - SECT 5B Coercive control (1) Coercive control, of a person, is a pattern of conduct that causes the person to fear for their safety, or the safety of another person in a domestic relationship with the person engaging in the conduct, that results in any of the following:

(a) controlling or subordinating the person;

(b) dominating, regulating or monitoring the person's daily activity;

(c) isolating the person from social, familial or cultural connections and support;

(d) depriving the person of freedom;

(e) frightening, humiliating, degrading or punishing the person.

(2) In deciding whether a person's conduct amounts to coercive control of the person, consideration must be given to what is reasonable in the circumstances of the relationship between the persons.

(3) Without limiting subsection (1), a pattern of conduct may be coercive control whether or not any of the conduct is physical behaviour.

The day of the shooting

122. In the days leading up to 3 October 2023, Ralph’s behaviour was described as "a little bit strange" by his brother Charles. Although Ralph usually consumed a large quantity of alcohol each day, he appeared not to be drinking as much.

123. On 3 October 2023, Ralph spent the day at home and he must have consumed a significant amount of alcohol. Charles returned for lunch and noticed that Ralph was awake. Charles told his brother that there was some left-over fried fish if he wanted to eat it. Charles then left to go back to work, before returning home after 5.00pm. Ralph was there, with their mother Nerissa.

124. At around 5pm, Ralph contacted Eileen on her mobile using a private number. He told her to “come and take your stuff or I’m going to throw it out.” Eileen was pleased to get the call, thinking that he was now being more reasonable about returning her property. She didn’t tell anyone at Dawn House, where she was still staying, that he had called, or that she was going to attend his house.

125. At about 6.00pm, Eileen arrived by car at the Donald family home in Milner, with her 11 month old daughter in the back seat. Nerissa was watering plants in the front yard and when she saw Eileen arrive, she opened the front gates so that Eileen could drive inside the property.

126. Nerissa greeted Eileen, lifted the baby out of her car seat and took her inside. It is evident that Nerissa had no idea of what was in Ralph’s mind and she went to him and told him that Eileen had arrived. Ralph kissed and cuddled the baby but remained inside. After seeing the baby with his mother, Charles went outside to greet and speak with Eileen.

127. After some thirty minutes of talking, Eileen asked if Charles could go and see Ralph and find out what was taking him so long. Charles went into the house and informed Ralph that Eileen was waiting outside for him. Ralph asked Charles who she was with and Charles said he didn't know, but he thought she was by herself.

128. Ralph went to the bathroom, and Charles went to make some calls. At that point, Ralph came out of the house. He walked to his vehicle, looked into it, and then walked back inside the house. He went into his bedroom and removed a Marlin 30-30 rifle and cartridges from the gun safe.

Charles, who had been outside on the phone, finished his phone calls and went back towards the house. He saw Ralph coming out of the bedroom and closing the bedroom door behind him, but he did not see the gun, which Ralph was concealing down by the side of his body.

129. Ralph walked back outside carrying the rifle. He walked towards Eileen and was approximately two metres from her when he said “do you want to die” while holding up the firearm. In fear for her life, Eileen turned to run away. She did not hear or see anything after that, but Ralph discharged a shot at her and she fell to the ground. Charles heard a gunshot and ran to the backyard to see Ralph pointing the firearm towards where Eileen had been standing. Charles screamed at his brother, asked what he was doing and ran to Eileen on the ground, who was bleeding from the stomach area.

130. In an act of enormous bravery, Charles stood between Eileen and Ralph.

When he saw Ralph begin to re-load the firearm, he thought he would shoot Eileen again, and he rushed over to her and dragged her around the corner of the house in the hope she would be safe. At that point, Charles heard a second gunshot. Initially he thought Ralph had fired after them, but when he looked back to where Ralph had been standing, he saw that he was laying on the ground, bleeding from the head. He realised that his brother had shot himself.

131. I find that when Ralph shot at Eileen he intended to kill her and when he shot himself in the head he did so with the intention of taking his own life.

132. It was the heroic and quick-thinking actions of Ralph’s brother in standing between Ralph and Eileen, and then moving Eileen out of the way, that saved Eileen’s life.

133. Charles called his other brother Angus, who did not answer. He called 000 and followed the Operator’s directions to administer first aid, while they waited for the ambulance to arrive. Nerissa called Angus and he rushed straight home.

134. Police radio received the call about the incident at 6.39pm. The information received was that a male had shot his partner and shot himself, but there was no further information with regard to the status of the shooter. That meant that as police arrived, they were not sure whether they were confronting an active armed offender.

135. Angus arrived before police. He assisted Charles with providing first aid to Ralph. He saw the firearm laying on the ground and picked it up and attempted to make it safe. When he couldn’t do that, he threw it under a parked vehicle to get it out of the way.

136. The first police units arrived at 6:55pm and met on the road to formulate a plan to enter the scene, where the threat level was still uncertain.

Members had their firearms out in the ready position as they approached the premises on foot.

137. At the suggestion of Charles, Angus ran down the street to find out where the ambulance was. He saw St John ambulance waiting and told them to go to the house, but they were waiting until police advised that it was safe to approach the scene. This was frustrating for Ralph’s family members but is understandable in the context of their uncertainty about an armed offender.

138. The first police officers arrived at the scene, along with a registered nurse from the Police, Ambulance and Mental Health Co-Response Team. At that time, Charles was doing chest compressions on Ralph, and the nurse went to assist him. One police officer saw Eileen lying by herself near the front corner of the house closest to the driveway.

Although he was concerned for her safety and asked how she was, the initial focus was on identifying whether there was still an active armed shooter. Once the gun was secured, his focus turned back to first aid for Eileen, and Angus ran back to the paramedics to tell them that the firearm was secure.

139. The paramedics entered the premises at about 7pm and identified that Ralph had passed away. They assessed Eileen’s injuries and Police helped them to move her to a trolley for transport to hospital.

140. Eileen was taken to Royal Darwin Hospital and underwent abdominal surgery. She remained in hospital for a number of weeks. Her injuries included: a. a shattered right kidney, which had to be removed, b. multiple bowel and colon injuries, requiring excising of a segment of her colon, c. perforations of part of her small intestine, requiring suturing, d. multiple fractures in her lower spine, sacrum and pelvis, and e. ongoing problems associated with nerve damage to her right hip.

141. A mandatory report was made to the Department of Children and Families following the shooting and Eileen had contact with DCF staff while she was recovering in hospital. On 17 October, Eileen spoke with a DCF child protection worker and told them about feeling sad for Ralph, and that no one had helped him when his behaviour was deteriorating (and when his coercive control was increasing).

Cause of death

142. Dr John Rutherford performed a postmortem examination and determined that Ralph’s cause of death was a gunshot wound to the head. He also detected that Ralph had been acutely intoxicated, with a very high blood alcohol reading of 0.34%.

ISSUES AND RECOMMENDATIONS

143. While progress has been made, the work of responding to the epidemic of domestic and family violence in the Territory is not done. That much is clear by the fact that there have been at least a further ten preventable domestic violence deaths (eight of which were intimate partner deaths) in the Territory since I delivered my Findings and recommendations in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood in November 2024.

144. NT police figures show a 117 per cent increase in the number of family and sexual violence reports over the decade leading up to 2024, with a 73 per cent increase expected in the next decade.

145. We cannot rely upon one response, or one agency alone, to turn the tide.

What is required is a coordinated and sustained response from all of the government and non-government agencies working in this space. The response needs to provide consistency and certainty, but also needs to evolve based upon constant evaluations of what is working, and how the response can continue to be improved.

The NT still needs a DFSV Peak organisation

146. In the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood I heard evidence that, despite

having the highest rates of domestic and family violence in Australia (by far), the Territory is the only jurisdiction without a specialist DFSV peak body. Members of the Territory’s DFSV sector told me that the sector needs a peak representative body, to coordinate the sector’s efforts to achieve meaningful and lasting change. I heard from service providers that the absence of a peak representative organisation adversely affects the sector’s ability to be strategic and well organised, and makes it more difficult for the government to consult with and take advice from the sector. I was told that a peak body would assist in elevating the voices of victim-survivors with “lived experience”. I was also told that NTCOSS had commenced designing a model for a peak body.

147. After the public hearings in those inquests, counsel assisting me circulated draft recommendations to the interested parties, to enable them to indicate their position and provide any comment. Based on the evidence I had received, one draft recommendation was: “R5) Peak body: Following consultation about the appropriate model, the NT Government should establish and adequately fund a peak body for DFSV in the NT. This expands on AP2 action 4.12.”

148. In the written submissions filed on behalf of the Department of Children and Families on 11 October 2024, that draft recommendation was “acknowledge[d] and expressly endorse[d]”.48 With the express support of the Department, I made the following recommendation: “Recommendation 2: Following consultation about the appropriate model, the NT Government should establish and adequately fund a peak body for DFSV in the NT. This expands on action 4.12 of Action Plan 2.” 48 Written submissions on behalf of the Department of Children and Families in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood, dated 11 October 2024 at [97].

149. However, this recommendation was not supported by the Government, which responded to my recommendation as follows:49 Not supported. DCF funds 2 DFSV Policy Officers based in the sector and has prioritised the DFSV Training and Resource Centre as a critical element to sector development and retention.

150. The details of those initiatives were provided in the Department’s Institutional Response in this Inquest and are:50 a. DCF has funded51 NTCOSS (the Northern Territory Council of Social Service)52 to employ a DFSV Policy Officer, whose purpose includes to:53 i. Facilitate consultation with the DFSV sector, and participation by the DFSV sector, in relation to DFSV policy development and implementation in the Territory, ii. Research and prepare briefing papers, policy advice and submissions for related consultations and inquiries, iii. Provide an advocacy and central coordination role to represent the interests of the sector, iv. Promote best practice DFSV resources, knowledge and responses, 49 Attorney-General’s Report to the Legislative Assembly Pursuant to section 46B of the Coroners Act 1993 In the matter of the Coroner’s Findings and Recommendations regarding the deaths of Miss Yunupingu, Ngeygo Ragurrk, Kumarn Rabuntja [sic] and Kumanjayi Haywood, Legislative Assembly Tabled Paper, 29 July 2025 [8-16] at p8.

50 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [180]-[183].

51 Pursuant to a funding agreement entered into in financial year 2021-2022, valued at approximately $1.18m over five years.

52 NTCOSS is the peak body for the Northern Territory’s not for profit social and community services sector.

53 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [181].

v. With the Government, coordinate the development of strategic responses to address systemic issues relating to DFSV in the NT, and vi. Promote interagency and inter-sector collaborations across the DFSV specialist and universal service sectors, ensuring that organisations and communities with specialist expertise, knowledge and lived experience are included.

b. DCF has funded54 AMSANT (the Aboriginal Medical Services Alliance Northern Territory)55 to employ a separate DFSV Policy Officer, whose purpose includes:56 i. Supporting effective engagement with Aboriginal Community Controlled Organisations working in DFSV and to enable their meaningful involvement and input into DFSV policy development and implementation, ii. Collaborating with the NTCOSS DFSV Policy Officer, and iii. Providing a central point of contact for government to consult with Aboriginal Community Controlled Health Services (ACCHS) and Aboriginal Community Controlled Organisations (ACCOs) working in DFSV.

c. DCF has committed ongoing funding57 to support the establishment of a new DFSV Training and Resource Centre to take over coordination and delivery of DFSV training and workforce support.

