Brown, Tara Matekino - Non-inquest findings

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

JURISDICTION: SOUTHPORT DATE: 27/01/2021 FILE NO(s): 2015/3540 FINDINGS OF: Jane Bentley, Deputy State Coroner CATCHWORDS: Coroners; Domestic and Family Violence ; Domestic Violence Protection Orders; Domestic and Family Violence Protection Act 2012; murder; Lionel Patea; Queensland Police Service; High Risk Teams; Queensland Health;

Contents

Findings into the death of Tara Matekino Brown Page 1

Domestic and Family Violence Death Review Unit In preparing these findings I have been significantly assisted by and I have heavily drawn upon the review, carried out by the Domestic and Family Violence Death Review Unit of the Coroners Court of Queensland, of the circumstances surrounding the death of Ms Brown as well as the Unit’s significant body of research into all aspects of Domestic and Family Violence. I very much appreciate their invaluable input.

Background Tara Matekino Brown was twenty-four years when she was killed by Lionel Patea on 8 September 2015. She had a three-year-old daughter with Mr Patea with whom she had been in a relationship with since 2011.

Ms Brown was an exceptional mother who doted on her daughter, a talented athlete, having played touch football at a representative level, and an excellent employee.

Circumstances of Ms Brown’s Death On the morning of 8 September 2015 Mr Patea phoned the childcare centre at Molendinar which his daughter attended and ascertained that she was due to attend there that day.

At 8am that day Ms Brown drove her daughter to the childcare centre in her 2010 grey Mazda 2 sedan.

At about 8.25am Ms Brown left the childcare centre. Mr Patea followed her in his 2014 black Jeep Grand Cherokee wagon. Ms Brown tried to escape him but he followed her at excessive speeds. Ms Brown had to stop at traffic lights at the intersection of Harper and Ashmore Roads. Mr Patea drove his car around and pulled up in front of her.

Mr Patea got out of his car and approached Ms Brown’s vehicle. He punched the car four or five times.

Ms Brown drove off and Mr Patea got back into his car and followed her. She drove north along Ashmore Road. At traffic lights at the intersection of Watford Crescent and Macquarie Avenue Ms Brown was forced to stop again. Mr Patea left his vehicle and again pounded on Ms Brown’s car.

Ms Brown drove off and turned right into Macquarie Avenue at Molendinar and then travelled south along Macquarie Avenue. Mr Patea followed closely behind. Both cars were travelling in excess of 100 kilometres per hour.

Ms Brown called 000 and was screaming for help.

At a location on Macquarie Avenue, Mr Patea used his car to ram Ms Brown’s car.

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The front passenger corner of the Jeep collided with Ms Brown’s driver side door as he was overtaking her which caused her vehicle to swerve and leave the road. She drove over a three-metre-high embankment and into the front yard of a house below on Batchworth Road. Her car came to rest on its side, driver’s side down, on an embankment outside the house.

Residents and passers-by came to the assistance of Ms Brown. She was calling out for help.

Mr Patea drove about 70 metres further down the road then parked his car in the middle of the road, exited the vehicle and ran back towards Ms Brown. At the corner of the street he removed a 25cm square solid steel water hydrant cover from the footpath and then continued on to Ms Brown’s car. The steel cover weighed 7.8 kilograms.

Mr Patea approached the car. A neighbour helped Mr Patea break the windscreen to gain access to Ms Brown, assuming that Mr Patea was going to assist her.

However, Mr Patea leaned through the windscreen and struck Ms Brown in the face multiple times with the hydrant cover. The neighbour attempted to stop Mr Patea by pulling him away from Ms Brown. Mr Patea freed himself and again began striking Ms Brown.

Mr Patea then got inside Ms Brown’s car and knelt on her chest and continued to hit her with the hydrant cover. The 000 call was still in progress and recorded sixteen strikes.

A witness asked Mr Patea what he was doing and he replied, “She’s got my kid.” Mr Patea then hit Ms Brown with the cover another thirteen times.

Mr Patea then left the hydrant cover sitting on Ms Brown’s face and ran to a nearby vehicle which he stole and left the scene.

Queensland Fire and Rescue Service attended and freed Ms Brown from the vehicle. Queensland Ambulance Service paramedics attended and found Ms Brown unresponsive and in a critical condition. She was transported to the Gold Coast University Hospital where she was admitted to the Intensive Care Unit. On admission she was bleeding from the nose, scalp and ear and had fixed dilated pupils.

Ms Brown was found to have sustained unsurvivable head injuries. Life support was removed and Ms Brown was pronounced deceased at the Gold Coast University Hospital at 9.03pm on 9 September 2015.

Autopsy An autopsy revealed that Ms Brown died from head injury. She had diffuse swelling and bruising of the left and anterior face with numerous lacerations, abrasions and discrete bruises. She had underlying fractures of the skull including comminuted depressed fracture of the left side of the skull with fractures extending through the Findings into the death of Tara Matekino Brown Page 3

petrous temporal bones (hinge fracture) and across the floors of the anterior and posterior cranial fossae on the left.

Ms Brown had multiple facial bone fractures.

Ms Brown had a dural laceration on the left vertex with subarachnoid haemorrhage and multiple cerebral contusions. She had raised intracranial pressure with cerebral swelling, descent of the midline structures with evidence of transtentorial herniation and Duret haemorrhages in the brain stem and widespread selective neuronal necrosis.

Ms Brown had multiple bruises and abrasions to the limbs and trunk. She had contracted pneumonia with sepsis due to her injuries.

At the time she was attacked Ms Brown had no alcohol or drugs in her system.

In summary, Ms Brown sustained severe head injuries with multiple bruises, abrasions and lacerations to her face and scalp, particularly at the front and on the back at the left. She had severe underlying fractures to the skull and facial bones, particularly on the left side including a depressed fracture of the skull. This caused severe injury to the underlying brain including subarachnoid haemorrhage around the brain. The dura (fibrous membrane over the brain) was lacerated beneath the depressed fracture.

As a result of these injuries, Ms Brown’s brain swelled (cerebral oedema) which put pressure on the vital centres in the brain stem and caused necrosis (death) of brain cells.

As a result of being unconscious Ms Brown developed pneumonia in both lungs and the infection spread through her body.

A number of the injuries to Ms Brown’s head were patterned and the pattern was similar to that on the hydrant cover.

Apart from the injuries caused by the vehicle collisions and the blows delivered by Mr Patea, Ms Brown was healthy and had no pre-existing natural disease.

Criminal Proceedings After attacking Ms Brown Mr Patea inflicted superficial stab wounds to his neck and leg. He then drove to the Coomera Police Station and surrendered himself to police.

He was transported to the Gold Coast University Hospital where he was treated for his wounds and remained overnight under police guard.

On the morning of his trial on 27 February 2017 in the Supreme Court at Brisbane Mr Patea entered pleas of guilty to charges of Murder (Domestic Violence Offence), Dangerous Operation of a Vehicle and Contravention of a Domestic Violence Order.

He was sentenced to life imprisonment.

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Ms Brown’s History of Domestic and Family Violence (Other Relationships) As a teenager, Ms Brown was exposed to domestic and family violence (DFV) perpetrated against her mother by her mother’s de-facto partner including emotional and physical abuse, threatening family members and damaging property. In May 2009 when Ms Brown was 18 years old, a domestic violence protection order (DVPO) was issued naming Ms Brown’s mother as the aggrieved and Ms Brown was listed as a named person.

On 5 December 2010, when she was 19 years old, Ms Brown was hospitalised after being assaulted by her then partner. They had been drinking and become embroiled in a verbal argument and Ms Brown’s boyfriend pushed her over. Ms Brown hit her head on the towbar of a parked car, leaving a bloodied laceration above her left eye.

Ms Brown was attended to by Queensland Ambulance Service before being taken to the Emergency Department of the Gold Coast University Hospital. She was tearful upon presentation and both parties confirmed how the injuries occurred but denied any other history of DFV. When she was alone with the clinician, Ms Brown stated that she did not want the police involved.

Mr Patea’s History of Domestic and Family Violence Mr Patea demonstrated a pattern of DFV perpetration in a previous intimate partner relationship with “H”. H ended a three-year relationship with Mr Patea in November 2009 as he was frequently violent and whenever they argued he would lose his temper very quickly and he would punch her. On occasions, Mr Patea pushed H to the ground and kicked her in the head numerous times.

