SW - Non-inquest findings

CORONERS COURT OF QUEENSLAND FINDINGS OF INVESTIGATION CITATION: Non-inquest findings into the death of SW TITLE OF COURT: Coroners Court

JURISDICTION: CAIRNS DATE: 16 May 2019 FILE NO(s): 2016/1444 FINDINGS OF: Ainslie Kirkegaard, A/Coroner CATCHWORDS: Domestic and family violence death; Aboriginal intimate partner homicide; remote indigenous community; perpetrator’s extensive domestic and family violence history; current domestic family violence order; perpetrator on parole; Queensland Domestic and Family Violence Death Review and Advisory Board; Queensland Government Framework for Action: Reshaping our approach to Aboriginal and Torres Strait Islander domestic and family violence (May 2019).

Table of Contents Domestic and Family Violence Death Review and Advisory Board consideration of

Circumstances of death SW was a 26 year old Aboriginal woman who was found deceased at her partner’s home in a remote indigenous community on 9 April 2016. At the time of her death, she was in a relationship with IN aged 46. She was mother to a seven year old son.

On the morning of 9 April 2016, IN attended the local police station and told police he had assaulted SW stating words to the effect of “I don’t remember if I did it. I think I killed my girlfriend. I’ve left her at home…” He told police he thought she was dead because when he tried to wake her up she was cold. He was then taken into custody.

When police attended the house that morning, they found SW face down on the bedroom floor partially naked, covered by a doona. She was obviously deceased, with traumatic injuries to the head and left bicep. Attending officers observed a lot of blood on the bed and a couch, the floor and walls. They located a small axe and a large serrated pruning saw in the room.

The subsequent police investigation revealed that the couple had been in the bedroom drinking sly grog from approximately midday on 8 April 2016. IN’s daughter and another woman attended the house and spent some time drinking with the couple. The couple were in good spirits and joking around while the women were there. After the women left the couple continued drinking alone in the bedroom into the evening and night.

IN’s brother was present in the house at the time of the incident. He told police the couple had been drinking cask wine and Jim Beam bourbon that night. The brother went to his bedroom and stayed there as IN would become violent when he was drinking alcohol. The brother heard a disturbance during the night which he described to police as banging, shouting and SW screaming. The brother did not do anything at the time because he was frightened of IN. The brother told police that while IN would never lay a hand on him while sober, he would become violent without provocation when under the influence of alcohol.

A friend of the family also overheard a heated argument between the couple while he was sitting in the driveway next door. He too did not want to get involved and went elsewhere because he felt uncomfortable.

When formally interviewed by police, IN said SW had convinced him to drink all the grog despite him wanting to save it for his birthday the following month. They started to argue. IN then hit SW in the face a number of times with an open hand before arming himself with a curved pruning saw he kept in the cupboard. He told police he used the saw to slash at SW to keep her away from him and leave him alone, striking her numerous times with the saw. He said she was on the floor with her arms wrapped around his legs begging him to stop. He stopped eventually, removed her clothes and had sexual intercourse with her, allegedly at her request. She was bleeding heavily from injuries to her arm at this time. He said he then took a pillow and a doona from the bed and lay down on the floor with SW and they both went to sleep. When he woke some time later he realised she was deceased. He said he was unable to exit the bedroom because the door handle was damaged, so he used an axe to smash his Findings into the death of death of SW 1

way out of the bedroom. He had a conversation with his brother and then attended the local police station.

IN was charged with murder, rape and interfering with a corpse. He was ultimately convicted of murder – domestic violence offence and sentenced to life imprisonment by the Supreme Court of Queensland at Cairns on 17 July 2017. When sentencing IN, SJA Byrne described the incident in which SW died as ‘…a brutal, sustained, armed attack involving shocking, lethal violence, fuelled by excessive consumption of alcohol.” Autopsy findings An external examination and full internal autopsy were performed by an experienced forensic pathologist on 11 April 2016. The autopsy revealed multiple cutting wounds to the scalp, face, trunk, upper and lower limbs, with severe damage to blood vessels in the right arm. There was evidence of significant blood loss. The pathologist noted the appearance of a number of the cutting wounds was suggestive of contact with a multi-toothed blade such as a saw. Microscopic examination revealed no underlying significant natural disease. Toxicological analysis revealed a non-fatal blood alcohol concentration of 0.14% but no other drugs were detected. Having regard to the autopsy findings and the circumstances of the death, the pathologist attributed the death to the consequences of multiple sharp force injuries to the limbs, head and trunk.

