DM

OFFICE OF THE STATE CORONER FINDINGS OF INVESTIGATION CITATION: Non-inquest findings into the death of DM TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2011/2140 DELIVERED ON: 9 February 2016 DELIVERED AT: Brisbane FINDINGS OF: John Lock, Deputy State Coroner CATCHWORDS: Coroners: Domestic violence, response by agencies to violence, recommendations, ‘Not Now, Not Ever’

Contents Not Now, Not Ever: Putting an End to Domestic and Family Violence in

Background to the death At the time of her death, DM was aged 35. She resided with her husband, B at a residence at Oakey. She had been in a relationship with B since about 1997 and they married in about 2005. At the commencement of their relationship, DM already had one child. During the course of their relationship, DM and B had a further eight children together.

Over the years, DM and B lived in a number of towns across Queensland, including Bundaberg, Cunnamulla, Dalby, Charleville and Chinchilla before they eventually settled in Oakey.

There was a very extensive history of domestic violence dating from about 1998 perpetrated by B against DM, with the children being removed from their care in 2009 because of concerns regarding their safety as a result of this abuse.

Circumstances of the death Between 4.30pm and 5.30pm on 26 June 2011, police were called to attend 56 Donely Street in Oakey, in response to a domestic incident between DM and B.

B’s biological mother, was at the house at the time along with four other people. DM was heard to say ‘B has said that he is going to cut my head off and put it in my mum’s mail box’.

They saw B punch DM in the right side of the head with his right fist. DM tried to block his punch by putting her hands up to shield her face and head. B then punched DM to the left side of the head. He then jumped on DM like he was kneeing her in the stomach. DM was yelling, ‘Help me, help me’. DM’s mother yelled at B to let DM go.

Someone asked B what he was doing and, as a result, B became aggressive towards that person and pushed him on the chest. He stumbled down the stairs, preventing him from intervening and aiding DM.

DM’s mother then heard B in the kitchen; she could hear the cutlery drawer opening.

DM yelled out ‘He’s getting a knife’. At this time, and due to the known violent nature of B, the occupants of the house ran from the house and telephoned triple zero.

B was then heard screaming at DM. DM was heard to yell out ‘don’t hit me, stop hitting me’. Police arrived shortly after and were directed by the witnesses to the upstairs kitchen area of the dwelling.

Police located B in the upstairs kitchen standing over DM. He was observed to be upset, wailing and crying. DM was on the ground on her back and police observed large amounts of blood.

Both police and ambulance officers commenced CPR in an attempt to revive her, but these attempts were unsuccessful and DM was declared deceased at 5:30pm.

Police observed DM to have significant facial injuries and a stab wound. B said to police that:  he had bitten DM  she had bitten him back  they had wrestled  he had a knife, and  he had thrown the knife over the fence.

Findings of the investigation into the death of DM 1

Autopsy External and full internal examinations were conducted on 28 June 2011 by forensic pathologist, Dr Phillip Storey.

Dr Storey noted evidence of two recent incised wounds:

1. To the left outer rear chest wall – this stab wound penetrated the full thickness of the chest wall between the left seventh and eighth ribs. There was a subsequent internal path for the incised wound through the substance of the left lung and then through the descending thoracic aorta to pass for a short distance into the substance of the right lung. The left lung had collapsed, and there has been some bleeding into that lung.

The descending thoracic aorta is a portion of the aorta. This is the major artery that takes blood away from the heart and it is under the full pressure of the pumping action of the heart. If the aorta is penetrated, then blood can pass rapidly out under pressure with the potential for rapid and life-threatening loss of blood from the circulation. Blood has flowed out from the aorta into each chest cavity. There has been a measured loss of 600mls of blood into each chest cavity. The loss of this amount of blood acutely from the circulation, together with some external blood loss through the chest wall wound, would be expected to be associated with clinical shock and to be life threatening.