Mr Patea also demonstrated possessive behaviours during and after the end of the relationship with H. For example, H had 37 missed calls on her phone from Mr Patea on the day police became involved in the violent relationship (15 February 2010).

Police sought protection for H following a DFV episode on 15 February 2010. The application included the following information:

• Mr Patea was continually calling H at work demanding to speak with her, but H refused and was worried he would turn up at her work;

• A friend walked H to her car after work when Mr Patea had approached her demanding she talk to him. She refused and Mr Patea took the car keys from H’s friend;

• When she attempted to get them back, Mr Patea grabbed her by the front of the shirt and pulled her from the car, tearing her shirt, pulling the buttons from the front. H asked her friend to go and get help;

• Mr Patea swung H from her seat and into the side of her vehicle, got into the car and begun reversing it from the carpark. H jumped into the passenger seat to prevent him from stealing it, asking him to stop and give the car back to her, and he threatened her saying “if you don’t shut up I will seriously hurt you”; Findings into the death of Tara Matekino Brown Page 5

• He drove a short distance with H in the car, driving erratically and grabbed her handbag and threw it from the car;

• He then slowed down and stopped on a side street. She attempted to get some of her possessions out of the car and he grabbed her by the back of her shirt and pulled her so hard that she could hear the shirt rip, and he kept punching her to the face and ribs. He threw her possessions on the road and then drove off;

• He kicked her as she was trying to get her property out of the front, continued to drive off and pushed her until she fell from the moving vehicle;

• Witnesses subsequently assisted her, including a 13 year old girl who told police: She went to H’s aid when she saw her pushed out of the car; o Mr Patea reversed the car and stopped and got out, she yelled o out for help and Mr Patea said to her “if you tell anyone about this I’ll come and find you”; She told him that police were on their way and he grabbed her o by the left wrist and tried to pull her towards the car; She managed to pull her arm away, resulting in scratches to her o wrist, and ran down the street; Mr Patea got back in the car and chased after her, subsequently o catching up to her; He got out of the car and ran towards her, grabbed her left o shoulder, spun her around and grabbed her shirt; She scratched at him and hit him in the eye as she was afraid o he was going to rape her; Mr Patea grabbed her by the arm and kept pulling her to the car; o He pushed her into the car and she hit her head on the left side o of the car; She was able to get away and started running and Mr Patea told o her to “get back here”; He drove after her, did a u-turn and drove towards her giving her o a ‘death stare’ before driving off;

• Police saw that H had bruising to her right eye and she reported having pain to her ribs on the right side; and

• The 13 year old girl also sustained injuries.

In addition to the application for a DVPO, police also charged Mr Patea (who was then aged 18 years) with unlawful use of a motor vehicle, robbery, deprivation of liberty, assault occasioning bodily harm and dangerous operation of a vehicle.

A temporary DVPO was issued but had not been served on Mr Patea when police were called to respond to a further DFV episode one week later on 22 February

2010. This episode involved Mr Patea threatening to kill H’s new partner and his family:

[H] UR WORK UR HOME N URR BF U GUYS ARE ALL FUKD NO FHYT I’D PIK UR FONE UP. LINDA SAM N KELLIE NAWW R THEY GUNA DIE??

I’M NOT KIDDING U… U CAN ACTUALLY HAV A CHANCE IF U PIKC UP UR FONE Findings into the death of Tara Matekino Brown Page 6

Responding police officers did not obtain images of the offending messages and the statement provided by H at the time did not feature the content of the threats. H subsequently lost her phone and as such Mr Patea was not able to contact her however, he posted threats on Facebook that H deleted.

The temporary DVPO was served on 25 February 2010 when Mr Patea attended the station in relation to the initial incident. He was subsequently charged with the criminal offences and remanded in custody. The DVPO was issued on 17 March 2010, listing Mr Patea as the respondent and H as the aggrieved.

As police were preparing the prosecution of Mr Patea for the aforementioned offences, on 2 May 2010 H withdrew her complaint and told police that she was not willing to provide evidence in court as she had moved on with her life. On 13 May 2010 charges were withdrawn by police given H had withdrawn her complaint and no action could be taken against Mr Patea for contravening the conditions of the DVPO (the events on 22 February 2020) as the temporary DVPO had not been served on Mr Patea at the time of the offences. Mr Patea had spent just over two weeks in custody on remand.

Mr Patea had previously threatened to kill himself on a number of occasions during his relationship with H. H told the police that Mr Patea threatened to harm her or to kill himself should she refuse to reconcile with him. On one occasion, H had to cut the rope away as Mr Patea was frothing at the mouth after he tried to hang himself.

On 6 December 2010, after reconciling and subsequently separating again, H saw Mr Patea’s car in the driveway and located him asleep in her house. H asked Mr Patea why he was there and the whereabouts of some of her clothes he had taken.

Mr Patea reportedly became enraged and punched several holes in the walls, then started smashing all the windows of the vehicle and denting the panels. H ran next door to her neighbours for refuge.

The two neighbours went next door to tell him to calm down and Mr Patea became angrier and smashed more property around the house. They called the police and Mr Patea left prior to police arrival. He subsequently handed himself into the police station telling police that he had gotten angry as H was having an abortion without consulting him. Police charged him with a breach of the DVPO and wilful damage.

Mr Patea was later convicted for these offences receiving a fine of $1000 and probation for 18 months. He was later convicted for breach of this probation order and fined a further $500.

Mr Patea completed a court ordered men’s domestic violence program from 16 February 2011 to 24 August 2011. Upon completion of the intervention program, Mr Patea was regarded as a high-risk respondent.

There are clear parallels between the behaviours perpetrated by Mr Patea against H and then a few years later against Ms Brown.

Research demonstrates that DVPOs are effective when breaches are swiftly responded to and there are punitive consequences for these breaches. However, Findings into the death of Tara Matekino Brown Page 7

the consequences Mr Patea received for his repeated violent assaults against H suffered were minimal which, as opposed to deterring future behaviours, may have encouraged them.

Mr Patea’s History of Criminality and Offending Mr Patea had a criminal history commencing in 2007 when he was a juvenile. These offences included assault, assault occasioning bodily harm, wounding, stealing and receiving tainted property, wilful damage, breaches of domestic violence orders and breaches of probation order.

Police intelligence suggested that Mr Patea was a senior member of an Outlaw Motorcycle Gang. Ms Brown told her co-workers that Mr Patea was a sergeant-atarms of the Bandidos Outlaw Motorcycle Gang.

On 29 May 2018, Mr Patea was convicted of murdering Gregory Dufty. Mr Dufty was assaulted by Mr Patea (who struck Mr Dufty with a 40-centimetre-long spanner) and a number of associates in relation to an outstanding drug debt. This assault occurred on 6 July 2015, only two months prior to Ms Brown’s death.

The History of Domestic and Family Violence Inflicted on Ms Brown by Mr Patea Ms Brown and Mr Patea had known each other since they were children as Mr Patea’s aunt resided next door to Ms Brown’s family home. They commenced an intimate partner relationship in 2011 and Ms Brown gave birth to their daughter in May 2012.

Mr Patea perpetrated significant violence against Ms Brown during their relationship.

There was an enduring pattern of coercive control by him. He perpetrated physical, verbal, emotional and financial abuse and threatened to harm and kill Ms Brown, her family members and himself.

In June 2013, Ms Brown commenced working as a personal assistant at a law firm in Southport. Ms Brown’s employer provided a statement to police. He indicated that Ms Brown was initially reluctant to discuss her relationship with Mr Patea. Mr Patea’s controlling behaviours extended to Ms Brown’s workplace. He refused to attend work social events but would wait for hours outside for her. In the year prior to her death he called her repeatedly on her mobile phone while she was at work. If she turned it off he called the office phone. Consequently, in periods when Mr Patea was contacting the law firm, another staff member would answer all incoming phone calls.

In November 2014, the law firm Ms Brown worked for implemented a locked door policy at the firm requiring contacts and clients to contact the office upon arrival to the law firm based on Ms Brown’s concern that Mr Patea would attend the firm to “get her” during a period in which she had separated from Mr Patea.