151. These funding initiatives are to be commended.

152. In its written submissions, the Department of Children and Families indicated that the Government has also recently established a DFSV 54 Pursuant to a funding agreement entered in 2024, valued at $440,000 over two years.

55 AMSANT is the peak body for Aboriginal community controlled health services in the Northern Territory.

56 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [182].

57 $1.5 million per annum until FY2029/30 and $1 million ongoing.

Partnership Group, which is an advisory and information sharing group, comprised of members from Government and Non-Government Organisations.58 This, too, is to be commended; however, it is not clear whether this Group receives any specific funding, or whether its members are being asked to take on the additional workload without any consideration for “backfilling” their primary roles.

153. Despite these initiatives, I am left in no doubt that there is still a need for a peak body. The evidence I received in this Inquest included that: a. two policy officers working in two different organisations are not sufficient to undertake the significant workload required of a peak body,59 b. CEOs of individual non-profit organisations are working with the NTCOSS officer to do the work of a peak body by default, in addition to the work for their individual organisations,60 c. the absence of a peak organisation means that members of the sector are having to advocate to a government upon who they are dependent for funding, resulting in “a very, very difficult power dynamic.”61 That is, their responsibilities to their individual organisations (particularly in maintaining Government funding commitments) mean that they cannot advocate as strongly as they would like for the sector as a whole, as a peak body would be able to,62 d. organisations in the NT have seen the benefits of peak bodies in other jurisdictions in Australia,63 58 Written submissions on behalf of the Department of Children and Families dated 20 February 2026 at [27]-[28].

59 Evidence of Dr Chay Brown in the Inquest into the death of Kumanjayi Emitja on 29 August 2025 [4-1B] at T314.

60 Evidence of Ana Aitcheson on 22 August 2025 at T61.

61 Evidence of Dr Chay Brown in the Inquest into the death of Kumanjayi Emitja on 29 August 2025 [4-1B] at T313.

62 Evidence of Ana Aitcheson on 22 August 2025 at T61.

63 Evidence of Ana Aitcheson on 22 August 2025 at T61, evidence of Dr Chay Brown in the Inquest into the death of Kumanjayi Emitja on 29 August 2025 [4-1B] at T313.

e. the sector remains underrepresented. A peak organisation would bring the sector together to speak with one voice, to be more coordinated, more integrated and more effective in advocating for increased resourcing and support for victim-survivors,64 and f. DFSV expert Dr Chay Brown is not aware of any specialist service that opposes the establishment of a peak DFSV organisation.65 In particular, Tangentyere Council, Women’s Safety Services of Central Australia (WoSSCA), Dawn House and NPY Women’s Council are all supportive of a peak.

154. After the close of evidence, AMSANT released a document, “Report card on the Northern Territory Government’s DFSV strategy 2025-2028 as a response to the Coroner’s report”, which was released in February 2026.

Given the apparent relevance of that document to these Findings and any recommendations I may make, Counsel assisting me notified the interested parties that I proposed to accept that document into evidence, and the parties were given the opportunity to object to that course, consistent with principles of procedural fairness.

155. The Department of Children and Families took objection, on two bases:66 a. “First, the Report Card is not capable of assisting in the discharge of the Coroner’s statutory functions in relation to these deaths.

The Report Card concerns recommendations from other inquests which occurred after, and did not consider, these deaths. The author of the Report Card is unidentified, and there is no relevant expertise or knowledge of theirs disclosed. In addition, its conclusions are vague, internally inconsistent, and untested” and 64 Evidence of Dr Chay Brown in the Inquest into the death of Kumanjayi Emitja on 29 August 2025 [4-1B] at T313.

65 Evidence of Dr Chay Brown in the Inquest into the death of Kumanjayi Emitja on 29 August 2025 [4-1B] at T314.

66 Objection on behalf of the Department of Children and Families to the tender of AMSANT Report Card, dated 6 March 2026, at [5].

b. secondly, because its receipt would be after the close of the evidence and making of submissions by the parties.

156. In its submissions, DCF identifies that “the Report Card purports to assess the alignment” between my recommendations in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood, and the Northern Territory Government’s response, as set out in the Attorney-General’s Report to the Legislative Assembly tabled on 29 July 2025 and the DFSV Reduction Strategy 2025-2028, released on 26 November 2025.67 DCF submits that the report card is not capable of assisting me in the discharge of my statutory functions.

157. As the Report Card was published after the close of evidence, and DCF has objected to its admission, I will not admit it into evidence, and give no consideration to its contents.

158. However, I note an apparent irony. Partially in lieu of a Peak body, the Department funds a dedicated DFSV Policy Officer at AMSANT whose role includes enabling ACCOs working in DFSV to have meaningful involvement and input into DFSV policy development and implementation, and yet now questions the value of the AMSANT Report Card. I consider that this minimisation of the weight to be given to the work of AMSANT highlights the ongoing need for a Peak organisation, to take on the significant workload of undertaking relevant analysis of sector needs, policy development and implementation, and, crucially, to advocate for the sector on an equal footing as, for example, DCF.

159. I accept the expert evidence of Dr Brown that:68 “a DFSV peak would reduce sector workload and take on an important advocacy role with government. The peak could also collate data and evidence, and support the workforce.” 67 Objection on behalf of the Department of Children and Families to the tender of AMSANT Report Card, dated 6 March 2026 at [6].

68 Statement of Dr Chay Brown dated 18 August 2025 [4-1A] at [5].

160. Following the public hearing in this Inquest, counsel assisting me circulated the following draft recommendation: “That the NT Government (in consultation with all relevant stakeholders as to the appropriate model) establish and adequately fund a peak body for DFSV in the NT, with funding committed for at least 5 years, whose responsibilities include the following: o Review current resources for crisis accommodation and service delivery, with a view to identifying the true level of unmet need across the NT, including the requirement for infrastructure upgrades; o map the need for additional secure accommodation options for women and children experiencing, or at risk of experiencing DFSV in Alice Springs and Darwin. This mapping should be done in consultation with Aboriginal community organisations and sector experts, and should consider crisis and transitional housing, with access to specialist case management support and throughcare; o Map the need for funding and resources across government and non-government sectors to identify what is required to effectively reduce the level of domestic and family violence in the NT (which is at least 7 times the national average at the time of these recommendations); o Provide advice to government as to the most effective way to commit and coordinate resources to reduce DFSV.

o Provide advice to government and non-government agencies to ensure a more cohesive response to DFSV; o Capacity building work to improve the skills and expertise of frontline service providers through training, research, and developing new resources to address the needs of communities; o conducting and supporting research to build the evidence base for effective DFSV interventions and providing strategic leadership for the sector o Advice to Government on effective strategies to recruit and retain the DFSV Workforce”

161. It remains my view that a peak organisation with these important responsibilities is essential to ensuring the success of responses to the domestic and family violence crisis.

162. However, in its written submissions in response to counsel assisting’s draft recommendations, the Department of Children and Families made it clear that this draft recommendation is not supported.

163. That is regrettable.

164. Despite the sector being very clear that a peak body would enhance the government’s ability to respond to the unacceptable rates of domestic and family violence in the Territory, it is apparent that there is no current will or commitment to funding a peak organisation. It appears that the Territory will remain the only jurisdiction in Australia without a peak DFSV organisation, when the evidence from this and other inquests points to it being the jurisdiction that needs one the most.

165. That being the case, I will focus on other recommendations that may be of assistance to the sector.

Need for a multi-agency Domestic and Family Violence Death Review Team

(DFVDRT)

166. At the time of delivering the Findings in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood, I recorded that at least 86 women had been killed by their intimate partners in the Northern Territory since the year 2000. The records held by my office show that at least 28 men had been killed by their domestic partners during the same period.

167. As of today, the records held by my office show that since the year 2000 there have been at least 204 domestic violence deaths in the Territory, of whom:

a. 95 were women who were killed by their male intimate partner, b. 29 were men who were killed by their female intimate partner, c. 24 further women were killed by someone else with whom they had a domestic relationship (for example, a sibling or cousin), d. 48 further men were killed by someone else with whom they had a domestic relationship, e. seven men died by suicide after killing their intimate partner and/or other family member/s, and f. one woman died by suicide after killing family members.

168. The raw numbers indicate an average of 3.5 women killed by their intimate partner in the Territory in the years from 2000 to July 2023, but a rate of 6.5 women per year for the two years to August 2025. It is too early to tell if this stark increase is a trend or an aberration.

169. As shocking as these numbers are, they still do not accurately record the true number of domestic and family violence deaths in the Territory.

Deaths like Ralph’s have traditionally not been counted in the DFV statistics, even though his death was integrally connected to a domestic violence incident. Upon further review of the records held by my office, there are at least a further 7 domestic violence deaths in the years since 2000, which were of men who died by suicide after killing their intimate partners and/or their children.69 These deaths are identifiable as deaths arising in the context of domestic violence from the available records, but it is almost certain that there are more that we cannot readily identify because the connection was not documented or considered relevant at the time. It is clear that the current statistics do not capture all deaths closely 69 For example, Inquest into the death of Wayne Walker & Jacqueline Morrison [2008] NTMC 058.

linked to and arising from domestic violence in the Territory since 2000.70

170. I acknowledge, as I have previously, that these numbers concern domestic violence deaths, which are only part of the full story of domestic and family violence in the Northern Territory, and the way in which it traumatises so many living in the community: the survivors (particularly children), the onlookers and the first responders.71

171. We must accurately understand the nature and extent of the domestic and family violence crisis to be able to respond to it effectively. It is important that all domestic violence deaths are being identified and analysed, to be able to understand the different contexts and drivers of domestic and family violence, and to recognise patterns and trends, to then know what must be done to prevent further deaths. As Ms Gamble said in her evidence:72 “…we need to know more about this. I think there is some evidence - and I've been fortunate to read some incredible research that was done in our team exploring a death review process, which is a way to look at learning from horrific tragedies, that go beyond the normal definitions of DV, homicide and include some of the tragic circumstances that go a little bit to - around the edges of that, including suicide.

Because we’re - we’re not capturing enough information and understanding what we need to address these horrific incidents. And so I think some of those areas, like death review processes, that can explore and help us learn more, what needs to be done, is what we need to consider.”

172. I agree.

173. The Government is to be commended for acknowledging the importance of domestic violence death reviews and committing to establishing and 70 See evidence of Seranie Gamble on 21 August 2025 at T54.

71 See Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [87], [89]-[92].

72 Evidence of Seranie Gamble on 21 August 2025 at T53.

implementing a systemic DFSV death review process.73 The scope of that systemic DFSV death review is currently under development.74 The inclusion of this initiative in the NT DFSV Reduction Strategy 20252028 is:75 “a demonstration of the Government’s commitment to learn from past deaths, and provides a clear, ongoing forum to identify opportunities for systemic improvements.