The appearance of the wound suggested to Dr Storey that a mild to moderate degree of force would have been used in causing the wound.

2. There was a second incised wound located just lateral to the right side of the mouth. It penetrated through the skin of the right cheek to enter the oral cavity.

In addition to the incised wounds, Dr Storey noticed other recent physical injury including:  A skin defect at the right temporal region which showed features of blunt force trauma. A piece of skin was completely missing;  Injuries to the mouth and lower lip consistent with a blow to the front of the face;  Scattered abrasions to the face;  Bruising and swelling to the left side of the face;  Localised bruising to the front of the neck one of which has a small scratch abrasion, the appearance suggested pressure at the neck by fingers;  A bruise above the right breast.

Toxicology testing detected amphetamine and methamphetamine at non-toxic levels and a therapeutic level of diazepam. No alcohol was detected.

Dr Storey opined that the most significant physical injury was the stab wound to the chest wall. This wound had resulted in the penetration of both lungs but, more significantly, had passed through the descending thoracic aorta resulting in catastrophic acute blood loss into the chest cavity and subsequently death.

The formal cause of death was determined to be as a result of the stab wound to the chest.

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Criminal proceedings The day after DM’s death, police charged B with her murder. This charge has proceeded through the criminal courts. There was considerable delay in the proceedings initially related to concerns as to B’s capacity to instruct his lawyers. The matter subsequently was heard at a trial and B was found guilty on 24 November 2014.

An appeal against conviction was lodged and this was dismissed on 28 August 2015.

He has been sentenced to mandatory life imprisonment.

Domestic violence history The history of violence between DM and B was extensive, including significant physical, emotional, psychological and verbal abuse.

This aspect of the investigation was completed by members of the Office of the State Coroner Domestic and Family Violence Death Review Unit. The extensive history is best demonstrated by the following timeline: 1998 February  B charged with assaulting a pregnant DM after punching and kicking her in the face and fracturing her jaw in two places, requiring hospitalisation.

 DM later withdrew her complaint to police.

December  B charged with wounding DM after she returned home and was accused by him of sleeping with other men.

 B punched DM in the face and she retreated to the bathroom.

 B then opened the bathroom door with a knife and punched DM again. He then placed his hands around her throat and squeezed hard so she could not breathe.

 B produced a knife and held it against her throat.

 DM bent over in an attempt to breathe and B punched her again in the head and stabbed her in the right ear. He then continued to punch her several more times.

 Police charged B with unlawful wounding, though the charge was later withdrawn as no evidence was offered in relation to this charge at the Magistrates Court.

1999 March  B charged with a breach of the Domestic and Family Violence Protection Act as the respondent.

July  B charged with a breach of the Domestic and Family Violence Protection Act, after an incident in which B entered the room DM was sleeping in and struck her in the head with a glass.

2000  The couple separated with B taking his son and commencing a relationship with another partner which was also characterised by domestic and family violence.

 A few weeks prior to this separation B reportedly stabbed DM in the ear with a bread and butter knife.

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2001 March  B charged with assault, deprivation of liberty and a breach of the Domestic Violence and Family Protection Act, as the respondent.

October  DM presented to Oakey Hospital with injuries from a domestic violence related assault and was admitted overnight. She did not wish police to be informed.

2003 June  B punched DM in the head, resulting in swelling to her eye. Police were called to attend and applied for a Domestic Violence Order (DVO) naming B as the respondent and DM as the aggrieved.

 B admitted to punching DM. DM did not wish to make a criminal complaint.

The DVO was registered in Toowoomba and Oakey Magistrates Courts.

August  B charged with assault and a breach of the Domestic and Family Violence Protection Act.

2004 May  Police were called to attend a domestic dispute between B and DM. Notes indicate no signs of domestic violence, and the incident was recorded as a verbal argument.

June  B punched DM in the head and upper body while she was driving the car.