By 2015, Mr Patea was working in the mines in Gladstone and was spending every fifth week on the Gold Coast and the other four weeks working away.

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Financial Control Despite living as a family unit, Ms Brown’s money was separate to Mr Patea. Mr Patea required Ms Brown to finance their daughter and her own living expenses including food and paying rent to Mr Patea (for the house that he had purchased).

Despite this, if Ms Brown did something that Mr Patea disapproved off, he would transfer money out of her account leaving her with minimal funds (sometimes as little as $8). Meanwhile, Mr Patea spent large amounts of money on himself, such as the purchase of a jet ski.

In late 2014, Mr Patea purchased a new car for Ms Brown. He later took this car from Ms Brown and gave it to his mother because he considered Ms Brown had done something wrong. Ms Brown was unsure what she had done wrong.

Sexual Jealousy Mr Patea constantly phoned Ms Brown when she was not with him, particularly if she was with friends.

Witnesses described numerous incidents whereby Ms Brown would be at a social event and Mr Patea would call and text Ms Brown incessantly. Whilst invited to a number of Ms Brown’s work events, he would refuse to attend and would wait outside some of these events waiting for Ms Brown to finish at the event. One friend indicated that Mr Patea demanded to know what she was wearing, demanded she send photos of her outfit, called her a slut and accused her of cheating on him.

Mr Patea frequently accused Ms Brown of infidelity. He allegedly recruited Bandido prospects to assault a friend of Ms Brown’s as he believed she was sleeping with him. When Ms Brown travelled with her touch football team Mr Patea paid for her to stay at a separate hotel away from the other team members as they included males.

Physical Violence and Threats Mr Patea allegedly strangled Ms Brown and pushed her downstairs when she was pregnant. When they argued he threatened to slit her dogs’ throats, bash her brother, destroy their house and take everything.

He threatened to take her daughter from her and took her away and prohibited Ms Brown from seeing her on a number of occasions. He also threatened to kill himself.

The first act of violence reported to police occurred on 22 April 2012 when Ms Brown was 33 weeks pregnant. Mr Patea became angry with Ms Brown when she went to a petrol station to buy a chocolate bar. He swore at her, called her names and drove erratically with her in the car. He kicked her car, ripped her dress and pushed her.

Ms Brown responded by throwing a 50-cent coin at Mr Patea in response to which Findings into the death of Tara Matekino Brown Page 9

he “went psycho”, threw a bucket at her, spat in her face and called her a “putrid dog mongrel slut” and ripped her dress completely off.

Ms Brown called her mother to pick her up and reported the incident to police as she was fearful for her own safety and that of their unborn child. She said that Mr Patea had recently become a prospect for the Bandidos Outlaw Motorcycle Gang (OMCG) which exacerbated her fears.

Ms Brown was too fearful of Mr Patea to make a formal complaint of assault against him but she disclosed previous violence including that he smashed her windscreen, threatened her with a handgun and threatened her family members.

Police who spoke to Ms Brown determined that there was a high likelihood of further violence and that the violence was escalating. They considered that Mr Patea had the capacity to carry out his threats. They applied for a DVPO with an ouster condition (i.e. a condition that Mr Patea leave their residence).

A temporary DVPO, with eight additional conditions, and listing Ms Brown’s mother and brother as named persons, was issued by the Southport Magistrates Court on 23 April 2012 but was not served on Mr Patea until 15 June 2012.

On 20 May 2012, Ms Brown attended hospital in labour. Her mother was present.

Mr Patea became angry when he perceived that Ms Brown’s mother ignored him and he threatened to slit her throat. Hospital staff became concerned and security personnel were involved in the matter but conceded to Ms Brown’s wish to have Mr Patea present for the birth of their daughter even though they were aware that Mr Patea’s presence breached the DVPO.

On 24 May 2012, police were advised that Mr Patea was breaching the DVPO by visiting Ms Brown at the hospital. QPS created an intelligence report based on this information.

On 5 June 2012, Ms Brown submitted an application to have the DVPO revoked on the basis that she and Mr Patea had reconciled and she wanted him to have contact with his daughter. Mr Patea had not been served by police with the temporary order at that time. Ms Brown stated on this application that when the order was made she was pregnant and not coping very well and that it was out of character for her and Mr Patea to have had an argument that led to the order being made. She stated that they had worked out their differences and were much happier and that she wanted her daughter to have a father. Ms Brown argued that the order was making it difficult for him to see his daughter. The application to revoke the order was set for hearing on 18 June 2012 to coincide with the original temporary order application hearing which was yet to be served.

Police eventually served the temporary DVPO on Mr Patea on 15 June 2012 although it was evident that he was aware of the application prior to this point. As the order had not been served prior to this occasion, the conditions of the order were not in effect and Mr Patea was unable to be charged with a breach for maintaining contact with Ms Brown and for his threats towards her mother at the hospital. The court heard the temporary DVPO application and the application to revoke the order Findings into the death of Tara Matekino Brown Page 10

on 18 June 2012, dismissed the application to revoke, and the order was made on this date.

By 25 June 2012, Ms Brown had separated from Mr Patea and moved in with her mother and her mother’s partner. On 12 July 2012, Ms Brown received 30 phone calls and 12 text messages from Mr Patea in the space of 2 hours, including abusive messages threatening harm to Ms Brown and her family. Just one of those messages read: if u dnt pickup Im guna smash d fuk owta our house n kill zuez at least I knw were to go to get ur mum I warned u wat wuld happen” (sic).

While making a complaint at the police station, Ms Brown continued to receive threatening text messages from Mr Patea, which officers downloaded and retained as evidence. Mr Patea was arrested for breaching the temporary DVPO and taken to the Southport Watchhouse where the full DVPO was served by police. Mr Patea was subsequently convicted with breaching the temporary DVPO and using a carriage service to make a threat to kill. He was sentenced to one-month imprisonment which was wholly suspended for 2 years.

On 28 July 2012, Mr Patea was once again arrested for breaching the conditions of the DVPO. Ms Brown permitted Mr Patea to visit for the purposes of seeing their daughter, but upon requesting him to leave after he refused to help with the baby, Mr Patea became angry, argued with Ms Brown, threw food at her and smeared a burger on the windscreen of her car. Ms Brown contacted police, upset and scared.

Mr Patea was charged with breaching the DVPO order and was again sentenced to one-month imprisonment suspended for two years, just two weeks after his previous conviction.

Due to the extent of the DFV, Ms Brown and Mr Patea were referred to Domestic Violence Repeat Call for Service Couple Case Management between October 2012 and February 2013. The investigator first contacted Ms Brown on 25 October 2012.

Ms Brown informed police that she had commenced proceedings through the Family Law Court for visitation rights for Mr Patea to see their daughter. Ms Brown reported there had been no episodes of violence since July and she did not require further assistance. Because of this, police passively monitored the couple on a monthly basis before finalising the couple from the case management process on 8 February 2013 as they no longer met the criteria for inclusion in the case management program.

There were no further episodes of DFV between Mr Patea and Ms Brown reported to police or other services, until the significant escalation of violence in the weeks preceding Ms Brown’s death. Mr Patea spent short periods of time in prison in relation to breaching his probation order previously issued due to his DFV against a former partner and other unrelated charges.

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Domestic violence events in the critical period preceding the fatal assault There was a significant escalation of violence by Mr Patea towards Ms Brown in the ten days prior to her death. Ms Brown booked a trip with her mother and daughter to New Zealand in August 2015 to scatter Ms Brown’s grandfather’s ashes. At the last minute Mr Patea booked a ticket to go as well, despite Ms Brown not wanting him to accompany them.

On 30 August 2015, Mr Patea, who was on a separate flight back to Australia, left his gate to go to Ms Brown’s departure gate. He discovered Ms Brown messaging someone whom he suspected she was a having a sexual relationship with. Mr Patea snatched the phone away from Ms Brown, chased her through the airport and took the phone from her and spat in her face before security at the airport intervened.