Engagement with stakeholders outside of the Government will be critical to the success of this project and ensure a genuinely ‘systemic’ or ‘system-wide’ approach.”

174. That commitment, however, does not extend to providing any dedicated funding for the development and operation of a systemic DFSV death review process. DCF is the lead agency for this initiative but has been directed to fund it from existing resources.76 Does this stated “commitment” reflect a seemingly continuing expectation that the dedicated workers in this sector (government and non-government) personally do more without any increase in resources? I have heard example after example of the real life effect of under resourcing in this sector – it means that calls go unanswered, victims are turned away, people who are using or at risk of using violence but motivated to change do not receive the help and support they need when they need it, and our dedicated workers burn out. It means missed opportunities to intervene and break cycles of violence. It means more violence. It means more death.

175. Accordingly, I recommend that a Death Review Team be established, and that it be allocated ongoing, specific and adequate funding to complete its important work.

73 Written submissions on behalf of the Department of Children and Families dated 20 February 2026 at [42]-[43].

74 Written submissions on behalf of the Department of Children and Families dated 20 February 2026 at [43].

75 Written submissions on behalf of the Department of Children and Families dated 20 February 2026 at [42]-[43].

76 Initiative 35, Northern Territory Domestic, Family and Sexual Violence Reduction Strategy 2025-2028.

Recommendation 1: Domestic and Family Violence Death Review Team To the NT Government: That (in line with other State/Territory jurisdictions, eg NSW), the NT Government establish and sufficiently fund a multi-agency Domestic and Family Violence Death Review Team (DFVDRT) to review deaths occurring in the context of domestic violence in the Northern Territory.

The DFVDRT should (in line with other State/Territory jurisdictions, eg NSW) be convened by the NT Coroner or Deputy Coroner and include representatives from any or all of the following: a. Aboriginal (ACCO) service providers, b. NT Police, c. Department of Children and Families, d. NT Corrections, e. NT Health, f. NAAJA, g. NT Legal Aid, h. Department of Education, i. Non-Government sector experts and non-government service providers, and j. Lived experience experts.

Part 9 of the Coroners Act 2009 (NSW) should inform the establishment, functions, obligations and powers of the DFVDRT, including the duty of persons to assist the team with full and unrestricted access to relevant records (see s101L).

The DFVDRT should be empowered and resourced to, when considered appropriate, engage directly with a deceased person’s family and community to acknowledge their loss and to inform the review process.

Issues relating to the response of NT Police

176. In this Inquest, as in previous inquests, I received evidence about how much of the workload of general duties officers is responding to reports of domestic and family violence. That evidence included: a. Senior Constable R, who has worked in Casuarina, Alice Springs, Yuendumu, Wadeye, Milikapiti Community (Tiwi Islands) and Palmerston during ten years in the NT Police Force, and who told me that it makes up 80% of work-related duties that a general duties officer is dispatched to respond to,77 b. Senior Constable O, who has had nearly 17 years of operational policing across all four major centres and several remote centres in the NT and who estimates that it had made up “70-80%, if not higher”, of his policing duties during that time,78 and c. Constable J has been employed with NT Police for about five years.

She estimates that responding to domestic and family violence takes up more than 80 per cent of her work.79

177. There is no doubt that responding to DFV is a huge part of the work that the NT Police Force does in our communities, and that the way that it responds to DFV is fundamental to the success of the whole of government response to the domestic and family violence crisis.

178. On an individual level, I cannot understate the importance of the way that individual police officers respond to reports of domestic violence: 77 Statutory declaration of Senior Constable R dated 10 August 2025 [2-7] at [3].

78 Statutory declaration of Senior Constable O dated 13 August 2025 [2-6A] at [6].

79 Evidence of Constable J on 19 August 2025 at T6.

they are on the frontline of this response. Their role is critical in identifying DFV, intervening including by arresting, charging and/or initiating DVOs, helping victim-survivors to escape from unsafe situations, facilitating and encouraging victim-survivors to seek help, and referring both victims and users of violence, or those at risk of using violence, to available support services. Our police officers deserve our express recognition and our appreciation for undertaking this difficult work. For this vital role they must also receive the appropriate training and support.

179. Previous inquests examined areas where the NT Police had failed in its response to DFV, and identified specific ways that this response could be improved. In this Inquest I received evidence about important changes that have been made.

180. The NT Police Force is to be commended for the very significant work that has been undertaken in the years since Ralph’s death to improve its response to domestic and family violence, and to provide improved training and support to its individual members who show up and do this work every shift.

181. Some of the examples of this significant work are: a. establishment of a permanent NT Police DFSV and Youth Command,80 including an increase in staffing. I was told that as at 22 July 2025, there were 158 dedicated DFSV positions within the DFSV and Youth Command (not including a further 25 co-responder positions), b. roll out of Prevent. Assist. Respond. Training (PARt),81 (see below), 80 Pursuant to Recommendation 12 in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was to commit to an expanded and appropriately resourced DFSV Command, and which was supported by the NT Police Force.

81 Pursuant to Recommendation 11 in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was supported by the NT Police Force.

c. implementation of the Police Risk Screening Tool on 1 July 2025, which is used by frontline officers to focus their attention on identifying risk and flagging those at risk of experiencing DFV. It was developed in collaboration with the Department of Children and Families to align with the Common Risk Assessment Tool (CRAT), which is used by NT Government agencies. The PRST is specifically designed for easy use by operational police responding to DFV callouts, d. embedding of Aboriginal language interpreters and/or Aboriginal Liaison Officers within the Police call centre (JESCC),82 e. implementation of the Alice Springs co-responder pilot, and development of a Darwin co-responder model, as well as efforts to expand co-responder services to other parts of the NT.83 This is a topic I examined more closely in the Inquest into the death of Kumanjayi Emitja, which proceeded in Alice Springs in the week following this Inquest, f. expansion of Strike Force Lyra (which responds to and investigates protracted domestic violence matters that do not meet the threshold of serious family violence offences), to provide support and guidance to frontline officers on how to respond to family violence, g. five new senior sergeant positions in JESCC, with a senior sergeant available there 24 hours a day. These senior officers provide real time advice to frontline members and assist with taskings and the prioritisation of reported domestic violence matters. They also conduct “deep dive” reviews or reported DFV incidents during their shifts, 82 Pursuant to Recommendation 10 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was accepted in full.

83 Pursuant to Recommendation 7 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was accepted in full by the NT Police Force.

h. establishment of a Governance Unit within the DFSV and Youth Command, consisting of: i. a Training Team, which liaises with the PARt coordinator and promotes lessons learned and best practice in DFSV response,84 and ii. an Audit team, which audits Tier 1 domestic violence occurrences to review the police response to these incidents,85 i. development of a Domestic Violence “Dashboard” to provide comprehensive analysis of DFV incidents across the Territory, drawing on data from SerPro and its predecessor PROMIS, to identify trends and respond accordingly, including by rostering extra police at times when DV incidents are known to increase, j. force-wide broadcasts being issued to all sworn and unsworn NT Police members in relation to legislative and procedural updates, k. improved training for Police in relation to when and how to make a police DVO,86 l. formation of the DFSV Coronial Recommendations Governance Committee to manage and implement the recommendations I made in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood, 84 Pursuant to Recommendation 12c in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was supported by the NT Police Force.

85 Pursuant to Recommendation 13 in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14, which was supported by the NT Police Force.

86 Affidavit of AC Michael White dated 14 August 2025 [2-9] at [145].

m. efforts to improve information sharing capabilities through SupportLink,87 n. review of training for NT Police officers in relation to SupportLink referrals,88 o. creation of an Early Intervention Project team to develop a program to enhance and support the physical and mental wellbeing of NT Police staff responding to DFV, p. delivery of Stress Management and Resilience training to members, with an optional vicarious trauma module, q. launch of the NT Police “MyWellbeing Portal”, allowing members in remote and regional areas to more easily engage with wellbeing services, r. direct engagement of Wellbeing Services with recruits during their time at the Police College, s. enhancement of the Family Safety Framework, including its expansion to Wadeye and work on a FSF portal, to support FSF administrative, record-keeping and reporting functions, and t. improved information sharing between hospital-based constables and social workers.

182. I heard evidence from the NT Police DFSV Audit team that:89 a. newly graduated officers who have received five days of face-to-face PARt are responding to DFV matters to a high standard, and are showing an improved understanding of DFV, 87 Pursuant to Recommendation 8 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

88 Pursuant to Recommendation 8 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

89 Affidavit of AC Michael White dated 15 August 2025 [2-10] at [98].

b. there is an observable increase in members’ understanding and application of mandatory prosecution requirements, in alignment with the DFV General Order, c. confidence has grown among officers in recognising and responding to patterns of coercive control, d. frontline officers are showing a greater awareness of misidentification risks, and e. members are demonstrating heightened awareness and confidence in undertaking safety planning.

183. One frontline officer told me about her positive experience of having a dedicated DFV senior sergeant available at JESCC, 24 hours a day. She told me that if any attending officers want to confirm anything or seek advice, they can c all that senior sergeant at any time. She said that this has been “more than helpful”.90 She also told me that if two junior members are responding to a report together, they need to ring the senior sergeant before they leave the job,91 to ensure that their response has been appropriate and they have not missed anything.

184. That same officer also told me about how the PRST forms are used in the field, and how helpful they are to police officers who are trying to identify and understand the level of risk in the circumstances they are attending.92

185. I also acknowledge improvement in the use of bodyworn video that I was able to observe during this Inquest. The availability of BWV is of enormous assistance to witnesses in being able to refresh their memory, and it is very helpful for the Court to be able to rely upon a direct recording of events.

90 Evidence of Constable J on 19 August 2025 at T18.

91 Evidence of Constable J on 19 August 2025 at T25.

92 Evidence of Constable J on 19 August 2025 at T15.

Prevent. Assist. Respond. Training (PARt)

186. This is a specialist DFSV training package, which was specifically designed for police and healthcare workers in the NT. It aims to improve understanding of and response to domestic and family violence. PARt also includes training on the expanded definitions of family violence in the Domestic and Family Violence Act 2007 (NT), which came into effect on 25 March 2024. Domestic violence is now defined to include emotional or psychological abuse and coercive control, and each of those terms is now defined in the Act.

187. NT Police have told me that as of 14 January 2026, out of the 1719 full time policing positions in the NT: a. 212 recruits had completed the extended in-person PARt recruit training package, b. 552 in-service members had completed the abridged two day PARt course, c. 1275 in-service members had completed online Module 1, d. 1237 had completed online Module 2, e. 852 had completed online Module 3, f. 788 had completed online Module 4 and g. 13 further face-to-face sessions were scheduled for the remainder of 2026, with an estimated further 440 officers (including recruits) expected to have completed in-person PARt in that time.