He then grabbed DM by the head and pushed her down into the centre console of the car.

 DM stopped the car and B attempted to pull her out of the vehicle by her shirt.

 During the incident, DM’s shirt was ripped off and she was left by the side of the road wearing just a bra and lower clothing.

 Queensland Ambulance were escorted by police to attend and provide treatment to DM on this occasion.

 Multiple bruises were noted all over her body and head requiring treatment at Bundaberg Hospital. DM had contacted the police to seek assistance with accommodation.

July  DM sought refuge with the Bundaberg District Women’s Domestic Violence Service after B assaulted her. She started working with Department of Child Safety in relation to this abuse.

 Information from Bundaberg Women’s Refuge to police reported that B had punched DM who was pregnant at the time, in the face.

 DM also stated that one of the children had been punched in the face by B.

 DM said she did not wish to make a formal complaint or provide a statement to police, though she sought medical assistance through Bundaberg Hospital.

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August  Private application for DVO in the Bundaberg Magistrates Court listing B as the respondent and DM as the aggrieved.

September  DM attended the Roma police station and asked for assistance to retrieve her car from her residence.

 Police noted DM had a swollen finger as a result of an altercation with B.

 Police attended the address with DM and as she attempted to drive away from the residence, B punched her car window causing it to smash.

 B charged with a breach of the Domestic and Family Protection Act.

 Nine days later police were called out again and DM told police that B had punched her in the face. Police observed injuries, but noted that DM was uncooperative.

 District police highlighted the repeat calls for service as an issue, and sought consent for a referral to a domestic violence service.

2007 March  The children’s grandmother presented at a police station with the couple’s children and reported they were victims of domestic and family violence and alcohol abuse, with the oldest child contemplating suicide.

May  DM told B she was going to have a shower and refused him entry into the shower with her. He retaliated by punching her in the head three times.

 DM attempted to get away from him by running to the bedroom, however, B gained access through another door and attempted to attack DM with a knife. DM ran to neighbours for help.

 B was charged with assault, with police making an application for a protection order listing B as the respondent.

 Police also made a referral to the Toowoomba Domestic and Family Violence Prevention service, she told them that she was overwhelmed with the children but had support and would follow up with them if she needed assistance.

 The following day DM also contacted DV Connect for support saying that B had hit her and chased her and her sister in law with butcher’s knives.

They arranged refuge accommodation for her.

 B was incarcerated for 17 months from mid-2007 for assault occasioning bodily harm with a weapon.

 Whilst incarcerated B completed a number of courses, including those focused on developing healthy relationships and building parenting skills.

2008 September  DM called DV Connect after being referred by Centrelink because she was seeking a crisis payment as she wanted to relocate to an interstate refuge as B was due to be released from prison in a couple of weeks.

 She believed that he would come after her on release as he had made threats against her and his family were also threatening her. She was also seeking support through an Aboriginal Health worker at this time.

 Refuge was arranged for her in Tamworth.

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2009 July  DM picked B up from Chinchilla and they started driving to Bundaberg with four children in the car. They became involved in a verbal argument and B accused her of lying and called her a ‘slut’ and a ‘dog’.

 B grabbed DM by the hair and dragged her towards him. B put her head under his arm in a headlock position, maintaining this hold for approximately 20-30kms.

 B told DM that he was going to stop the car near the sugar cane field and kill her.

August  B punched DM in the face while she was driving the car with three of their children, which caused her to veer onto the wrong side of the road.

 B decided to take over driving but continued to punch DM in the head as he drove and said he would put her in a coma and then he would throw her out of the vehicle.

 B then pulled the car over and put DM in the boot as he didn’t want her to yell out or get police attention.

 B then told DM to get out of the boot and back into the car, stating ‘I shouldn’t be putting the woman I love into the boot of the car’.

 This incident was reported three days later to police who made an application for a DVO, listing B as the respondent.