Ms Brown and Mr Patea flew back separately to Australia (Mr Patea to Brisbane and Ms Brown to Coolangatta). On her return, Ms Brown started to pack her belongings so that she could leave the house before Mr Patea arrived but he got there before she could leave. Mr Patea dragged her to a room, threw her on the bed, closed the door and put scissors to her neck. He threatened to stab her and cut off her ear. Ms Brown was scared for her life and was crying. Mr Patea refused to let her leave or check on her daughter. This torment lasted for between ten and twenty minutes and only ceased when Mr Patea’s Aunt arrived at the house and intervened. Mr Patea locked Ms Brown in a room with their daughter for the night and he threatened to take their daughter away from Ms Brown and to restrict the access she would have with her. He also emptied Ms Brown’s bank accounts, leaving her to scrounge for change on the floor of her car to purchase a loaf of bread. Mr Patea used Ms Brown’s phone to message her work colleagues, telling them she was having an affair. He also messaged her friends using her phone pretending to be Ms Brown.

On 31 August 2015, Ms Brown attended work and disclosed to her employer that Mr Patea had posted photos of her in lingerie on Facebook and a friend of Mr Patea’s posted a demeaning video of Mr Patea demanding Ms Brown tell him who she had been having an affair with whilst Ms Brown was on her knees crying and covering her face with her hands. These posts were confirmed by Ms Brown’s friends. Ms Brown also disclosed to her employer that Mr Patea had kicked her out of home and that he was keeping her daughter.

Despite Ms Brown’s personal circumstances, she attended and worked on 1 and 2 September 2015. Her clothes were packed in her car as she had been kicked out of her home.

Throughout 2 September 2015, Ms Brown’s employer observed that Ms Brown was receiving a high frequency of calls and text messages so he asked to speak to Ms Brown in his office. He observed the text messages that Mr Patea had sent Ms Brown. These messages were abusive and stated that “he was going to kill himself and if he died someone would come and get her”.

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His emotional abuse continued through his refusal to allow Ms Brown to see or speak with her daughter, stating in a phone call that Ms Brown’s boss heard on speaker phone “you can’t for what you have done you are not allowed to speak to her, she is not your child”.

Mr Patea went to Gladstone as he was a fly-in fly-out worker in the mines, allowing Ms Brown to stay overnight at their house, but their daughter was staying in his aunt’s care. Mr Patea called his aunt repeatedly and demanded photo proof that his daughter was with her and that Ms Brown was not there. Despite this, Mr Patea’s aunt invited Ms Brown to the house to see her daughter and stay the evening.

On 3 September 2015, with Mr Patea away, Ms Brown discussed her options to safely separate from Mr Patea with her boss. Ms Brown decided that she would seek assistance from a range of services to aid her separation. Contact was made with DV Connect who arranged for Ms Brown to receive motel accommodation for her and her daughter that night, and for her to receive refuge accommodation at a women’s refuge (in an location that none of Ms Brown’s family, friends or work colleagues were advised of) the following day. Ms Brown’s mother picked her daughter up from childcare and accompanied Ms Brown and her boss to the Southport Police Station to seek a domestic violence protection order. Ms Brown advised the officer on duty of the threatening text messages that she was receiving from Mr Patea.

Ms Brown received over 270 text messages and calls from Mr Patea between 3am and 1pm that day. An example of the messages received from Mr Patea included (7.23am):

U COLD HEARTED DOG U CAN GET FUCKED I WANT MY 3 GRAND IM UPLOADING VIDEOS TO FACEBOOK AND SERISLLY IF I DON’T ANSWER UR FONE I WILL TXT AND EMAIL ALL UR WORK MATES VIDEOS OF U FINGER BASHING URSELF IM LOOSING IT TARA SERISLLY IM A SINGLE DAD IF U WANNA DITCH US IM GUNNA MAKE U FEEL LIKE U WISIH U NEVER HAD UR DAUGHTER YOUR NOT BEING FAIR TARS Police asked to look at the phone, however, they determined that Ms Brown “failed to locate or show police any text messages in which she had been directly threatened or Mr Patea had threatened any other person with any violence; however the majority of the texts revealed that Mr Patea wanted to take her daughter away from her.” Noting that Ms Brown had responded to some messages, police advised that they were unable to assist Ms Brown and provided information on how to apply for a private DVPO. The responding officer did not notate this contact as a DfV occurrence, instead completing an intelligence report.

Ms Brown left the police station and sought a private DVPO through the Southport Magistrates Court. Ms Brown demonstrated her fear of Mr Patea in the application, stating: Findings into the death of Tara Matekino Brown Page 13

im going into a shelter with my daughter until we go to court for a family court order so Mr Patea doesn’t grab her and run away with her. Once he finds out I have a DVO he will come and find us he will go to my mums, my nans, my mum’s partners my work and thereafter and even hurt them until he finds me I just want everyone safe.

In the application, Ms Brown reported that Mr Patea had access to firearms and said, “he can get one in a heartbeat”.

A temporary DVPO was granted by the Southport Magistrates Court. It listed Mr Patea as the respondent and Ms Brown as the aggrieved, with eight named persons (friends and family of Ms Brown’s including her daughter). The order included mandatory conditions plus 13 additional conditions including that he was not to approach to within 100 metres of Mr Brown or have any contact with her. Her boss, who was now acting as her solicitor, emailed a copy of the temporary protection order to Mr Patea’s email account. Ms Brown then sent two text messages to Mr Patea; the first advising to check his email so that he was aware of the order; the second was to make arrangements so that Mr Patea could talk to their daughter. Ms Brown also advised police that her solicitor had sent a copy of the order to Mr Patea via email. Ms Brown and her daughter then went to accommodation arranged by DV Connect There is no record of police making any attempts to serve Mr Patea with a copy of the order as per their responsibilities under the Domestic and Family Violence Protection Act 2012 (DVPA). Ms Brown’s solicitor also furnished Mr Patea’s lawyer with a copy of the order on 4 September 2015. Subsequent to Ms Brown’s communication with them, police accepted that the order had been served and did not take steps to serve the order on Mr Patea. The courts scanned a copy of the private DVPO application to QPS at 3.58pm on 3 September 2015 and the temporary protection order was forwarded at 4.51pm. The DVPO application was adjourned until 2 October 2015.

With Ms Brown going into hiding, Mr Patea targeted his abuse and threats towards her mother and her solicitor, surmising that they were responsible for Ms Brown’s recent actions. Mr Patea threatened that he would come to the solicitor’s house and take his child away from him, and told Ms Brown’s mother, “I’ll keep doorknocking until I find her”.

Both Ms Brown’s mother and solicitor (over the course of the weekend) took these threats so seriously that they temporarily relocated to protect themselves and their families.

Mr Patea intimated to Ms Brown’s solicitor that he was not aware of the presence of the DVPO when they spoke on 4 September 2015 to discuss custody issues. With regards to the non-contact conditions on the protection order, Mr Patea stated, “that’s not fair she needs to answer to me for what she has done. She needs to answer to me. She must pay for what she has done…. I have the right to make her answer for what she has done”, demonstrating his prevalent male proprietariness and misogynist attitudes.

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Later that day, Ms Brown’s solicitor met with Mr Patea’s solicitor to organise temporary consent orders for custody arrangements of their daughter. Ms Brown and her solicitor discussed what her instructions would be if anything were to happen to her, and she waived all privilege and confidentiality so that he would not be hampered in relating what had transpired.

Ms Brown’s solicitor requested Mr Patea’s solicitor ensure that Mr Patea was aware of the conditions of the protection order as he was concerned that he would breach the order. Both parties agreed on interim arrangements for a safe drop off so that Mr Patea’s daughter could spend the upcoming Father’s Day with Mr Patea.

Arrangements were made for Ms Brown and Mr Patea to drop off and pick up their daughter from Mr Patea’s aunt’s residence with a half hour window to ensure Ms Brown and Mr Patea would not be present at the same time. Mr Patea’s aunt raised concerns with this proposal because she considered Mr Patea would wait outside for Ms Brown.

Ms Brown returned to the Gold Coast on 5 September to facilitate the drop-off of her daughter to Mr Patea’s family on Father’s Day.

On 6 September 2015, Ms Brown dropped her daughter off at a pre-arranged location to Mr Patea’s mother. Ms Brown collected her daughter that evening.

Ms Brown signed the court documentation with her solicitor on 7 September 2015.