188. Dr Chay Brown developed PARt and is delivering much of the in-person training with the assistance of a small (but mighty) cell of trainers (including trainers with lived experience). She gave this evidence:93 “I’m extraordinarily proud of PARt. I am mostly proud of the fact that PARt even exists, because a couple of years ago, it…would’ve been unthinkable. We had to…fight and advocate for a very long time for PARt to exist and I’m…especially proud of the relationship that we have developed with NT Police. We have a wonderful relationship, collaborative relationship - particularly with the domestic violence training cell that’s been established. I’m very proud of that. I’m very proud of all of our achievements to date and even if it is hard work - I cannot understate how difficult PARt training is, for many different reasons - but you do get to the end of that course, that five-day or that two-day course, and you do feel like you’re creating system change. You do feel like you’re on the same side and that, you know, good things are happening. So it is really rewarding work and the - yeah, I’m incredibly proud of it.”

189. Based on the trends they are seeing so far, Assistant Commissioner Michael White expects that as more members complete PARt “we will see a much more improved ability for all members”.94

190. I heard evidence from a number of the police officers who tried to help Eileen when she called, and who are still serving officers. They were asked about PARt training: a. Cst J told me how helpful PARt had been and, that, in particular, the videos of victim-survivors telling their stories were particularly valuable.95 She said that the training she has received has changed her practice, particularly in prioritising building rapport and making an individual feel safe, as a basis for obtaining more information from them.96 b. Senior Constable O told me that PARt has been “absolutely” useful and “a gamechanger. It has changed the way I personally have viewed 93 Evidence of Dr Chay Brown on 20 August 2025 at T28.

94 Evidence of AC Michael White on 22 August 2025 at T18.

95 Evidence of Constable J on 19 August 2025 at T21.

96 Evidence of Cst J 19 August 2025 at T23.

incidents”. Learning about “the coercive control element, for me, was a big learning step. The depth that it runs and the level to which it can go to in terms of what may, in a police dealing with one incident as a…domestic violence response – you may overlook that tiny, little element because the incident you’re dealing with doesn’t…have that overall, big picture. However reviewing that sort of an incident through a coercive control lens may also give an indication that there might be something to dig a little deeper at and get to more truth of the matter or try and get some more information on that point.”97

191. Senior Constable O was the senior officer who spoke with Eileen at Casuarina Police Station on 4 April. This officer picked up on the dynamics that Eileen was describing, and understood that there was a significance to them, but, without having had the benefit of PARt training, he didn’t understand what that significance was. He told me that, with the benefit of the education and training he has now received, he now recognises that what Eileen was describing was coercive control.

He told me that, if faced with the same complaint today, he would have pressed harder, asked more questions, and looked to initiate a DVO for her protection. This is very positive evidence of the impact of PARt.

192. The NT Police Institutional Response indicated that the DFV Audit team has identified that there remains variance in the frontline policing response delivered by PARt-trained and non-PARt-trained members. I heard that the introduction of the DFV Senior Sergeant in JESCC is helping to reduce this disparity;98 however, in my view the best way for this to be addressed is to ensure the continued roll out of PARt as a priority.

193. One specific issue that arose in relation to the roll out of PARt was whether there is an advantage in face-to-face delivery, as opposed to online training modules.99 Dr Brown explained that PARt was designed 97 Evidence of Senior Constable O on 18 August 2025 at T39.

98 Affidavit of AC Michael White dated 15 August 2025 [2-10] at [98].

99 For example, in the evidence of Senior Constable O on 18 August 2025 at T40.

to be delivered in-person, followed by online “refresher” modules. This method of delivery was preferred because important conversations can be had between participants and trainers when they are together in the same room, which do not occur in the online format. Also, during the development consultations, police members told Dr Brown’s team that they would prefer in-person training.

194. The way that PARt has been rolled out means that members are often doing the online modules before they have undertaken any face-to-face PARt training.

195. One officer told me that by receiving the training online, instead of inperson, “there are elements that come up that may be slightly confusing, or – not confusing, maybe trying to contextualise it and understand where that might fit. And you would have discussions amongst your colleagues about their perception of it or what your perception may be”.

196. The NT Police Institutional Response indicated that the DFV Audit team has identified that newly graduated constables who had received the five day face-to-face PARt, in particular, have showed an improved understanding of DFV and are responding to DFV call outs to a high standard.100

197. I understand that the NT Police Force is supportive of a prioritisation of face-to-face training for all members but does not think that a recommendation to this effect is required.

198. The roll out of PARt training has been a significant undertaking, for which I commend NT Police. It is clear that, although the roll out is not complete, PARt training is already having a considerable impact on the way that officers are responding to reports of domestic and family violence. I remain firmly of the view that face-to-face delivery of this critical training is so important that it should be prioritised, and that I 100 Affidavit of AC Michael White dated 15 August 2025 [2-10] at [98].

should make a recommendation to that effect. I think that it is a real and practical way that members can be supported in their training.

199. In my Findings in the Inquest into the death of Domestic violence victim (Jingili Water Gardens) 17.01.25, I recommended that all serving police officers who are identified as falling substantially short of expected standards, when responding to or supervising responses to domestic and family violence incidents, be fast tracked for and rostered to complete appropriate PARt training, if they have not already completed that training. For the same reasons as those above, the PARt training for these officers should be delivered in-person.

200. NT Police support the intention behind a recommendation to this effect, but suggest it is not required. I disagree. It is particularly important that these officers receive this training in the most effective way, because: they have demonstrated a lack of understanding or commitment in their response to domestic violence, changing entrenched attitudes and behaviours is hard, in-person training is more impactful, and in-person trainers can better hold participants to account.

Recommendation 2: Prioritisation of face-to-face PARt To the Northern Territory Police Force: The NT Police Force should continue its roll-out of Prevent. Assist. Respond.

training (PARt). In doing so, the NT Police Force should: a. prioritise delivery of the face-to-face component of PARt training to any police officer who may respond to incidents involving domestic, family or sexual violence in the course of their day-to-day duties and for any JESCC call taker who has not completed PARt;

b. endeavour to have all NT Police officers and auxiliaries undertake initial PARt by way of face-to-face training, to be followed by a program of refresher and/or supplementary online modules; c. further to the recommendation made in Findings in the Inquest into the death of Domestic violence victim (Jingili Water Gardens) 17.01.25, in relation to all serving police officers who are identified as falling substantially short of expected standards, when responding to or supervising responses to domestic and family violence incidents, the NT Police Force should ensure that these officers are fast tracked for and rostered to complete face-to-face PARt training, if they have not already done so.

Embedding of domestic and family violence death reviews

201. In this and previous domestic violence inquests I have had the benefit of detailed reviews of all relevant Police interactions with the offender and victim of violence.

202. I understand that it is now police practice for a preliminary review to be performed by the DFV Senior Sergeants at the time that a death is reported and, where there is a “cogent and causal link” between the death and domestic or family violence, the DFV audit team analyses police responses to DFV allegations. This analysis aims to identify missed opportunities or systemic failings, in an attempt to formulate recommendations necessary to improve practice and procedure.

203. This practice is to be commended, and NT Police is supportive of this practice being formalised in the relevant General Order. In those circumstances, a recommendation is not needed.

204. Once established, these analyses should also be referred to the multiagency Domestic and Family Violence Death Review Team (DFVDRT), recommended above.

Information provided in SupportLink referrals

205. SupportLink Australia Limited is a service provider used by several NT Government agencies, including NT Police. It provides a Referral Management Service and a Client Management System. It is an automated digital support resource that enables referrals to be made to a variety of services. The person making the referral must have the consent of the person being referred, and then may enter that person’s details and selects the category of service that would best assist them. The referral is automatically directed to the support service or services on the SupportLink database that offer the services requested, and are geographically located closest to where the referee lives. That service then calls the contact number for the person being referred.101

206. I received helpful evidence about the process by which NT Police submit SupportLink referrals, including that officers are able to copy and paste narratives from their SerPro entries into a SupportLink referral.

207. It seems to me that it may assist the service to which a person has been referred if other relevant documents, such as CRATs, PRSTs or other risk assessment documents, could be submitted with a SupportLink referral. NT Police supports the objectives of a recommendation to this effect.

208. I also received evidence from Relationships Australia NT that they are not able to contact around 80-90% of referrals that they receive from SupportLink; their phone calls are either not responded to, or the service is declined.102 One contributing factor is that, due to privacy and risk concerns, Relationships Australia intake staff are unable to leave voicemail messages when making contact following a SupportLink 101 Affidavit of AC Michael White dated 15 August 2025 [2-10] at [51]-[53].

102 Evidence of Nathalia Perez Alfonso on 20 August 2025 at T37.

referral, which may increase the likelihood of clients not answering calls and therefore not engaging with the service.

209. Nathalia Perez Alfonso, the Director of Practice Quality for Relationships Australia NT, suggested that it would be helpful if SupportLink referrals included an indication of whether it is safe to send a message to the number provided, or if there was an alternative way of contacting the person.103 I understand that NT Police is generally supportive of this also, but is not responsible for the SupportLink system.

Recommendation 3: Inclusion of relevant information in SupportLink referrals To the Northern Territory Police Force: That NT Police: a. explore with SupportLink Australia Ltd whether the following system architecture changes can be made to the SupportLink system: i. to prompt and enable referrers to include CRATs, PRSTs or other risk assessment documents, and relevant SerPro narratives when submitting SupportLink referrals, and ii. to prompt and enable referrers to indicate whether it is safe to send and/or leave a message on the contact phone number for the person being referred and/or whether there is an alternative contact number that can be used safely; and b. if these changes are made, that NT Police update the Domestic and Family Violence General Order to require members, where possible, 103 Evidence of Nathalia Perez Alfonso on 20 August 2025 at T41.

to upload these documents and record this information in SupportLink referrals.

Police powers to seize firearms while investigating allegations of domestic and family violence

210. Ralph had a firearms licence and lawfully possessed three firearms, including the Marlin Rifle that he used in his attempted killing / completed suicide.

211. Allegations of domestic violence can immediately affect a person’s ability to hold a firearms licence, in the following ways: a. a firearms licence is automatically suspended if an interim DVO is made against them,104 b. a firearms licence is automatically revoked upon the making of a final DVO,105 c. a licence is automatically revoked if the holder of the licence is found guilty of a disqualifying offence or an offence of violence,106 d. a member in charge of a police station or of the rank of senior sergeant or higher may suspend a firearms licence in certain circumstances, including:107 i. if the holder has been charged with an offence that would render them not fit to hold a licence, 104 s39 of the Firearms Act 1997 (NT).

105 s40(1)(a) of the Firearms Act 1997 (NT).

106 s40(1)(b) of the Firearms Act 1997 (NT).