Domestic and family violence context At the time of the fatal assault, IN was named as the respondent in a current Domestic Violence Protection Order with SW as the aggrieved. The order was made by the local Magistrates Court on 13 July 2015 in relation to an incident in which IN had assaulted SW with a large knife and threatened to take her out bush to chop her head off. This incident occurred in the context of him accusing her of looking at other men. He was charged with assault occasioning bodily harm though it appears police did not seize the weapon on that occasion.

While SW had told health care centre staff she felt threatened by IN and would not be returning to the relationship, IN maintained full contact with her after this assault and the couple reconciled. On 19 July 2015, IN assaulted SW with a large knife, once again in the context of accusing her of infidelity. IN was taken into custody and charged with assault occasioning bodily harm and breaching the protection order. He was subsequently convicted and sentenced to nine months imprisonment with directions to abstain from alcohol for three months on release from custody. He was released on parole on 21 October 2015 under community based supervision. The couple reconciled on his release from prison.

IN is documented as having engaged appropriately with his probation and parole officer, acquired stable employment, reported he was abstaining from alcohol, denied any family or community issues and reported no changes to his circumstances.

IN’s behaviour in the community had not come to the attention of police or the courts prior to 21 January 2016. On this occasion, police responded to a disturbance between the couple in which SW alleged IN had threatened her with a woomera. For Findings into the death of death of SW 2

reasons unable to be clarified by this investigation, police determined the allegation to be unfounded and no further police action was taken. This was the last known contact between SW and service agencies prior to her death some three months later.

IN told his probation and parole officer he had been involved in a ‘growl’ with his expartner several days earlier but reported the issue was resolved without verbal or physical violence. Without confirming this version of events, the probation and parole officer took IN’s word on face value and commended him for his pro-social behaviour.

No risks or intervention needs were identified by the probation and parole officer between that time and SW’s death.

Offender management records reveal that during IN’s parole period, there was no indication he had breached the direction to abstain from alcohol during the three month period following his release from prison; IN denied recommencing alcohol use after this period expired and there was no indication he had presented with any physical indicators of alcohol or illicit drug use (though this was not confirmed by urinalysis).

While it was initially planned to require IN to attend the local Alcohol and Drugs Service, he was ultimately never directed to attend because his full time employment obligations were considered to be a barrier to his participation in the program.

The domestic and family violence context within which SW’s death occurred was examined by the Domestic and Family Violence Death Review Unit with the Coroners Court of Queensland with reference to information obtained from a range of service agencies including police, courts, corrective services, health and local support service providers.

SW had been in an on-and-off relationship with IN for approximately 12 months preceding her death. Their relationship was characterised by a sustained pattern of physical, verbal and psychological abuse perpetrated by IN against SW. He was known to exhibit unpredictable, aggressive and anti-social behaviours when affected by alcohol, demonstrating poor emotional regulation and control. Throughout their relationship, SW was the victim of significant acts of physical violence by IN, often involving the use of weapons. There were three known episodes of violence where SW sustained severe injuries during assaults by him involving the use of a knife, a woomera and a saw. The intensity and brutality of this violence is described as ‘particularly severe’.

There was also evidence of other forms of domestic violence in the relationship including threats to kill as a mechanism by which IN maintained control over SW.

Much of the violence appears to have been triggered by sexual jealousy in response to an actual or perceived threat of sexual infidelity. SW had also expressed sexual jealousy within the relationship but she was not physically violent in response.