These documents were delivered to Mr Patea’s solicitor’s office that afternoon. Ms Brown was confident in her safety after the successful visitation the previous day and wanted to return to her life including her work on the Gold Coast. Ms Brown returned to the safe house at which she had been staying to pick up her belongings and she returned to her aunt’s place that night, ahead of her plan to recommence work on Tuesday 8 September 2015.

Service System Contact In addition to the assistance Ms Brown sought from the QPS, she and Mr Patea also had contact with a number of government agencies, health professionals and agencies providing DFV services (service systems). These services included Queensland Health; DV Connect; the Gold Coast Domestic Violence Prevention Centre; Erin House (women’s refuge); and a private psychologist.

Queensland Health (Ms Brown) Ms Brown attended a series of antenatal appointments with the Gold Coast Health Service District. Her first appointment was on 12 March 2012 and included screening questions about DFV. She denied any assaults in the last year and denied being frightened of Mr Patea. However, she reported that she had some anxiety in her relationship and her partner had recently joined The Bandidos. She declined an offer for further assistance in relation to DFV.

Ms Brown missed her appointment on 23 April 2012 (the day after she was assaulted by Mr Patea and the day the temporary DVPO was made). She attended Findings into the death of Tara Matekino Brown Page 15

an appointment the next week and advised that she had started smoking due to the stress of her relationship but did not disclose the assault or the DVPO.

Ms Brown went into labour on 20 May 2012 and Mr Patea drove her to hospital and was present for the birth. It was there that he threatened to slit her mother’s throat because she didn’t say hello to him when she walked into the birthing suite. The midwife overheard the threat and called security officers and a social worker to attend.

The social worker spoke to Ms Brown and her mother who disclosed the DVPO which prevented Mr Patea from having contact with them. Ms Brown’s mother was fearful of what would happen if he was prevented from staying at the hospital. The hospital staff concluded that, “he is the father and he has a right to be here”.

Ms Brown was discharged at 9pm on 21 May 2015, less than twenty-four hours after giving birth and there was no mention of DFV in the discharge summary. She was visited at home by maternity care practitioners on 23, 24 and 25 May 2012 and there is no record of any inquiries about DFV being made at these visits.

Ms Brown had no further contact with Queensland Health until she was taken to hospital following the fatal assault on 8 September 2015. On that day Ms Brown and Mr Patea were treated in adjacent bays in the Emergency Department which was undesirable taking into account that Mr Patea had only superficial injuries, was conscious, in close proximity to his victim and had the capacity to inflict further injuries on her.

Queensland Health (Mr Patea) Mr Patea had contact with mental health services as a juvenile. He had a history of self-harm, emotional dysregulation and a suicide attempt (although he allegedly stated he did not intend to harm himself and only wished to scare H).

In July 2009 he has admitted to a mental health unit for several days after attempting suicide by overdose in the context of relationship issues with H with whom he was reportedly obsessed.

After his discharge he completely disengaged with mental health services.

Mr Patea demonstrated a pattern of coercive controlling and abusive behaviours from a young age, and despite appropriate detection and intervention planning, there was limited evidence of meaningful engagement with any service to address these behaviours of concern.

Due to a lack of intensive service response and disengagement by Mr Patea, his problematic behaviours were not effectively addressed at a young age, significantly impacting the lives of many people he subsequently had contact with.

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Psychologists Shortly before her death, Ms Brown’s employer referred her to the employee assistance service provider for his law firm. On 3 September 2015 she had an intake session with a counsellor from Counselling Psychotherapy Clinic regarding her DFV and custody concerns. She disclosed the recent controlling behaviours of Mr Patea and that she was fearful that if she obtained another DVPO, “it will be all over”.

She disclosed that Mr Patea continued to threaten her and her family, threatened suicide and made her feel as if it were all her fault. She said that she planned to obtain a court order to get full custody of her daughter.

Ms Brown’s next appointment was to be the day she was killed. She had phoned to confirm that appointment minutes before the fatal assault.

Specialist Domestic Violence Services DVConnect On 3 September 2015 Ms Brown requested assistance to enter a refuge, fearing that Mr Patea would pursue her.

DVConnect completed a risk assessment and Ms Brown was recorded as ‘high risk’ in all fields. Ms Brown and her daughter were put into a motel that night and sent to a refuge shelter away from the Gold Coast the following day.

On her arrival at the refuge Ms Brown was again assessed as ‘high risk’ and was extremely fearful of Mr Patea.

On 5 September 2015, Ms Brown returned to the Gold Coast so that her daughter could spend Fathers’ Day with Mr Patea. When that went well and Mr Patea complied with the changeover arrangements and did not breach the DVPO, Ms Brown felt safer.

At 3pm on 7 September Ms Brown advised that she was leaving the refuge as she believed she would be safe as Mr Patea had given an undertaking that he would not commit any acts of violence towards her. The manager expressed her concerns about Ms Brown leaving the refuge but could not prevent her from doing so. The manager and a support worker developed a safety plan for Ms Brown and told her she could return at any time.

Domestic Violence Prevention Centre Ms Brown was referred to the centre on two occasions. Ms Brown was referred to the service on 23 April 2012 after Mr Patea assaulted her when she was pregnant and she occasionally engaged in counselling and case management.

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On 4 May 2012, Ms Brown told a counsellor that she was confused about whether to revoke the DVPO as Mr Patea wanted to be present at the birth and see the baby at home. The counsellor advised that she could not revoke it as it was a police DVPO and it would be at the discretion of a magistrate.

The counsellor advised Ms Brown that if there were ongoing concerns about Mr Patea being a risk to Ms Brown or the baby the Department of Child Safety would not hesitate to remove the baby from her care. This advice had the potential to have had a significantly negative impact on Ms Brown’s future engagement with formal social supports by making her fear that she would lose her child if she disclosed

DFV.

DVPC liaised with other stakeholders regarding the risk to Ms Brown including Queensland Corrective Services and QPS. Ms Brown refused to engage with further attempts of support until 16 July 2012 when she was advised that Mr Patea had been remanded in custody for breaching the DVPO. She then disclosed ongoing and significant verbal, emotional and physical abuse and consented to DVPC providing that information to QPS for use in opposing Mr Patea’s bail.

Ms Brown reported that Mr Patea had punched her in the head whilst she was holding the baby and he had often pushed and shoved her. She said he had locked her in the house and told her she could not leave because he owned her. DVPC offered to temporarily relocate Ms Brown and her family to a motel so that a risk assessment could be conducted but she declined that offer.

Mr Patea was sentenced to a suspended sentence after serving one month in custody and was released from prison on 17 July 2012. Ms Brown subsequently disengaged with DVPC.

There was a second police referral on 28 July 2012 after Mr Patea assaulted her by throwing food at her and damaged her property but Ms Brown again refused to engage with the service.

On 3 September 2015, a DVPC support worker assisted Ms Brown to complete a private application for a DVPO at the Southport Magistrates Court. The worker arranged the accommodation through DVConnect whilst at the court.

DVPC run the Men’s Domestic Violence Education and Intervention Program (MDVEIP) which Mr Patea was referred to as a condition of his probation order made on 14 December 2010 for breaching the DVPO in relation to H. Although he attended for twenty-seven weeks, his attendance was the extent of his engagement and he was assessed as a future high risk DFV offender in each of the twenty-seven sessions he attended.

Findings into the death of Tara Matekino Brown Page 18

Failures of the System Queensland Health Queensland Health failings included:

• Ms Brown’s disclosure at her first antenatal appointment that she experienced anxiety in her relationship was not followed up at subsequent appointments; and

• Staff witnessed DFV whilst Ms Brown was in labour but made arrangements for Mr Patea to be present at the birth although it was known that his presence was a breach of a current DVPO and did not contact police.

Queensland Police Service The actions and inactions of police officers at Southport Police Station on 3 September 2015 when Ms Brown attended seeking assistance were the subject of an investigation by the Ethical Standards Command of the QPS after Ms Brown’s death.

Prior to attending the police station, Ms Brown’s solicitor contacted the Southport police station and requested a private room be arranged so that Ms Brown could speak to police about Mr Patea in private as she was in fear due to him being a high profile OMCG member. When they arrived at the police station, police refused to provide a room and when Ms Brown and her solicitor attended the counter the constable refused to discuss the matter with the solicitor. Ms Brown had seen a member of Mr Patea’s family outside the police station and was fearful that they were watching her and would report back to him that she had been at the police station but the constable would only speak to her at the front counter. He then separated her from her solicitor and her mother and did not speak to them or take statements from them although they had independently witnessed DFV committed by Mr Patea.