107 s42 of the Firearms Act 1997 (NT).

ii. if the officer believes on reasonable grounds that the holder is suffering from a physical or mental infirmity and their possession of a firearm may be a danger to their safety or the safety of another (s42(1)(c) of the Firearms Act 1997 (NT), or iii. after receiving a report from a health practitioner, counsellor or social worker who believes that in the interests of public safety the person is not fit to possess a firearm, or e. the Commissioner of Police may revoke a firearms licence because the holder is no longer a fit and proper person, or for any reason that would lead to refusal of a licence. This can include if the Commissioner has reasonable cause to believe that the holder may not exercise responsible control over firearms because of the holder’s intemperate habits or because the holder is of unsound mind.108

212. In its institutional response, NT Police suggest that police who attended on 21 September should have taken steps to suspend Ralph’s firearms licence using the provision in s42(1)(c) of the Firearms Act 1997 (italicised above), based on the observation that Ralph looked “a bit mentally unwell”. For this provision to have been used, an officer of sufficient rank would need to have been satisfied that Ralph was suffering from a physical or mental infirmity or incapacity, and may have been a danger based on possessing a firearm. I am not satisfied that the officer should have taken these steps, based on the information he had and the observations he made of Ralph. The other attending officer, Constable S, was asked about this during her evidence and said:109 108 ss10(3)(b), 10(4)(c) of the Firearms Act 1997 (NT).

109 Evidence of Constable S on 20.08.25 at T11.

“I don’t know if Mr Donald was mentally unwell. To me and my limited interactions with him, he appeared stressed, upset, more so that his daughter was being taken from the location.”

213. Police do have the power to search and seize restricted weapons if the member:110 a. has entered a home because they believed on reasonable grounds that: i. A person has suffered, is suffering, or is in imminent danger of suffering personal injury at the hands of another person, or ii. Another person at the place has contravened, is contravening or is about to contravene a DVO, or iii. There is a serious and imminent risk to the welfare of a child

AND b. Believes on reasonable grounds that: i. A restricted weapon is located at the place and ii. That leaving the restricted weapon at the place could put a person in imminent danger of suffering personal injury or an aggravation of personal injury already suffered.

214. I am not satisfied that the officers who attended on 21 September should have formed the view that they had a proper basis to exercise this power to seize Ralph’s firearms.

215. The only other available way for Ralph’s firearms licence to be suspended was for the Firearms Policy and Recording Unit (FPRU) to take action. That unit receives daily, automatically generated reports alerting them to firearms licence holders who may fit criteria to have 110 s126B and s126C of the Police Administration Act 1978 (NT).

their licence suspended, such as by having been charged by police. Due to the system in place at that time, in 2023, Ralph’s name would only have appeared in the daily FPRU report if he had been charged with an offence or if a DVO had been issued against him, neither of which occurred.

216. A new Police information management system (SerPro) has since been implemented and, as a result, the daily FPRU reports now capture all DV involvements of any licence holder. The FPRU then reviews the nature of the DV and, if a pattern of escalating behaviour is identified, the licence may be suspended and a “show cause” notice issued, requiring the licence holder to explain why the licence should not be revoked. That is, if the same reports had been made about Ralph’s behaviour now, the FPRU would be notified and would consider whether they needed to do anything about his licence or firearms.

217. That is clearly a positive change; however, in my view, there is room to further strengthen the police response in circumstances where firearms are present when they are investigating a complaint of domestic violence, but the existing provisions to suspend a firearms licence or to seize firearms are not enlivened.

218. During the Inquest I heard about the NSW regime contained in Part 6 of the Law Enforcement (Powers and Responsibilities) Act 2002 (NSW).

Section 85 of that Act provides that when a police officer lawfully enters a dwelling in accordance with that Part, believing on reasonable grounds that a domestic violence offence is being, or may have been recently, committed, or is imminent or likely to be committed, that police officer “must inquire as to the presence of any firearms in the dwelling and, if informed that there is or are a firearm or firearms, must take all such action as is reasonably practicable to search for and to seize and detain the firearm or firearms.” The regime provides a mechanism for the owner of the firearms to apply to have them returned.

219. The NSW provision is powerful. It is easy to understand. It provides police with a significant power which protects DFV victims from potential gun violence.

220. Eileen was asked what she thought of Police having a power like this and was supportive, particularly because for her, it would have enabled Police to take control of the seizure of Ralph’s firearms without her having to ask for it or to trigger it in some way.111

221. Senior Constable O, who has considerable operational experience, particularly in responding to reports of domestic violence, was also supportive of this proposal, He said:112 “I believe any legislation that would improve or strengthen [our response to] domestic violence and protect our community would be beneficial.”

222. In its submissions to me, the NT Police Force indicated that it was supportive, in principle, of a legislative change that would give its members the discretion to seize firearms when they are lawfully in a house to investigate a DFV complaint; however, submitted that the only way such a regime could be feasible was if Police resources were appropriately increased. That is, more officers would need to be in attendance to ensure that any weapon seizure could be safely affected.

223. Unlike the NSW regime, I do not propose to make a recommendation mandating seizure of weapons whenever Police are inside a dwelling to investigate a report of domestic violence; however, I consider that Police should have the power to exercise their discretion to search for and seize firearms present in a home, if they are in that home investigating a domestic violence complaint. This would not be limited to a first attendance, but could be actioned at a later investigative attendance 111 Evidence of Eileen Gibbons on 18 August 2025 at T32.

112 Evidence of Senior Constable O on 18 August 2025 at T56.

when Police are lawfully in the home and when proper planning has occurred.

Recommendation 4: Legislative change to give police increased powers to seize firearms when investigating complaints of domestic and family violence To the NT Government: That the NT Government effect legislative change to give police the discretion to seize firearms when officers are lawfully in a dwelling to investigate a DFV complaint. Such legislative change may require a commensurate increase in police resourcing to ensure such seizures can be effected in a way that minimises risk.

Issues relating to the Department of Children and Families (DCF)

224. The Department of Children and Families is the other key NT Government agency responding to domestic and family violence.

Although it is a child protection agency it also has the responsibility of leading the whole of government response to domestic, family and sexual violence (DFSV) through its DFSV Prevention Division.

225. As with Police responses, previous inquests identified areas where the Department had failed in its response to DFV and identified specific ways that the response could be improved.

226. In this Inquest I received detailed evidence about the significant body of work that is being undertaken by DCF to better respond to this crisis.

The Department is to be commended for the efforts, expertise and funding that are being dedicated to this work.

227. I acknowledge that this work is being undertaken in the context of record government funding towards combatting DFSV in the Territory, which

is also to be commended. In providing this record funding, the Government recognises that:113 a. the Territory has the highest rates of DFSV in the country, with a large proportion of violent crime linked to DFSV. There is a clear need for a coordinated, holistic and integrated approach to addressing DFSV in the Territory, involving both Government and non-Government services, b. DFSV is preventable, and its impacts can be reduced, c. Commonwealth investment in DFSV initiatives in the Territory has generally been ad hoc and time limited in nature, d. historically, Territory and Commonwealth Government funding has primarily been allocated to tertiary, frontline responses, including those delivered by Police, Courts, crisis accommodation and counselling, and e. despite this, the funding for DFSV in the Territory has not been sufficient to meet the demands on those tertiary services.

228. The allocation of DFSV funding across Government agencies, in real and percentage terms, and the programs for which that funding has been provided, from financial year 2025-2026 onwards, is as follows: Agency / Program FY2025-26 FY2025-26 Ongoing $000 % $000 Department of Children and Families 21 394 59 18 808

• Circuit Breaker

• DFSV Specialist services funding

• Programs in community

• Remote Safe House support

• DFSV Risk Assessment

• Primary Prevention

• DFSV Training and Resource Centre

• Whole of Government Policy & Coordination 113 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [16].

NT Police 7 828 22 8 915

• Co-Responder

• Family Safety Framework Department of Health 400 1 425

• Specialist health response Department of Corrections 4 210 12 4 416

• DFSV Programs in prison (existing)

• New DFSV Program in Prison

• DFSV Counselling for women in prison Attorney-General’s Department 1 918 5 3 311

• Specialist Domestic Family Violence (DFV) Courts

• Specialist DFV Prosecution & Witness Assistance Department of People, Sport and 250 1 125 Culture

• Community innovation activities Total 36 000 100 36 000

229. As indicated in this table, the NT Government has committed to $36 million in funding per year for the DFSV response. That is the exact cost of implementing Action Plan 2, which was very carefully developed and costed in 2023 by the Domestic, Family and Sexual Violence Interagency Coordination and Reform Office (DFSV-ICRO).114 I considered that Action Plan in the previous domestic violence inquests and recommended that it be fully implemented.115

230. While the level of investment is the same as that costed in Action Plan 2 by the interagency group, a separate process was undertaken to determine the actual allocation of this funding. I am told that this process involved:116 a. reviewing existing commitments from DFSV Action Plan 2 to identify non-negotiable DFSV work required to continue, including 114 As discussed in Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

115 Recommendation 33 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

116 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [26].

any funding cliffs with service providers and across Government agencies, new priorities and innovative programs, b. consideration of initiatives that could be funded from other sources, including Commonwealth funding for homelessness, education and legal services, c. supporting the implementation of DFSV Coronial recommendations, handed down on 25 November 2024, d. supporting the implementation of national DFSV policy, particularly the National Plan and Rapid Review. The Rapid Review was commissioned by the Commonwealth Government and undertaken by an independent expert panel. Acknowledging that evidence is emerging with pockets of good practice around the country, the Rapid Review made recommendations to invest in and evaluate a range of interventions, mechanisms and system levers for a whole-ofcommunity approach to prevention over the longer-term, e. prioritisation of programs based on emerging evidence to deliver outcomes and strengthen integrated service delivery across the Territory, and f. alignment with Government priorities of reducing crime, rebuilding the Territory and restoring the Territory lifestyle.

231. In addition, the $36 million investment addresses funding cliffs for existing programs, and an increase in specialist services funding to implement my previous recommendation117 of a 10% baseline funding increase for frontline services.118

232. 17 programs or initiatives are funded by the NT Government (and listed in the above table). The Department of Children and Families is the lead agency for eight of these and the relevant funding breakdown and number 117 Recommendation 34 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

118 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [32].

of Full Time Equivalent (FTE) positions for those programs is as follows: No. Program 2025-26 2026-27 2027-28 2028-29 2029-30 Ongoing $000 $000 $000 $000 $000 $000 1 Circuit Breaker 6 550 6 550 6 550 6 550 6 550 6 550

FTE 43 43 43 43 43 43 2 DFSV 5 200 5 200 5 200 5 200 5 200 5 200 Specialist services funding 3 Programs in 3 428 3 178 3 489 3 939 3 939 3 813 community for people committing violence

FTE 1 1 1 1 1 1 4 Remote Safe 500 500 500 250 250 245 House support

FTE 1 1 1 1 1 1 5 DFSV Risk 250 250 250 250 250 250 Assessment by universal services 6 Primary 1 400 1 162 250 250 250 250 Prevention Grants

7 DFSV 1 500 1 500 1 500 1 500 1 500 1 000 Training and Resource Centre 8 Whole of 2 566 1 500 1 500 1 500 1 500 1 500 Government DFSV Policy, Coordination & Governance

FTE 21 15 15 15 15 15 Total $ 21 394 19 840 19 239 19 439 19 439 18 808

233. These programs/initiatives are: a. Circuit Breaker: Family and Youth Support Program, which provides voluntary, early intervention intensive support targeted at young people aged 10-17 years old and their families, in Alice Springs, Katherine, Tennant Creek and Darwin. It identifies and engages young people demonstrating anti-social behaviour and who require proactive and assertive interventions, then provides

case work and works to increase parents’ accountability through Family Responsibility Agreements. If DFSV is identified as a contributing factor to the safety of the young person, Circuit Breaker workers must make a mandatory report to the DCF Central Intake and NT Police.

b. DFSV Specialist services funding: consistent with my previous Findings, the Commonwealth Government’s Rapid Review highlighted the critical need to build and invest in the specialist DFSV workforce.119 The specialist DFSV sector provides case management, therapeutic supports, safety planning, safe accommodation, financial support and connections to other supports across four domains:120 i. primary prevention to stop violence before it starts, ii. early intervention and accountability to identify violence early, stop it escalating and prevent it from reoccurring, iii. response, recovery and healing to address the impacts of violence and reduce trauma, and iv. systemic enablers and reform to provide effective architecture for a coordinated and evidence-based system.

c. Programs in community for people committing violence: primarily targeting offenders in the justice system, offering sentencing options to the Court and Community Correction Order for the Department of Corrections and focussing on holding perpetrators accountable and facilitating behaviour change.121 These programs include Men’s Behaviour Change Programs, which are discussed below.