IN was known in the community for his use of violence towards women and was reportedly nicknamed ‘killer’ due to his prior history of domestic violence perpetration in which it was rumoured that he had “killed his old girlfriends”. I note he had no prior convictions for manslaughter or murder of a previous partner and the rumour was not further investigated by police. He was considered to be a habitual domestic violence offender who perpetrated ‘cruel and savage violence’ towards his intimate partners and following episodes of violence, would often demonstrate limited insight into his Findings into the death of death of SW 3

offending behaviour (including minimising his violence and apportioning blame to his victims).

SW’s family had tried many times to dissuade her from starting and remaining in a relationship with IN as they were concerned for her safety. It was understandably very frustrating for them when she did not take their advice to leave him. It appears she was initially proactive in seeking help from social supports during crisis situations when she needed medical attention and was forthcoming about how she had come to be injured. After being discharged from hospital after an episode of violence by IN in July 2015, SW was referred to the local women’s shelter for accommodation support as her family had refused to allow her back into the family home. It appears this was the last occasion on which she sought assistance from social supports prior to her death some nine months later.

Review of available records shows there was extensive service system contact with SW and IN, not only as a result of IN’s violence against SW but also as a result of his propensity to commit acts of violence against others.

IN’s criminal history demonstrated a pattern of violent and non-violent offending dating back to 1988, with assault, domestic violence and alcohol related offences comprising the majority of his convictions. His history of domestic violence related offending was extensive, having been named as the respondent in domestic violence orders relating to seven women including SW over the period 1994-2017. Police recorded multiple breaches of these orders over the period 1995-2015. SW also had a history of violent offending, though to a lesser extent than IN. Her use of violence was often associated with alcohol intoxication and directed towards other women in her family network or in the community.

SW’s death led to IN’s tenth custodial episode for violence related offending. He is documented as having largely been a compliant prisoner with few conduct breaches while incarcerated. His response to community-based supervision was also generally acceptable though he was occasionally non-compliant with parole reporting conditions. He had undergone multiple risk and needs assessments over the course of his engagement with Queensland Corrective Services. These identified the link between his alcohol use and criminal behaviour and recommended that he complete offender behaviour programs relating to alcohol and drugs, domestic violence and anger management. Many of these interventions were largely targeted to the special needs of Aboriginal and Torres Strait Islander offenders. He had been referred to and successfully completed intervention programs over the period 1999-2009. There were mixed responses to his participation ranging from enthusiasm and motivation to change to minimal interaction due to being ‘culturally shy’. Despite ongoing rehabilitative attempts to address issue of domestic violence and alcohol use, IN maintained a strong pattern of recidivist domestic violence offending across multiple intimate partner relationships.

Systemic analysis of the circumstances leading up to SW’s death highlighted the critical importance of robust interventions for serious family violence offenders given it was well recognised within the community that IN presented a sustained risk of harm to his intimate partners. Further, it highlighted the intersections between alcohol Findings into the death of death of SW 4

misuse and family violence perpetration and the critical importance of reducing alcohol related harm.

At the time of SW’s death, the community was one of several indigenous communities in which an Alcohol Management Plan was in place to limit the sale and consumption of alcohol outside controlled settings. Despite this, IN was able to acquire and consume excessive quantities of ‘sly grog’ immediately prior to his fatal assault on SW.

His intoxication was a significant factor in the escalation of events preceding the assault that night.

The ‘sly grog’ trade is recognised as a significant issue within the community, with sellers circumventing retailers’ takeaway liquor licence conditions, stockpiling alcohol outside restricted areas and illegally on-selling supplies to customers within alcohol restricted communities for sizeable profits. Over time, this activity has undermined the initial impact of Alcohol Management Plans in reducing violence. It has also been suggested that alcohol restrictions may prompt consumers to adapt their drinking behaviour towards heavier, episodic drinking when accessing illegal supplies this in turn increasing harm to themselves and others. The couple drank at dangerous levels consuming all the alcohol available to them over 8-9 April 2016.

I note the Department of Aboriginal and Torres Strait Islander Partnerships is continuing to work with communities in the ongoing review of their Alcohol Management Plans.