Ms Brown showed the constable the threatening text messages that Mr Patea had sent her. He looked at some but considered that there were no direct threats of violence. He did not consider the fact that she had been sent hundreds of messages in the space of hours to constitute DFV.

Ms Brown reported that Mr Patea held scissors to her throat and threatened her but the constable’s recollection and reporting of events differed dramatically from that of the solicitor and Ms Brown’s mother who were also present. He recorded that scissors fell out of Mr Patea’s pocket after he pushed her onto the bed and that it was not a violent push.

Ms Brown was reluctant to sign a statement about the events. The constable spoke to his shift supervisor, a Sergeant, and both concluded that they had no evidence to confirm that DFV had occurred.

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Instead of recording the matter as a DFV occurrence the constable recorded it as intelligence in the police database.

Ms Brown’s solicitor stated: To my complete and utter bewilderment, the police did not consider that there was enough evidence to warrant them acting and they sent her away.

It was his impression that they would not act on Ms Brown’s information unless she provided information about Mr Patea’s links to the Bandidos. Ms Brown’s mother also believed that was the case.

The shift supervisor sergeant stated, “she doesn’t want to sign anything that may implicate the respondent [Mr Patea] and I got the impression that she may have been scared of him, she may have feared repercussions.” This was obviously correct but does not explain why he and the constable decided not to investigate the complaint or make an application for a DVPO on behalf of Ms Brown. There is nothing within the police Operational Procedures Manual (OPM) or DFVPA legislation that requires a signed statement be included in a police application for the DVPO. Further, there is no requirement for a victim to provide a signed statement of ‘consent’ to criminal charges to be laid for a criminal prosecution to commence. The constable could have obtained copies of the text messages and taken statements from the solicitor and Ms Brown’s mother.

Victims of DFV are often too fearful to provide signed statements or they advise police after proceedings have commenced that they do not wish to proceed with their complaint. This is often due to pressure or threats from the perpetrator of DFV. If police have or can obtain independent evidence of breaches of DVPO or criminal offences they can continue with criminal proceedings without a signed statement from the victim.

The DFV Liaison Officer, a Senior Sergeant, also stated that she considered that the constable had insufficient evidence to apply for a DVPO without a signed statement from Ms Brown. It was part of her duties to audit the DFV occurrences, however, she was so far behind due to being removed for other priorities, that she had not conducted one audit that year (in nine months).

Concerningly the shift supervisor Sergeant was unaware of the Domestic Violence Protective Assessment Framework (DV-PAF) which is a checklist used by police to determine the seriousness of the DFV incidents that was implemented in 2012 to improve police responses to DFV.

Further, the Sergeant told ESC investigators that it was: Commonplace for women to make false allegations [of DFV] to further their position in relation to Family Court matters.

Findings into the death of Tara Matekino Brown Page 20

The ESC investigation found that there was sufficient evidence for the constable to make an application for a DVPO on behalf of Ms Brown and he failed to investigate the complaint properly. The investigation also found that his failure was a breach of discipline and sufficient grounds for disciplinary action to be instituted.

The ESC investigation determined that the (shift supervisor) Sergeant failed in his duty to properly supervise the constable or to ensure action to investigate the allegations of DFV were taken which was a breach of discipline and sufficient grounds for disciplinary action to be instituted.

The lack of an appropriate response by police is highlighted by the fact that when Ms Brown attended the Magistrates Court after leaving the police station she was assisted to complete an application for a DVPO which was finalised and submitted in about one hour and a temporary DVPO was issued by the court less than an hour after that.

It is clear that the frontline officers on duty that day lacked a comprehensive understanding of applicable legislation and policies. They also failed to identify the risk that Mr Patea posed to Ms Brown.

DFV is often a predictable pattern of behaviour which is likely to escalate over time and in response to certain triggers. These triggers (risk lethality factors) have been the subject of research which has led to the development of risk assessment tools.

Determining the severity of abuse and level of dangerousness of a case can help services make appropriate decisions about actions required to assist victims.

The Ontario Domestic Violence Death Review Committee created a list of 40 risk factors that may indicate the potential for lethality within an intimate partner relationship. In 80% of cases reviewed by the Committee from 2003 to 2014, seven or more lethality factors were present in victims and perpetrators, indicating that these domestic homicides were predictable and may have been prevented with earlier recognition and action. The presence of multiple risk factors should be interpreted as requiring an immediate response.

An examination of the circumstances surrounding Ms Brown’s death reveal that at least twenty-seven intimate partner homicide lethality risk factors were present at the time of her death. These were known to formal support services but it seems that none of them identified the extremely high level of risk to Ms Brown.

The lethality factors present for Ms Brown were:

1. Prior history of DFV;

2. History of Mr Patea’s violence outside the family;

3. Prior threats with a weapon;

4. Prior threats by Mr Patea to commit suicide;

5. Prior suicide attempts by Mr Patea;

6. Prior threats by Mr Patea to kill Ms Brown;

7. Prior assault by Mr Patea when Ms Brown was pregnant;

8. Mr Patea’s control of most or all of her daily activities; Findings into the death of Tara Matekino Brown Page 21

9. He had choked/strangled Ms Brown in the past;

10. He had previously taken her hostage or forcibly confined her;

11. He had attempted to isolate her;

12. Threats of violence against family pets;

13. Obsessive behaviour by Mr Patea;

14. Ms Brown had an intuitive sense of fear of him;

15. Child custody or access disputes;

16. They were in a defacto relationship;

17. There had been prior destruction of Ms Brown’s property;

18. There was an escalation of violence;

19. There was extreme minimisation and/or denial of spousal assault history by Mr Patea;

20. There was an actual separation;

21. Mr Patea had psychiatric problems;

22. Mr Patea had access to firearms;

23. Mr Patea believed that Ms Brown was involved in a new relationship;

24. Mr Patea’s failure to comply with authority;

25. Their youth;

26. Sexual jealousy; and

27. Mr Patea’s misogynistic attitudes.

The police officers who spoke to Ms Brown did not understand or identify these lethality factors and the associated risk to her. The constable told ESC investigators that his understanding of the police database was so lacking that he could not access the relevant historical information about Ms Brown and Mr Patea.

The ESC investigators concluded that although the QPS response to Ms Brown’s circumstances had been inadequate the inactions of police officers did not contribute to her death as there was a DVPO in place at the time of her death.

Police officers who dealt with the complaint made by H also failed to respond appropriately. This was a missed opportunity to hold Mr Patea accountable for his actions in perpetrating DFV at an early stage.

Ms Brown’s Employer Ms Brown disclosed the DFV to her employer. In 2014 she told him that she had moved out of the home and she was incredibly scared of Mr Patea. Ms Brown’s employer made concerted efforts to protect her. He implemented a locked door policy to prevent Mr Patea entering the office. During the week before her death Ms Brown’s employer was instrumental in providing her advice and assistance to obtain the temporary DVPO, interim consent parenting orders and refuge in a DFV shelter.

He gave her leave from work so that she could protect herself and her daughter and was supportive when she decided to return to work, giving her time to find new accommodation.

The steps Ms Brown’s employer took to try and assist Ms Brown’s safety were admirable and went above and beyond what might be expected of an employer. It is of significant concern that police did not obtain a statement from Ms Brown’s Findings into the death of Tara Matekino Brown Page 22

employer or listen to his concerns regarding Ms Brown’s safety when he attended the police station with on 3 September 2015.

Changes Implemented by QPS Since Ms Brown’s Death The Not Now, Not Ever: Putting an End to Domestic and Family Violence in Queensland report (Not Now, Not Ever report) released in 2015 included several recommendations directed at the QPS about improving police officers understanding of the dynamics of DFV and to strengthen options for perpetrator accountability.

Specifically:

• improve the criminal investigation and prosecution of perpetrators of DFV;

• achieve a more pro-active investigation and protection policy;

• ensure that arrest is prioritised where a risk assessment indicates the action is appropriate; and

• improve governance, supervision, and training of police officers in relation to

DFV.

These recommendations collectively focused around changing culture to promote and embed best practice policing strategies to deliver appropriate support and protection to victims and their family while strengthening processes to increase the accountability of DFV offending.