119 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [53].

120 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [53]-[54].

121 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [58]-[60].

d. Remote safe house support: there are 29 crisis accommodation services for DFSV victim-survivors in the NT. Twelve of these are operated by DCF but will be transitioned to providers in remote locations, including Aboriginal Community Controlled Organisations. The need for crisis accommodation services is significant: from 1 July 2024 to 31 March 2025 4,663 clients were provided with safe house services, totalling 28,579 bed nights and the creation of 3,035 safety plans.122 e. Risk assessment and promotion in universal services – RAMF Champions: The Territory’s DFV Risk Assessment and Management Framework (RAMF) is a practice framework allowing all organisations to have a common understanding of DFV risk and how to manage that risk. The Common Risk Assessment Tool (CRAT) is an evidence-based risk assessment tool that uses predictive risk factors to support safety planning.

This funding is for dedicated positions within eight universal services including CatholicCare NT, Relationships Australia NT, and a number of Aboriginal Community Controlled Health Organisations, to ensure that RAMF and CRAT have been implemented within their organisations.123 f. Primary prevention grants: These grants fund projects aimed at stopping violence early and preventing escalation by addressing gender inequality, fostering respectful relationships and supporting community-led solutions. These grants include Aboriginal Led Prevention Grant funding.124 g. DFSV Training and Resource Centre: The Government has committed to support the establishment of a new Training and Resource Centre to develop, deliver and coordinate locally 122 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [68]-71]. But note the evidence of unmet need, for example [264] below.

123 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [85]-[92].

124 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [93]-[104].

relevant and accessible DFSV training options to meet the professional development needs of the DFSV specialist and nonspecialist workforce. It is anticipated that the Centre will commence in FY2026/27. This is an excellent initiative.

h. Whole of Government DFSV Policy, Coordination & Governance: the DFSV Prevention Division is responsible for establishing and driving DFSV policy, governance, coordination and grant management across Government. This initiative is to maintain a sustainable DFSV coordination mechanism and to lead consistent and evidence-based DFSV policy and practice across the Territory.125

234. Additional initiatives/funding streams include: a. funding of DFV homelessness services: to DAIWS, YWCA Australia and Mission Australia. The total FY2024/2025 funding was $0.95million across five grants, but it is anticipated that this will be increased to $5.453million in FY2025/2026 and to an additional three services,126 b. supporting the DFV Co-Responder model and Family Safety Framework, which are led by NT Police, c. Commonwealth funding for DFSV responses in the Territory in FY2025/2026 is $17.3million, which includes:127 i. $12.75 million under the NT Remote Aboriginal Investment Agreement, including for delivery of services in remote women’s safe houses, and 125 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [105]-[106].

126 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [116]-[117].

127 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [161]-[166].

ii. $4.1 million under the National Partnership Agreement (noting that the total NPA funding for the five years from 1 July 2025 will be $6.64 million).

235. This all represents a very significant commitment from the NT Government and the Department.

236. I note that some of these programs/initiatives have not yet commenced (such as the Training and Resource Centre). Furthermore, the cornerstone program of the $36 million funding commitment appears to be $6.55 million for the Circuit Breaker program, which is a Family and Youth Support program for young people demonstrating anti-social behaviour. That program was identified prior to the increased $36 million annual funding commitment for DV. 128 While it may be a “DVinformed” program, it is not a specialist DFSV program;129 however, it is receiving nearly 20% of the annual NTG DFSV funding.

DFSV-ICRO

237. One recommendation I made in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood was for the establishment of a permanent inter-agency domestic family and sexual violence whole of government coordination and reform office (DFSV-ICRO).130 This recommendation was “supported in principle consistent with existing whole of government unit in DCF”. That unit is the DFSV Prevention Division, which sits within the Department of Children and Families.

238. The DFSV Prevention Division is an important initiative; however, it is not consistent with my recommendation for a permanent inter-agency 128 Evidence of Seranie Gamble in the Inquest into the death of Kumanjayi Emitja on 28 August 2025 [7-3A] at T279.

129 Evidence of Seranie Gamble in the Inquest into the death of Kumanjayi Emitja on 28 August 2025 [7-3A] at T266.

130 Recommendation 1.

office. The significance of this is highlighted by the evidence I received that, while there is regular consultation between DCF DFSV Prevention Division members and NT Police, “the extent of that consultation is less than what was initially anticipated.” This is apparently because the Police have been directly funded to facilitate and operate several DFSV programs, and to make direct representations and proposals to the Minister for Police.131

239. The extent of interagency cooperation and coordination has not, and cannot, be achieved by a body that sits within one of the government agencies. It remains my view that a permanent inter-agency office is required to best coordinate the whole of government response.

DCF DFV death reviews

240. In this and previous inquests, I have had the benefit of detailed practice reviews conducted by the Department of Children and Families. These reviews “focus on continuous improvement, public accountability and enhanced outcomes for children”, with a view to learning what might be done to keep families safer.132 I am grateful for, and commend, the Department’s efforts in preparing and providing these very helpful reviews.

241. As with the NT Police domestic violence death reviews discussed above, it is my view that these reviews should be embedded into DCF practice and procedure.

242. I understand that pursuant to Initiative 35 of the DFSV Reduction Strategy, the Government has committed to establishing and implementing a systemic DFSV death review process and, given the 131 Affidavit of AC Michael White dates 15 August 2025 [2-10] at [31].

132 Evidence of Joanne Green on 19 August 2025 at T30.

commitment to that process, I do not propose to make a separate recommendation to DCF in relation to this.133 Enhanced capability to receive information related to reports of DFV

243. The evidence in this Inquest identified that the two mandatory reports that had been made to the Department did not contain important information, including that Eileen had been detained in Ralph’s home on 26 August, and that there were firearms present in the home. When mandatory reports are made to our child protection agency, those reports should include all relevant information. When the report is being made by a police officer this information should include risk assessment documents and relevant SerPro narratives.

244. In their written submissions, both the NT Police Force and the Department of Children and Families supported a recommendation aimed at facilitating the provision of this information and, accordingly, I make this recommendation.

Recommendation 5: System architecture changes to enhance ability to receive information relating to DFV reports To the Department of Children and Families: That DCF make system architecture changes to prompt and enable people submitting reports relating to allegations of DFV to include copies of CRATs, PRSTs or other risk assessment documents and for Police reporters to submit relevant SerPro narratives (where information sharing restrictions permit).

133 Submissions on behalf of the Department of Children and Families, dated 20 February 2026 at [39]-[43].

Ensuring DFV specialists are involved in assessing reports to DCF

245. In her evidence, Seranie Gamble, the Executive Director of the DFSV Prevention Division, told me about a suggestion that had been made for a specialist DFV practitioner to be embedded at the DCF Central Intake Team, to provide a specialised DFV lens on the initial enquiries being made in response to mandatory reports to the Department.134 This is an excellent idea and it is supported by the Department in its submissions.

Accordingly, I make the following recommendation: Recommendation 6: Embedding a specialist DFV Practitioner at DCF Central Intake To the Department of Children and Families: That DCF embed a specialist DFV practitioner at Central Intake, to assist in assessing reports made alleging domestic or family violence. That specialist practitioner should have undertaken RAMF, Safe and Together and face-toface PARt training.

Prevent. Assist. Respond. Training

246. In addition to providing RAMF and Safe and Together training, the Department currently funds foundational DFSV training for its staff through PARt, WoSSCA and Dawn House.135 Having heard the evidence about the positive benefits of the PARt rollout to the Police response (discussed above), I am of the view that all DCF employees who are responding to DFSV in their day to day duties would benefit from undertaking this training. I understand that the Department is supportive 134 Evidence of Seranie Gamble on 21 August 2025 at T51.

135 Submissions on behalf of the Department of Children and Families dated 20 February 2026 at [69].

of consideration being given to this additional training136 and, accordingly, make the following recommendation.

247. I anticipate that, as a DFV informed program, Circuit Breaker staff in particular would be considered DCF employees who may respond to allegations of DFV in the course of their day to day duties and, accordingly, would be considered for PARt training.

Recommendation 7: Prevent. Assist. Respond. Training for DCF staff To the Department of Children and Families: That DCF consider rolling out face-to-face PARt training to all employees who may respond to allegations of domestic or family violence in the course of their day-to-day duties. This training should be followed by a scheduled program of online training by way of refresher and/or supplementary PARt modules.

Non-government services Support for people experiencing relationship problems or family separation: current services are crisis-driven rather than being preventative

248. Ralph and Eileen accessed counselling services with Relationships Australia NT in March to May 2022. That service is funded by the Commonwealth for the following programs relevant to assisting couples:137 a. Family and relationships Services: Counselling & Group Education which aims to strengthen family relationships, prevent breakdown and ensure wellbeing and safety of children through to provision of 136 Submissions on behalf of the Department of Children and Families dated 20 February 2026 at [68]-[70].

137 Letter of Nathalia Perez Alfonso dated 19 August 2025 [3-13A], at p3.

broad-based counselling and education to families of different forms and sizes.

b. Family Law Counselling: Help couples and families to manage relationship issues arising from relationship changes, separation and divorce. Counselling services will focus on the needs of children.

c. Family Relationships Centre: FRCs are a gateway to broader family law and family support service system. Objectives: Give intact families help with family relationships and parenting through information and referrals. Support separating families to achieve workable parenting arrangements (outside of court). Support family dispute resolution services.

d. Regional Family Dispute Resolution Services: Meet particular needs of regional communities, providing services to help separating families resolve disputes and reach agreement on parenting and property. Services include dispute resolution, education, information and counselling.