Domestic and Family Violence Death Review and Advisory Board consideration of Aboriginal Family Violence Homicides The Domestic and Family Violence Death Review and Advisory Board (the Board) is established under the Coroners Act 2003 to undertake systemic reviews of domestic and family violence deaths in Queensland and is tasked with identifying common systemic failures, gaps or issues and making recommendations to improve systems, practices and procedures that aim to prevent future domestic and family violence deaths (https://www.courts.qld.gov.au/courts/coroners-court/review-of-deaths-fromdomestic-and-family-violence) In its 2016-17 Annual Report, the Board reported on its consideration of the disproportional impact that family violence has on Aboriginal and Torres Strait Islander families and communities. Many of the key issues and themes identified by its review of Aboriginal family violence homicides are present in the circumstances leading up to SW’s death including the victim’s experience of persistent verbal, physical and sexual violence; the victim’s reluctance to seek help (particularly in a small interconnected community); reluctance by others to intervene; excessive alcohol use; sexual jealousy; prior assault with a weapon; repeated breaches of protection orders with multiple intimate partners by a high-risk perpetrator over a sustained period and for serious acts of violence and the death occurred while the perpetrator was on court-ordered parole.

The Board recommended that the Queensland Government, in partnership with community Elders and other recognised experts, develop a specific Aboriginal and Torres Strait Islander family violence strategy as a matter of urgent priority. In Findings into the death of death of SW 5

response, the Queensland Government publicly acknowledged the Board’s call for change to respond to Aboriginal and Torres Strait Islander family violence and a commitment to explore options to build on existing initiatives under the Domestic and Violence Prevention Strategy 2016-26.

In its 2017-18 Annual Report, the Board reaffirmed its strong concern about the absence of a distinct culturally appropriate strategy to address family violence and the unique needs of Aboriginal and Torres Strait islander people.

In May 2019, the Queensland Government released Queensland’s Framework for Action: Reshaping our approach to Aboriginal and Torres Strait Islander domestic and family violence (https://www.csyw.qld.gov.au/resources/campaign/end-violence/qldframework-for-action-reshaping-approach-atsidfv.pdf). This framework documents the Government’s commitment to taking a new approach to working with Aboriginal and Torres Strait islander families and communities to address the causes, prevalence and impacts of domestic and family violence. It identifies a range of strategies including working in partnership with communities to utilise knowledge and experience of Aboriginal and Torres Strait islander people; delivering programs and holistic wraparound services that are stress and trauma informed and culturally appropriate; engaging Aboriginal and Torres Strait Islander communities and community controlled organisations to deliver the services needed; and to improve the approach to monitoring and evaluating changes in outcomes for Aboriginal and Torres Strait Islander families experiencing violence.

Findings required by s. 45 Identity of the deceased: [deidentified for publication purposes] How she died: SW died from serious injuries sustained in a violent assault upon her by her partner IN after a prolonged drinking session with her over 8-9 April 2016. He was ultimately convicted and sentenced to life imprisonment for her murder. The fatal assault occurred while a domestic violence protection order was in force naming IN as the respondent and SW as the aggrieved and while IN was on court-ordered parole following a term of imprisonment relating to a previous assault on her and breach of the domestic violence protection order. The couple’s on-and-off relationship over the preceding 12 months was characterised by repeated, serious violence perpetrated by IN when affected by alcohol and often involved the use of weapons. IN was well known in the community for his use of violence against women. He had an extensive history of domestic and family violence across multiple intimate partners over a long period and repeatedly breached domestic violence protection orders.

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The independent Domestic and Family Violence Death Review and Advisory Board has and continues to examine Aboriginal family violence deaths and identify opportunities to improve system responses with the objective of preventing future domestic and family violence deaths. In May 2019, in response to the Board’s recommendation, the Queensland Government released a specific Aboriginal and Torres Strait Islander family violence strategy.

Place of death: a remote indigenous community Date of death: 09 April 2016 Cause of death: 1(a) Multiple sharp force injuries of limbs, trunk and head 2 Alcohol intoxication I close the investigation.

Ainslie Kirkegaard A/Coroner Coroners Court of Queensland 16 May 2019 Findings into the death of death of SW 7