QPS has implemented all recommendations and the ongoing commitment to servicewide culture change is reflected in the Queensland Government’s Domestic and Family Violence Prevention Strategy 2016-2026 and the Service’s Strategic Plan 2020-2024 and the Operational Plan 2020-21 and DFV Prevention Strategy.

Organisational Changes In late 2015 the QPS:

• appointed a Deputy Commissioner as a DFV Cultural Change Champion to oversee the delivery of the Service’s DFV reforms. That same Deputy Commissioner was also appointed as a member of the DFV Implementation Council and remains a member of the new DFV Prevention Council;

• reinstated the State DFV Coordinator role; and

• established the State Domestic, Family Violence and Vulnerable Persons Unit (SDFV&PU) to provide specialist advice, enhanced operational support and governance at state and national levels to help formulate appropriate frontline policing strategies and referral pathways for vulnerable people, coming into contact with police, at times of crisis or intervention. The portfolio scope of the SDFV&VPU has grown to now cover: DFV and high risk teams; mental health and suicide prevention; elder abuse and disabilities; Police Referrals and homelessness; and Victim Assist Queensland.

The primary consideration for police when interacting with at-risk and vulnerable persons is to apply appropriate supports and safeguards to ensure timely, quality and efficient policing responses. An effective police response identifies Findings into the death of Tara Matekino Brown Page 23

characteristics of vulnerability, provides appropriate supports for the vulnerable persons, and ensures a procedurally just outcome through the criminal justice system. Architecture supporting these considerations includes legislation, the OPM and new frameworks.

Legislation Amendments to the Domestic and Family Violence Protection Act 2012 (DFVPA) from 2015 onwards have provided a platform for the QPS to shape the way it approaches, investigates and resolves DFV matters. For example: legislation introducing Police Protection Notices (PPN) has allowed police to provide immediate protection for victims of DFV and named persons until such time as a court can determine the necessity for a Domestic Violence Order. It also allowed relevant information about victims and perpetrators of DFV to be shared across prescribed government and non-government entities to improve victim safety and perpetrator accountability.

Section 169F(1) of the DFVPA states a police officer may refer person to specialist DFV service provider if the police officer reasonably believes—

(a) the person fears or is experiencing DFV and there is a threat to the person’s life, health or safety because of the DFV; or

(b) the person has committed DFV against another person.

The QPS Referrals system allows police officers to refer DFV victims or perpetrators with or without their consent.

An amendment to the Criminal Code in 2016, introduced a new section 315A ‘Strangulation, choking, suffocation in a domestic setting’. The new offence has enhanced the ability of police and the justice system to hold perpetrators accountable for non-lethal strangulation offences.

In 2017, amendments were also made to section 16 ‘Refusal of bail generally’ of the Bail Act 1980 to widen the circumstances in which a police officer authorised to grant bail can refuse bail, to include where an offender has been charged with a relevant DFV offence.

Operational Procedures Manual The SDFV&VPU is currently reviewing Chapter 9 (Domestic violence) of the OPM to ensure it is contemporary and responsive to emerging issues, such as identifying the person most in need of protection and recognising coercive control. This review also aims to simplify processes to ensure there is no ambiguity regarding how police are to investigate DFV.

Vulnerable Persons’ Framework People affected by DFV may also experience multiple other forms of disadvantage making their needs complex and multi-faceted.

The QPS has recognised it is vital to understand the multi-faceted and complex nature of vulnerability to efficiently formulate preventative strategies, implement evidence-based interventions and identify appropriate referral pathways for Findings into the death of Tara Matekino Brown Page 24

vulnerable Queenslanders. This led to the development of a person-focused policing approach and Vulnerable Persons Framework.

The person-focused approach encourages police to “see the person” and to consider the individual and their unique circumstances in all aspects of the policing response.

It focuses on creating a holistic picture of an individual to help police deliver a more nuanced and considered policing response.

The Framework has been refreshed to broaden the scope of the strategic guide from its original purpose of establishing Vulnerable Persons Units. The new focus includes: promoting person-focused policing practices; developing templates and resources that promote investigative practices based on the principles of responsiveness to the needs of vulnerable and diverse communities; thorough investigation based on a “right the first time” principle; and consistent interface between general duties and criminal investigation within a DFV context.

District Instructions The QPS District DFV Coordinators (DFVC) provide guidance to frontline officers when responding to DFV through District Instructions. These instructions are based on legislation and Service policy, but tailored to incorporate responses to local issues. For example, the use of interpreters at DFV incidents, including contact details for approved services.

Information Repositories The SDFV&VPU maintains an internal webpage where QPS members can source information and resources related to DFV and vulnerable persons.

In addition, the SDFV&VPU uses Workplace as a forum to address operational issues and provide important information in easily digestible bites. Workplace in an online forum, similar to Facebook, which connects members of the QPS and provides information on operational and policy issues. Recent Workplace posts have included, non-lethal strangulation, reporting DFV at the front counter of police stations, non-consensual sharing of images, police referrals for respondents and use of interpreters. Workplace also provides a platform for frontline officers to raise operational matters and receive a timely response.

Training, Education and Professional Development In response to the Not Now, Not Ever recommendations, the QPS engaged the Queensland Centre for Domestic and Family Violence Research at the Central Queensland University to conduct an audit and review of training. Their final report: Evidence-based review of Queensland Police Service’s DFV training was delivered in 2017, with recommendations including:

• develop a state-wide DFV education and training framework recognising foundational, promotional and ongoing professional development needs of all QPS employees; Findings into the death of Tara Matekino Brown Page 25

• annual DFV refresher training, continual education opportunities for the DFVC network and development of an evaluation strategy to enable ongoing review of programs;

• review of delivery models and methods of current training programs to ensure they achieve optimum learning outcome; and

• address identified training gaps through inclusion of specific communication and interpersonal skills, cultural awareness and understanding of the complexities of DFV within specified communities, enhanced understanding of the role and benefits of police referrals and in knowledge and understanding of strangulation.

The QPS has introduced a number of training and education packages to assist police recognise and investigate DFV, focusing on the relationship rather than the incident. Including:

• Vulnerable Persons Training Package in 2017 which is a two-day workshop, and which has been delivered to all police officers up to the rank of inspector and selected non-sworn employees;

• Domestic and Family Violence Specialist Course which is a five-day, face to face course designed for specialists in the area of DFV such as liaison officers, prosecutors, detectives, child protection investigation unit members, intelligence officers and DFV high risk teams;

• post graduate studies in DFV prevention: between 2016 and 2019 the SDFV&VPU supported and funded 17 o officers to undertake the Graduate Certificate in DFV; between 2018 and 2019 QPS prosecution service supported and funded o 42 sworn and non-sworn prosecutors to undertake postgraduate studies in DFV; four commissioned officers have completed a Master of Studies in o Applied Criminology and Police Management through the University of Cambridge which provides world leading training on DFV crime prevention and harm reduction;

• Domestic and Family Violence Culture Change Program has been developed and delivered in late 2019 to selected culture change champions in fifteen police districts;

• training of Policelink and other civilian staff have mandatory online training to improve their awareness of DFV issues;

• specialist training for police in relation to non-lethal strangulation has been incorporated into the Vulnerable Persons Training Package delivered to recruits, first year constable and detective training programs;

• the first-year constable program and recruit training programs have been amended to include additional training on DFV; and

• in October 2020 it was confirmed that QPS would receive funding to facilitate training to frontline police to improve recognition of, response to, and, investigation of coercive control within the DFV context and it is expected to be rolled out in 2021.

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Preventing, Disrupting, Responding to and Investigating DFV The DFV Process Improvement Action Plan was developed in 2019. The initiative seeks to enhance the Service’s effectiveness in responding to DFV, through the refinement of processes, policies and legislation that maintain the focus on victim safety and perpetrator accountability. Some initiatives include the ability to adduce video recorded statements of victims as evidence in chief and immediately enforceable extended Police Protection Notices (mandatory conditions only).

Queensland Police Referrals Queensland Police Referrals is a process that allows officers to connect at-risk and vulnerable people with external support providers to address social and lifestyle issues impacting on their life. Offering a referral has become an embedded strategy in the frontline policing response to all occurrences.