249. The demand for Relationships Australia NT’s counselling services is consistently higher than the organisation can meet, and this has been an ongoing issue. To protect staff wellbeing and sustain service quality, counsellors are limited to seeing four clients a day, with at least one of those being a new client. The complexity of presentations is often high, and counsellors must also complete mandatory reporting, risk management, and associated administration. New clients can usually be offered an appointment within one to two weeks, but when waitlists are in place, it can take up to six weeks for a new client to be seen.138

250. The evidence from Relationships Australia was that they could have done more to help Ralph and Eileen if they were better resourced to provide more services. In particular, if they had: 138 Letter of Nathalia Perez Alfonso dated 19 August 2025 [3-13A] at p5.

a. a specialist family and domestic violence counsellor or worker who was specially qualified to identify domestic violence risk,139 and b. funding for early intervention casework services, to engage individuals when there is evidence of initial stages of potential abuse.

251. Specifically, Ralph and Eileen could have been better supported by access to case management, alongside counselling.

252. Nathalia Perez Alfonso, the Director of Practice Quality at Relationships Australia NT, told me that it was “huge” that Ralph had engaged in counselling,140 “…and the learning was starting to come through. But you cannot keep a person coming with an appointment-based thing…you have to go to them as well.”

253. Case management could have supported his and Eileen’s ongoing participation, strengthened safety planning and enabled warm referrals to other relevant services. It would also have allowed for a more holistic response by looking at broader needs, like Eileen’s pregnancy and Ralph’s alcohol abuse. Practical supports could have been progressed, like health connections, alcohol support services and early parenting resources, all of which may have reduced the stressors in Ralph and Eileen’s relationship, and, importantly, improved their engagement in counselling. Unfortunately, Relationship Australia NT’s funding only allows for counselling.141

254. The evidence I received from Relationships Australia NT was that for clients in the position that Ralph and Eileen were when they sought counselling in 2022, where domestic and family violence is emerging and not fully acknowledged, group educational programs focusing on building knowledge, self-reflection and skills would be valuable in 139 Evidence of Nathalia Perez Alfonso on 20 August 2025 at T46.

140 Evidence of Nathalia Perez Alfonso on 20 August 2025 at T47.

141 Letter of Nathalia Perez Alfonso dated 19 August 2025 [3-13A] at p2.

helping them to participate more effectively in counselling and move away from unhealthy patterns that lead to violence. Relationships Australia NT is not funded for this type of program, and most other services in the NT are focused on crisis intervention. At the time they contacted Relationships Australia in 2022, Ralph and Eileen were not yet in crisis.142

255. This is a significant issue.

256. Nathalia Perez Alfonso said that:143 “The unmet need in Darwin is provision of early intervention and preventative programs that could assist more couples with FDV identified within first steps in seeking assistance.”

257. That is, the focus of current service provision is crisis-driven rather than being preventative.144 This may be the product of a sector that is under resourced: services flow to the points of crisis, and there is not enough left to undertake the early intervention/prevention work.

258. Ralph told his brother that he had tried to get help, but the service he called did not call him back. Ana Aitcheson, the CEO of Dawn House said:145 “I’d love to see more support for the men in their earlier stages so that we don’t get to this stage [of needing men’s behaviour change programs for perpetrators]. I think that that’s a key gap in terms of accessibility for the men” “…As soon as they identify they need the support, they should be able to access that support.” 142 Letter of Nathalia Perez Alfonso dated 19 August 2025 [3-13A] at p2.

143 Letter of Nathalia Perez Alfonso dated 19 August 2025 [3-13A] at p5.

144 See evidence of Nathalia Perez Alfonso on 20 August 2025 at T46-47.

145 Evidence of Ana Aitcheson on 22 August 2025 at T45, 60.

259. I understand that DCF currently funds twelve DFSV specialist counsellors in the Territory, through existing DFSV specialist services, and supports funding specialist DFSV counsellors through a merit-based process. Given the high level of need for this type of support, I recommend an increase in the number of specialist DFSV counsellors funded by the Department.

Recommendation 8: Increased number of specialist DFV counsellors To the NT Government: That the NT Government provide funding for an increased number of specialist DFV counsellors to be employed (following merit-based processes) by a range of services across the Territory, such as Relationships Australia NT. The NT Government should ensure that the services include organisations likely to be accessed by a range of people, including men and women, Aboriginal and non Aboriginal people, in both remote and urban areas.

Online resource for families experiencing breakdown

260. Ralph was frustrated and angry about being separated from his child and sought help to put a parenting agreement in place. Unfortunately, this did not progress beyond his initial enquiry with Relationships Australia.

261. Counsel Assisting me proposed a recommendation aimed at assisting people experiencing family breakdown to understand what resources and services are available to support them through that process. It was framed in the following terms: Proposed recommendation: That the NT Government give consideration to developing a website with easily accessible information about supports available for men and women experiencing family breakdown, including:

(a) an outline of available supports,

(b) contact details for relevant support services in each area, and

(c) contacts for legal support services.

The NT Government should then consider a social media and general community education campaign to raise awareness of this website.

262. In responding to that proposed recommendation, the Department of Children and Families indicated that it is in the process of updating its website to include further information about available support services.

Now that DCF has had the opportunity to consider the terms of the proposed recommendation, I am hopeful that it will update its website in a way that is consistent with the intention of the proposed recommendation, and no further recommendation is needed.

Accommodation for women experiencing, or at risk of experiencing violence

263. Prior to the shooting, Eileen was effectively homeless. Her experience highlights that for some women, including educated, English speaking, capable, resilient, and resourceful women, like Eileen, who are at risk of experiencing domestic violence, have nowhere else to go.

264. Ana Aitcheson, the CEO of Dawn House told me that they turn away women every single day, because they do not have enough beds. She said that on average, they have to turn away 100-200 women per month who reach out to them and usually turn away women the first time they call, because “he hasn’t hurt you enough yet” or “you’re not in immediate risk of death”.146 Sometimes they are able to accommodate women in hotels when police call them after hours about a woman who needs to flee “right now”. This can result in a heightened risk because they have 146 Evidence of Ana Aitcheson on 22 August 2025 at T58-60.

fled for one night but cannot be accommodated beyond that night, so may have to return to the danger they escaped from.147

265. For those in crisis, the resources are inadequate. In addition to the realworld consequences for the women who are turned away, I am mindful of the effect that this has on the workers at Dawn House, who are “triaging” who is the most at risk and gets a safe bed to sleep in, and who does not.

266. This is unacceptable.

267. As indicated above, the Government has committed to an increase in its funding to DFV homelessness services, from $0.95 million to three services in FY2024/2025, to $5.453 million to six services in FY2025/2026. Ms Gamble told me that Eileen would have been eligible for the associated housing pathways program, which assists people experiencing DFSV to access private accommodation.148

268. This is very positive and will hopefully help women in the situation that Eileen was initially in; that is, who need alternative accommodation but are not at crisis point.

269. For the Darwin women who are in crisis and need to flee, Dawn House currently remains unable to help them all. I heard about $6.5 million in infrastructure funding that had been promised since 2021 for Dawn House to replace aging crisis accommodation, to increase its crisis accommodation capacity, from six crisis shelters to ten, and to provide disability access rooms. I was also told that in the 2025 budget, that funding had been removed, without warning or explanation. This was understandably devastating for Dawn House and all who rely on its crisis services. Dawn House needs that infrastructure funding (plus more for staffing and other costs) if it is to have capacity to meet the need for its crisis accommodation services.

147 Evidence of Ana Aitcheson on 22 August 2025 at T57.

148 Evidence of Seranie Gamble on 21 August 2025 at T45.

270. I understand that the Department is supportive of a recommendation that this infrastructure funding be restored, but it is obviously a decision for the Government.

Recommendation 9: Restoration of DLI funding to Dawn House To the NT Government: That the NT Government urgently restore the $6.5m Department of Logistics and Infrastructure funding to Dawn house to upgrade its facility and increase its number of shelters.

Availability of services for men using, or at risk of using violence

271. In the Territory, there is a lack of adequate services for men who are using or at risk of using violence.149

272. I understand that in Darwin, the services are: a. Men’s Shed, which has limited capacity150 b. Darwin Indigenous Men’s Service, which is an Aboriginal focused men’s space, and c. CatholicCare’s No More program, which is a prevention program.

273. Ms Gamble told me that the NT Government makes small grants for Men’s Spaces, through the Department of People, Sport and Culture. She said that these grants are for very small initiatives, and the program has been oversubscribed. In a positive development, some of the new DFSV 149 Evidence of Seranie Gamble on 21 August 2025 at T55.

150 Evidence of Senior Constable O on 18 August 2025 at T56.

funding will be allocated to that Department to try to increase these locally based men’s initiatives.151

274. Recommendation 29 of the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood was directed to funding and development of men’s community-based programs and prevention related activities. That recommendation was supported by the Government.152

275. The response to the domestic and family violence crisis must involve making appropriate programs available to all men using violence, or at risk of using violence. I am of the view that there needs to be a thorough review of what programs and services are available for men using or at risk of using violence, and for the Government to commit to addressing identified unmet need in that area. The Department has told me that a review of this type aligns with work that is currently being undertaken,153 so a specific recommendation is not required.

Men’s Behaviour Change Programs

276. There are currently two established Men’s Behaviour Change Programs (MBCPs) operating in the Territory: a Darwin based program run by CatholicCare, and Tangentyere’s Alice Springs program. Between 1 July 2024 and 31 December 2024, 456 referrals were made to these MBCPs and 313 were assessed as eligible.154 Clearly, this number of referrals in just two locations reflects a huge demand for this type of program.

151 Evidence of Seranie Gamble on 21 August 2025 at T41.

152 Attorney-General’s Report to the Legislative Assembly Pursuant to section 46B of the Coroners Act 1993 In the matter of the Coroner’s Findings and Recommendations regarding the deaths of Miss Yunupingu, Ngeygo Ragurrk, Kumarn Rabuntja [sic] and Kumanjayi Haywood, Legislative Assembly Tabled Paper, 29 July 2025 [8-16] at p8; Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [227].

153 Submissions on behalf of the Department of Children and Families dated 20 February 2026 at [50].

154 Affidavit of Seranie Gamble dated 15 August 2025 at [63].

277. A further MBCP is under development in Katherine, led by Wurli Wurlinjang Aboriginal Health Service.

278. These programs are supported by NT Government funding and National Partnership Agreement funding. Under Action Plan 2, additional funding of $5.32 million was allocated to support these services to increase their program capacity, in addition to $1.14 million annual ongoing funding.155

279. I considered the importance of Men’s Behaviour Change Programs as part of the response to the domestic and family violence in the Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14 at [681]-[692].

280. In this Inquest, I received evidence from CatholicCare about the operation of its MBCP. I heard that they run a program in Wadeye and one in Berrimah, with twelve men in each session, and 65-75% of participants are there because a Court has ordered them to participate.

In the twelve months to August 2025, twenty-four men had completed the CatholicCare program. At the time of the evidence, there were 65 men on the waiting list to start the program.156

281. I also heard that staffing issues were preventing CatholicCare from running at full capacity,157 and from starting an intended third group in Palmerston.158

282. Beyond that intended Palmerston group, CatholicCare currently has no plan to expand its MBCP services; however, they expect that the new Darwin co-responder program will result in an increase in the number of referrals it receives.159 155 Affidavit of Seranie Gamble dated 15 August 2025 at [64].