October  DM presented to Oakey Hospital with injuries to her right hand and wrist as a result of an assault by B that lasted for over four hours. He reportedly crushed her hand, bruised her neck and tried to wrap a pillow around her face. The hospital referred her for counselling with a social worker.

 Ten days later, DM told police B kicked her in the right hip and back of her right leg as she was lying on a mattress on the floor of their residence.

 B then laid down beside DM and punched her in the back of the head three times.

 DM tried to retaliate and punched B in the head. B then verbally abused DM for not visiting him while he was in jail and accused her of sleeping with other men.

 DM went into the bedroom and B followed her and placed his foot on her head and twisted down on her ear. B then grabbed DM by the mouth with his hand.

 At this point three of their daughters entered the bedroom and B picked up one of them by her hair and lifted her approximately 6 inches off the ground and moved her towards the bedroom door.

 B charged with a breach of the Domestic and Family Violence Protection Act.

 Child Safety removed all children shortly after this assault on the daughter, following a report by Queensland Health.

 Police referred DM to the Toowoomba Domestic and Family Violence Prevention Service at this time. DM reported that everything was OK and she was staying with her mum and did not want to talk.

December  DM attended an appointment at the Toowoomba Domestic and Family Violence Prevention Service, but did not attend a follow up appointment the week after.

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2010 February  DM told hospital staff that she was separated from B because he was destructive at an antenatal appointment, requesting a referral for alcohol and drug treatment services for her alcohol use.

May  Toowoomba Hospital received an Unborn Child High Risk Alert because of risk concerns related to the couple’s substance abuse, B’s violent perpetration and the couple’s failure to engage with Child Safety Services.

March  After a few days of heavy alcohol and amphetamine misuse, DM and B were simultaneously admitted to Toowoomba hospital after a domestic violence incident, in which he had cut his arm. She alleged that she had hit herself in the head with a beer bottle.

 A week later B located DM in the kitchen and kicked her in the stomach causing her to fall back after she had been socialising at home with friends.

 B proceeded to punch her several times in the head with a clenched fist.

DM was pregnant at this time.

 A private application for a domestic violence protection order was taken out in the Oakey Magistrates Court with B listed as the respondent and DM as the aggrieved.

April  A temporary domestic violence protection order was granted in the Oakey Magistrates Court, with B listed as the respondent.

June  The couple had another daughter, who was removed shortly after birth by Child Safety Services. The couple reportedly separated a few weeks later and he had a relationship with another partner.

2011 April  B assaulted DM in the front seat of the car whilst she was pregnant, threatening to tie her up to a tree and kill her.

 She started panicking and went into labour. B refused to let her go to hospital. He has delivered the baby in a shed, and a friend convinced them to take the baby to the Dalby Hospital.

 They admitted DM under a false name, with B staying outside the hospital with a knife, ringing her repeatedly.

 The baby was removed by Child Safety Services. B removed DM from the hospital before she could be treated.

 B was charged with a breach of the Domestic and Family Violence Protection Act.

May  DM was admitted to the Toowoomba Hospital with stab wounds to the neck which she alleged were accidental, though a friend later confirmed they were inflicted by B. Previous injuries and bruising around the neck were noted by staff, though DM denied this was from being strangled.

 DM was anxious about leaving B, although staff made a number of attempts to ensure she had a safe location away from B, she declined a referral to a DV service or refuge.

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 B had been admitted separately on an EEO after this incident because he had also self-harmed, and police were concerned that he was a threat to himself or others.

 B was at the hospital at this time and he has started shouting at her and other staff, requiring intervention from a security officer.

 After being admitted on an Involuntary Treatment Order, B was discharged from hospital a week later on the 16 May with a diagnosis of Adjustment Disorder, with multiple stressors noted (financial, increased alcohol misuse, relationship conflict and moderate depression).

 It was noted on clinical files that B posed a risk of impulsive self-harm or harm to others, however this risk was identified as low, as he was more stable and agreeable to take medication.