The fully automated system has over 510 service providers covering 67 different issues, which are broadly grouped into 22 referral categories, with these categories linked to ten themes including: DFV (for both victim and perpetrator); homelessness; mental health; seniors; and victim support. Police Referrals is integrated with QPRIME enabling police to be better informed of a person’s referral history, including situations where a client has declined an offer of a referral. Service provider actions in relation to previous referrals are also available in QPRIME.

District DFV Coordinator Network Specialist DFVCs are located in each of the 15 police districts. These officers are responsible for developing and coordinating appropriate locally based policing strategies and responses to DFV within their districts, in collaboration with their respective District Officers.

The State DFVC provides overall guidance on the strategic direction related to DFVrelated reforms.

Since 2015, the QPS has hosted annual workshops for the DFVC network, Mental Health Intervention Coordinators, High Risk Team members and Police Referrals Coordinators. These workshops provide participants with the opportunity to hear from guest speakers from academia, government and non-government agencies, practitioners and internal specialists. Topics have included: intimate partner violence, culturally and linguistically diverse communities, non-lethal strangulation, disability and risk assessment. The workshops also provide opportunities for DFVCs to network and discuss local issues affecting their community.

DFV and Vulnerable Persons Units The QPS has established several district Domestic, Family & Vulnerable Persons Units (DFV&VPU) throughout Queensland. These units actively engage with victims and perpetrators of DFV. This engagement includes identification of support options via police referrals, investigation of criminal elements of DFV incidents and perpetrator accountability.

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High Risk Teams Eight integrated High Risk Teams have been established in Queensland in response to recommendation 76 of the Not Now, Not Ever report. They are located in the following areas:

• Cherbourg (discrete indigenous community) (established 2017);

• Mount Isa with outreach (established 2017);

• Logan-Beenleigh (established 2017);

• Cairns District (established 2018);

• Ipswich District (established 2018);

• Brisbane Region (established 2018);

• Mackay (established 2019); and

• Moreton District (established 2019).

The High Risk Teams are led by the Department of Child Safety, Youth and Women and supported by a coordinator drawn from DFV support services. Membership of the High-Risk Teams include government and non-government agencies such as police, courts, corrections, health, housing, child safety and domestic violence support services.

High Risk Teams operate using a three-tiered approach to assess and manage high risk DFV. Level One includes referrals are made by frontline police, hospital emergency staff and social workers. QPS DFVCs and/or District Domestic Violence Liaison Officers (DVLO) and/or HRT members are referred to as Level Two referrers. Level Two referrers review DFV occurrences, including the DV-PAF, which is completed by police who attend a DFV incident, to identify high risk incidents requiring further attention.

A case remains with the High Risk Team until members are satisfied that safety management strategies are in place and the risk of harm to victims and their children has been mitigated and perpetrators are held to account whenever possible. A final risk assessment may be conducted prior to the case concluding with the HRT. The Multi-agency Risk Assessment (MARA) is used to ensure appropriate measures are in place. Avenues exist for a case to be re-referred to the High Risk Team should additional information come to light or new incidence of domestic violence occur.

Most High Risk Teams operate from a local police station which allows police officers to ask questions related to DFV and to build and maintain relationships between the High-Risk Teams and local police.

Operation Sierra Alessa The aim of Operation Sierra Alessa is to identify and target domestic and family violence perpetrators, through applying focused deterrence strategies to disrupt the offending cycle. It also aims to reposition domestic family violence within the social values system from normalisation to criminalisation, from passive acceptance to intolerance.

The operation is coordinated by the SDFV&VPU and involves general duties, DFV & Vulnerable Persons Units, HRTs and specialist officers and investigators from across all parts of the organisation. The operation provides opportunities for QPS officers to place eyes on prolific offenders and provide greater support to some of our most Findings into the death of Tara Matekino Brown Page 28

vulnerable Queenslanders, including children and family members whose routine activities have changed under Covid-19.

The operation is made up of three tranches, which will each operate for two months.

The active stage of the operation started on 15 August 2020. This stage tasks operational police across 15 Queensland districts to proactively target recidivist DFV offenders by implementing early intervention strategies to disrupt the offending cycle and prevent further incidents of DFV.

These involve:

• ensuring police conduct a timely and thorough investigation of all DFV offending;

• developing strategies specific to the individual DFV environment to safely navigate the easing of COVID-19 restrictions and the impact that increases in unemployment and social disruptions may potentially have on DFV in the community;

• identifying whether perpetrators and victims have been provided with access to appropriate police referral pathways and whether there was appropriate engagement by the service provider;

• ensuring there are appropriate referral pathways for children impacted by DFV and the appropriate government agencies are provided with timely and relevant information about children at risk; and

• ensuring Domestic, Family Violence Coordinators are available to provide support, training and advice regarding DFV legislation, policy and processes.

Case Management Teams In addition to the teams already mentioned, the QPS is represented on integrated case management teams which also deal with DFV, including:

• Suspected Child Abuse and Neglect (SCAN) teams which focus on providing a multi-agency response to cases requiring statutory intervention to protect a child;

• Domestic Violence Cross Agency Meetings (DV-CAM) which aim to provide a DFV integrated response within the district to support multi-agency assessment and planning to address repeat calls for service and increase the safety of families experiencing DFV. These teams include members from local DFV service (non-government) providers and other government departments;

• the Prosecutions Review Committee which examines the processes, policies and procedures involved in matters before the Magistrates Court to seek to identify areas for improvement; and

• PRADO which is an interagency partnership between the QPS, Caboolture Child Safety, Caboolture Probation and Parole and Caboolture Regional Domestic Violence Service for high risk families.

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QPS DFV – Protective Assessment Framework The DV-PAF framework was developed in 2013 to improve the decision making of frontline officers when assessing the protective needs of families experiencing DFV.

It ensures a consistent approach is applied during the assessment process. It has been re-evaluated and changes are being considered.

QPRIME Reporting In 2017 changes were made to require an Officer in Charge of a station to approve the finalization of specific offences and/or occurrences.

Crime managers in each district regularly review all reported crime (including DFV related) on QPRIME and are responsible for assigning appropriate investigative taskings to officers in relation to these occurrences.

District DFVCs or relevant officers conduct audits of DFV occurrences including, Police Application – Domestic Violence (Police Protection Notice and Application for a Domestic Violence Order), DV – Other (referral), Contravention of a Domestic Violence Order and any other associated criminal (Domestic Violence) offences including strangulation. Where necessary or as issues are identified, DFVCs will task the investigating officer to follow up with specific actions. DFVCs and DVLOs report to the Officers in Charge of Divisions within their District on identified exceptions and compliance issues.

Conclusion I find that Ms Brown died from head injuries which were inflicted on her by Mr Patea when he struck her repeatedly to the face and head with a steel fire hydrant cover.

The fatal attack was the culmination of a long history of DFV committed on Ms Brown by Mr Patea.

Police officers at the Southport station failed to respond appropriately to Ms Brown’s complaint on 3 September 2015.

Whilst it is impossible to determine whether the tragic outcome for Ms Brown would have been avoided if QPS had addressed the issues adequately, it is clear that Ms Brown was not assisted as comprehensively as she could have been had the information provided to QPS been dealt with appropriately.

However, I accept that since the death of Ms Brown and the Not Now, Not Ever Report there have been significant improvements throughout the Queensland Police Service in relation to procedures surrounding identifying and preventing DFV.

Taking into account the initiatives and improvements implemented by QPS, I am satisfied that an inquest into the death of Ms Brown is not required as I could not identify any recommendations for preventing similar deaths in the future that have not already been, and continue to be, identified and implemented.

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Findings required by s.45 Identity of the deceased – Tara Matekino Brown How she died – Ms Brown died from head injuries which were inflicted on her by Mr Patea when he struck her repeatedly to the face and head with a steel fire hydrant cover.

Place of death – Gold Coast University Hospital QLD AUSTRALIA Date of death– 9 September 2015 Cause of death – Head injury My sincere condolences to family, friends and all persons who have been affected by the tragic death of Ms Brown.

I close the investigation.

Jane Bentley Deputy State Coroner

CORONERS COURT OF QUEENSLAND - SOUTHERN REGION Findings into the death of Tara Matekino Brown Page 31