156 Evidence of Lorraine House and Tomas Hansford on 21 August 2025 at T21, T24.

157 Evidence of Tomas Hansford on 21 August 2025 at T22.

158 Evidence of Lorraine House on 21 August 2025 at T22.

159 Evidence of Lorraine House on 21 August 2025 at T17.

283. There is a “linked” women’s safety worker at Dawn House, who works with the partners or ex partners of the men undertaking the CatholicCare MBCP. That role is “always at capacity”, and I heard that Dawn House could do with four workers filling that role, because of the level of demand.160

284. The Australia's National Research Organisation for Women's Safety (ANROWS) undertook a process evaluation of the Tangentyere and CatholicCare MBCPs in 2023.

285. ANROWS concluded that the two behavioural change programs play an important role in the domestic and family violence service system in the Territory and are valued by community and service-system stakeholders, by program participants and their (ex)partners, who were interviewed for the evaluation. The programs were found to be delivering quality practice in relation to the prioritisation of women’s safety support; the ability to provide flexible responses to men, in addition to group work; and their commitment to continuous learning and improvement.161

286. ANROWS made a number of recommendations, one of which was that:162 “The NT Government should fund and support the NT MBCPs to prepare for and participate in an outcome evaluation of the programs.”

287. The recommendation contained specific detail for how the MBCPs should prepare for this evaluation.

288. It is entirely sensible that an outcome evaluation should be undertaken.

It is important that the limited resources that are available to respond to this crisis are being used in the most effective way. Funding decisions should be data-based.

160 Evidence of Ana Aitcheson on 22 August 2025 at T46.

161 See affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [232]-[233].

162 ANROWS Evaluation Report Evaluation of the NT’s men’s behaviour change programs April 2025 [8-17] at p34.

289. The Government has committed to an outcome evaluation in initiative 13 of the DFSV Strategy 2025-2028, and the Department of Children and Families supports a recommendation to give effect to the ANROWS recommendation.

Recommendation 10: Outcome evaluation for NT Men’s Behavioural Change Programs To the NT Government: With respect to Men’s Behavioural Change Programs (MBCPs), the NT Government should implement the ANROWS recommendation for an outcome evaluation of the NT MBCP programs.

The NT DFSV workforce

290. A recurring issue in this and previous inquests has been the chronic skills shortage affecting DFSV services in the Territory, both in recruiting and retaining staff, and in the interpreting services. In previous domestic violence inquests, I made recommendations about workforce planning in the DFSV sector and the Aboriginal Interpreter Service.163

291. I heard that, in response to my previous recommendation concerning the DFSV workforce, the following work has been undertaken, or commitments have been made:164 a. DCF has finalised a new funding agreement with Charles Darwin University (CDU) for $0.9 million in relation to the creation of a unit on supporting victim-survivors of DFSV, 163 Recommendations 3 and 4 of Inquests into the deaths of Miss Yunupiŋu, Ngeygo Ragurrk, Kumarn Rubuntja and Kumanjayi Haywood [2024] NTLC 14.

164 Affidavit of Seranie Gamble dated 15 August 2025 [7-2] at [184]-[191].

b. CDU will undertake a review of a further three units in the Graduate Certificate of Safe Communities (Child Protection) to include DFSV content and updated resources, c. CDU is to develop a new standalone Graduate Certificate in DFSV Response, d. a research repository and sustainable research unit is being established within CDU, to be known as the NT DFSV Knowledge Exchange. This will be an online platform, and e. DCF is amending its own workforce plan in relation to its remote DFSV workforce, consistent with my previous recommendation.

292. This is positive progress; however, given the size of the problem, I think that it is important that an evaluation should be undertaken to see what more can be done.

FINAL REMARKS

293. Ralph Donald’s acts of violence towards himself and Eileen were brutal and tragic. While lucky to survive, Eileen still lives with physical injuries and significant emotional trauma. Ralph’s family, including his young daughter, have all suffered the grief of losing him, and the trauma caused by the way that he died.

294. Those close to Ralph were completely shocked by his actions, including Eileen. Undoubtedly, the police officers who had interacted with Ralph and Eileen in the months before his death were shocked too.

295. His actions were heinous; but must be understood in the context of his escalating coercive control towards Eileen, and his anger and frustration about being separated from his baby, and not knowing what he could do about it. The CRAT completed on 21 September 2023 correctly assessed Eileen as being at high risk; but unfortunately, neither she nor most of

the people she sought help from recognised how serious the risk actually was, as Ralph had never been seriously physically violent to her.

296. Eileen’s evidence in this Inquest was incredibly helpful. It was a powerful example of what coercive control looks like, how debilitating it can be and how difficult it can be to escape from. The tragic outcome of her experience demonstrates how seriously we should take coercive control, it is as serious as physical violence and is a known pathway to domestic homicide.

297. I am very grateful to Eileen and to Ralph’s mother Nerissa, brothers Charles and Angus, and sister Alissa who provided evidence and assistance to this Inquest. They continue to grieve, but want to help this process in the hope that men like Ralph can be better supported and have better access to the right services. They each showed tremendous courage and grace, and compassion towards each other.

298. There is still much work to be done in strengthening our response to the domestic and family violence crisis, but there is an enormous amount of goodwill between the different agencies and services in this space, and a lot of good work underway.

299. I make recommendations today in the sincere hope that they will assist those working in this space and complement the work that is already being done. I hope that they will be implemented fully and will assist in achieving meaningful, long-term change that will save lives.

FORMAL FINDINGS

300. Pursuant to Section 34 of the Coroners Act I make the following formal findings:

(a) The identity of the deceased is Ralph Donald, born on 6 August 1988 at Royal Darwin Hospital, in the Northern Territory.

(b) The time of death was 6:36pm on 3 October 2023. The place of death was 10 Sprigg Street, Milner, in the Northern Territory.

(c) The cause of death was a self-inflicted gunshot wound to the head.

(d) The further particulars required to register the death under the Births, Deaths and Marriages Registration Act are: i. The deceased was not of Australian Aboriginal or Torres Strait Islander origin.

ii. The deceased’s usual occupation was tyre fitter.

iii. The cause of death was confirmed by a post-mortem examination conducted by Forensic Pathologist Dr John Rutherford.

iv. The deceased’s mother is Nerissa Donald, and his father was John Andrew Donald.

RECOMMENDATIONS Recommendation 1: Domestic and Family Violence Death Review Team To the NT Government: That (in line with other State/Territory jurisdictions, eg NSW), the NT Government establish and sufficiently fund a multi-agency Domestic and Family Violence Death Review Team (DFVDRT) to review deaths occurring in the context of domestic violence in the Northern Territory.

The DFVDRT should (in line with other State/Territory jurisdictions, eg NSW) be convened by the NT Coroner or Deputy Coroner and include representatives from any or all of the following: a. Aboriginal (ACCO) service providers, b. NT Police, c. Department of Children and Families, d. NT Corrections, e. NT Health, f. NAAJA, g. NT Legal Aid, h. Department of Education, i. Non-Government sector experts and non-government service providers, and j. Lived experience experts.

Part 9 of the Coroners Act 2009 (NSW) should inform the establishment, functions, obligations and powers of the DFVDRT, including the duty of persons to assist the team with full and unrestricted access to relevant records (see s101L).

The DFVDRT should be empowered and resourced to, when considered appropriate, engage directly with a deceased person’s family and community to acknowledge their loss and to inform the review process.

Recommendation 2: Prioritisation of face-to-face PARt To the Northern Territory Police Force: The NT Police Force should continue its roll-out of Prevent. Assist. Respond.

training (PARt). In doing so, the NT Police Force should: a. prioritise delivery of the face-to-face component of PARt training to any police officer who may respond to incidents involving domestic, family or sexual violence in the course of their day-to-day duties and for any JESCC call taker who has not completed PARt; b. endeavour to have all NT Police officers and auxiliaries undertake initial PARt by way of face-to-face training, to be followed by a program of refresher and/or supplementary online modules; c. further to the recommendation made in Findings in the Inquest into the death of Domestic violence victim (Jingili Water Gardens) 17.01.25, in relation to all serving police officers who are identified as falling substantially short of expected standards, when responding to or supervising responses to domestic and family violence incidents, the NT Police Force should ensure that these officers are fast tracked for and rostered to complete face-to-face PARt training, if they have not already done so.

Recommendation 3: Inclusion of relevant information in SupportLink referrals To the Northern Territory Police Force: That NT Police: a. explore with SupportLink Australia Ltd whether the following system architecture changes can be made to the SupportLink system: i. to prompt and enable referrers to include CRATs, PRSTs or other risk assessment documents, and relevant SerPro narratives when submitting SupportLink referrals, and ii. to prompt and enable referrers to indicate whether it is safe to send and/or leave a message on the contact phone number for the person being referred and/or whether there is an alternative contact number that can be used safely; and b. if these changes are made, that NT Police update the Domestic and Family Violence General Order to require members, where possible, to upload these documents and record this information in SupportLink referrals.

Recommendation 4: Legislative change to give police increased powers to seize firearms when investigating complaints of domestic and family violence To the NT Government: That the NT Government effect legislative change to give police the discretion to seize firearms when officers are lawfully in a dwelling to investigate a DFV complaint. Such legislative change may require a commensurate increase in police resourcing to ensure such seizures can be effected in a way that minimises risk.

Recommendation 5: System architecture changes to enhance ability to receive information relating to DFV reports To the Department of Children and Families: That DCF make system architecture changes to prompt and enable people submitting reports relating to allegations of DFV to include copies of CRATs, PRSTs or other risk assessment documents and for Police reporters to submit relevant SerPro narratives (where information sharing restrictions permit).

Recommendation 6: Embedding a specialist DFV Practitioner at DCF Central Intake To the Department of Children and Families: That DCF embed a specialist DFV practitioner at Central Intake, to assist in assessing reports made alleging domestic or family violence. That specialist practitioner should have undertaken RAMF, Safe and Together and face-toface PARt training.

Recommendation 7: Prevent. Assist. Respond. Training for DCF staff To the Department of Children and Families: That DCF consider rolling out face-to-face PARt training to all employees who may respond to allegations of domestic or family violence in the course of their day-to-day duties. This training should be followed by a scheduled program of online training by way of refresher and/or supplementary PARt modules.

Recommendation 8: Increased number of specialist DFV counsellors To the NT Government: That the NT Government provide funding for an increased number of specialist DFV counsellors to be employed (following merit-based processes) by a range of services across the Territory, such as Relationships Australia NT. The NT Government should ensure that the services include organisations likely to be accessed by a range of people, including men and women, Aboriginal and non Aboriginal people, in both remote and urban areas.

Recommendation 9: Restoration of DLI funding to Dawn House To the NT Government: That the NT Government urgently restore the $6.5m Department of Logistics and Infrastructure funding to Dawn house to upgrade its facility and increase its number of shelters.

Recommendation 10: Outcome evaluation for NT Men’s Behavioural Change Programs To the NT Government: With respect to Men’s Behavioural Change Programs (MBCPs), the NT Government should implement the ANROWS recommendation for an outcome evaluation of the NT MBCP programs.