 There was another incident after this that went unreported in which B allegedly bashed DM and threw her over a fence according to witness statements.

June  Two days prior to her death, DM had an appointment with Child Safety and was excited as they told her if she successfully completed a number of courses she would have her children returned to her.

Other relevant criminal justice information The most serious court response B received in regard to perpetrating repeated acts of domestic violence and committing DV Order breaches was a conviction for assault occasioning bodily harm in 2007 after an incident in which he assaulted DM, chased her with a knife and threatened to kill her. He was convicted and sentenced to two years imprisonment for this incident.

In 2004, B was convicted for a breach of a protection order for which he received a fine.

B was also convicted of a breach of a protection order in 2010 receiving a sentence of six months, to be suspended for two years after serving two months.

B has an extensive criminal justice history outside the context of domestic and family violence, including resist arrest, incite, hinder or obstruct police, unlawful possession of a weapon and discharge of a weapon in a public place, producing, possessing and supplying dangerous drugs, drunk and disorderly, dangerous operation of a motor vehicle, wilful damage and assault on police.

He was also convicted for assault occasioning bodily harm in 2007 against another person, after he attacked an associate who had reportedly told DM that B was having a sexual relationship with another female.

DM also had a criminal justice history including several assault convictions (against other persons) in the mid 1990’s.

Identified issues for review Responses by the Queensland Police Service, Queensland Health, Child Safety Services and non-government domestic and family violence services to the reported incidents of domestic violence were reviewed in relation to this death. Given the extent of contact it is not possible to outline each response in specific detail, however a number of recurring issues were identified.

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On numerous occasions, police, health, child safety and domestic violence support services worked collaboratively in an attempt to provide DM protection from B’s ongoing violence. It was noted on many occasions that DM was reluctant to engage with these services, particularly over the longer term.

It is evident that she sometimes denied or minimized the extent of the abuse perpetrated against her by B which likely made it more difficult for services to provide an appropriate level of support or protection for her.

DM’s reluctance to engage with the police and other services was not unusual for a victim of domestic violence. Aggrieved persons are at times hesitant to utilise criminal justice system options in particular as they may lack confidence in its effectiveness for their situation1, they may delay reporting abuse to police because they fear a lack of support from them or they are afraid of retribution or further victimisation from the perpetrator2.

At times DM actively sought support from the police, whilst on other occasions she refused to engage or provide evidence in instances where police have attended.

According to family and friends, B would also reportedly manipulate and coerce DM into dropping charges against him for those incidents where he was charged with assault.

This reluctance to engage is further exacerbated amongst Aboriginal and Torres Strait Islander families and communities because of an ongoing fear and distrust of police, the justice system and other government agencies3. This is particularly salient in relation to a fear of having children removed, which remains a barrier to seeking assistance from government agencies or other mainstream services in relation to domestic and family violence.

DM separated from B multiple times, although the couple would reconcile after a few months apart. She told others that she would go back because B would threaten her family and friends, she didn’t have faith the system would protect her and that B would promise her that he would change. She would also say she had married B for better or worse and that he was the father of her children so she couldn’t leave him.

Many family and friends indicated in statements that they tried to encourage DM to leave B permanently. DM would often seek refuge with family members after an attack on her by B, which provided her with an immediate source of safety. Family members who witnessed the violence were at times hesitant to call the police because it would reportedly lead to an escalation in violence and they feared for their own safety. It is notable on many occasions they would attempt to assist through direct intervention, calling police or providing support after the event.

Recent recommendations surrounding domestic violence On 17 November 2014, Coroner Hutton handed down his findings in relation to the death of Noelene Buetel. It was found that Ms Beutel died as a result of violence inflicted on her by her partner. There was a long history of domestic violence between 1 Gillis et.al. (2006) Systemic Obstacles to Battered Women’s Participation in the Judicial System – When will the Status Quo Change? Violence Against Women, 11, 290-310.

2 In intimate partner relationships. Meyer, S. (2011) Seeking Help for Intimate Partner Violence: Victim’s Experiences when Approaching the Criminal Justice System for IPV Related Support ad Protection in an Australian Jurisdiction. Feminist Criminology 6:268.

3 Willis, M. (2011). Non-disclosure of violence in Indigenous communities, Trends and Issues in Crime and Criminal Justice, no. 405, Australian Institute of Criminology, Canberra.

Findings of the investigation into the death of DM 9

Ms Beutel and her partner, and as a result of this history Coroner Hutton made a number of recommendations as follows:

1. That additional Domestic and Family Violence Coordinator positions be established in parts of Queensland where domestic violence is prevalent, and that a state-wide coordination role be re-implemented within police headquarters.

2. That there remains a potential problem with the identification of domestic violence incidents within the QPS, and that the QPS should note this potential vulnerability in its processes and identify an appropriate and realistic way to ensure, so far as possible, that domestic violence assaults are not misclassified as non-domestic assaults.

3. That the medical profession, along with the Queensland Government, explore the issues facing practitioners when they are placed in a position where they are treating both the perpetrator and the victim of domestic violence, with a view to establishing simple guidelines to assist General Practitioners.

4. That General Practitioners be allowed to report their concerns about domestic violence to the police, even in circumstances where there is no immediate and severe threat to the patient’s life, so that police involved in supporting the victim, or involved in an interagency support model, can be more fully informed.

5. That the appropriate government agencies should examine the SCAN model and, using that model as a base, should develop a similar team-based approach to supporting victims of domestic violence.

6. That the relevant government departments should establish an appropriate interdepartmental process, with engagement from appropriate community organisations, with a view to establishing a pilot ‘Domestic violence centre’ in an appropriate part of Queensland. This process should be informed by these findings.

7. That a common risk assessment tool be implemented in Queensland, with the effect that when agencies cooperate with one another in relation to a vulnerable person, they are ‘speaking the same language’ and communication difficulties will be reduced.

On the 23 October 2015, the State Coroner, Terry Ryan handed down findings into the death of Elsie Robertson. He found that she died as a result of violence inflicted on her by her partner, after a prolonged assault that occurred in front of other family members.

There was an extensive history of domestic violence between Ms Robertson and her partner, which required medical assistance or hospitalization on many occasions due to the severity of injuries.

The State Coroner noted the high rates of family violence within Aboriginal and Torres Strait Islander communities and families, both in incidence and severity, the interrelationship of this violence with alcohol misuse and the reluctance of bystanders to intervene on occasion for fear of retaliation or not wishing to be involved in what is seen as a private matter.

Noting the significant reform currently being undertaken across Queensland in relation to domestic and family violence, the State Coroner recommended that the Queensland Police Service extend their current review of police training to all officers within the Service who are likely to have contact with domestic violence situations, irrespective of whether they are administrative or sworn officers.

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Not Now, Not Ever: Putting an End to Domestic and Family Violence in Queensland On Saturday 28 February 2015, The Honourable Quentin Bryce released her Domestic and Family Violence Taskforce Report: Not Now, Not Ever: Putting an End to Domestic and Family Violence in Queensland.

The Report's 140 recommendations for reducing domestic and family violence are extensive and cut across universal, primary and secondary systems; government, community and business sectors; and policy, funding and legislation.

A significant proportion of these recommendations, when implemented, are likely to improve outcomes for victims of domestic and family violence similar to DM including recommendations that aim to:  Improve hospital and health service’s responses to domestic and family violence and child harm (Recommendations 55 through to 63);  Enhance funding for specialist domestic and family violence services including perpetrator intervention initiatives and specialist shelters, improve responses to high risk clients and service system integration and provide more support for victims trying to leave domestic and family violence (Recommendations 71 through to 89)  Improve court responses to domestic and family violence including a focus on increased perpetrator accountability and the implementation of specialist domestic and family violence courts (Recommendations 100, 118, 120-123, and 126 are of particular relevance)  Improve policing responses to domestic and family violence including a review of training and the adoption of a pro-active investigation and protection policy that considers the safety of the victim as paramount (Recommendations 132, 134, 135 and 138).

Of particular relevance to the coronial jurisdiction are:  Recommendations for strengthening the Domestic and Family Violence Death Review Unit within the Office of the State Coroner, and for establishing an independent multi-disciplinary Domestic and Family Violence Death Review Board (see section 4.3.4 and Recommendations 6 to 8).

 Multiple references to the recent coronial inquest into the death of Noelene Beutel as summarised above, and direct and indirect adoption of a number of Coroner Hutton’s recommendations (see Chapter 7 and Recommendations 50 (GP practice guidelines), 74 (an integrated response model to DFV with pilots at three trial sites) and 77 (a common risk assessment framework for use by all relevant service providers, both general and specialist).

The Queensland Government has agreed to implement all recommendations. The Criminal law (Domestic Violence) Amendment Act 2015 has been passed. As well, the Domestic and Family Violence Death Review Unit (DFVDRU) within the Office of the State Coroner has received extra resources for the purpose of providing assistance to coroners in their investigations of these types of deaths.

A Domestic and Family Violence Death Review and Advisory Board has also been established with the passing of the Coroners (Domestic and Family Violence Death Findings of the investigation into the death of DM 11

Review and Advisory Board) Amendment Act 2015. This Board will be chaired by the State Coroner, and supported by the DFVDRU.

It is important to note further that since this death, the then Domestic and Family Violence Protection Act 1989 has been modified and updated to the current Domestic and Family Violence Protection Act 2012 (the Act). The Act was passed on 16 February 2012 and commenced on 17 September 2012. Amendments to the Act include a broader definition of domestic and family violence, greater police powers when investigating a domestic or family violence incident, improved grounds and immediate protection for the aggrieved when making a Protection Order application, and increased penalties for breaching a current Protection Order.

This Act will again be reviewed as part of the implementation of recommendations from this Taskforce (Recommendation 140).

Conclusion DM suffered many years of domestic violence at the hand of her husband, B.

Numerous Domestic Violence Orders were issued in courts at various locations throughout Queensland. Police were involved in some but not all incidents.

On 26 June 2011, DM died at her residence at Oakey as a result of severe violence inflicted on her by B. In addition to inflicting other non-life threatening injuries on DM, B stabbed DM in the chest with such force as to penetrate the chest wall, and to pass through her thoracic aorta resulting in catastrophic blood loss.

Reform surrounding domestic and family violence is a prevalent national issue of high importance. In deciding whether to hold an inquest into DM’s death, I have considered the recent recommendations made in the Noelene Buetel coronial inquest, and the Domestic and Family Violence Taskforce Report, in addition to the finalisation of the criminal proceedings brought against B in relation to the death.

Ultimately, I have decided that holding an inquest is unlikely to provide any new information, or result in any useful recommendations being made over and above those already discussed above. I am unable to make any further preventative recommendations on anything connected with the death, with respect to matters of public health and safety, the administration of justice, or ways to prevent deaths from happening in similar circumstances in the future.

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Findings required by s. 45 Identity of the deceased –DM How she died – DM suffered many years of domestic violence at the hand of her husband, B.

Numerous Domestic Violence Orders were issued in courts at various locations throughout Queensland. Police were involved in some but not all incidents.

On 26 June 2011, DM died at her residence as a result of severe violence inflicted on her by B.

Date of death– 26 June 2011 Cause of death – 1(a) Stab wound to chest I close the investigation.

John Lock Deputy State Coroner Brisbane 9 February 2016 Findings of the investigation into the death of DM 13