Palhares, Fabiana - Non-inquest findings

CORONERS COURT OF QUEENSLAND FINDINGS OF INVESTIGATION CITATION: Non-inquest findings into the death of Fabiana Yuri Nakamura Palhares TITLE OF COURT: Coroners Court

JURISDICTION: SOUTHPORT DATE: 20/01/2021 FILE NO(s): 2015/452 FINDINGS OF: Jane Bentley, Deputy State Coroner CATCHWORDS: Coroners; Domestic and Family Violence; DVConnect; Queensland Police Service; High Risk Teams

Table of Contents

Ms Palhares was 34 years old at the time of her death. She was ten weeks pregnant to her estranged partner, Brock Wall.

Ms Palhares had migrated to Australian from Brazil in 2004. She married soon after her arrival in Australia but she separated from her husband in 2009 and they divorced in 2012.

Ms Palhares commenced a relationship with Mr Wall in September 2012 after meeting him on an online dating site.

Circumstances Surrounding the Death of Ms Palhares At 1.53pm on 2 February 2015 Ms Palhares called 000. She didn’t have time to identify herself but said, “Please help me.” Queensland Police Service officers tracked the location of call and police officers were dispatched to her address. On the way they intercepted Mr Wall who was covered in blood. He told officers he had hit Ms Palhares in the head with a tomahawk and believed she was dead.

Queensland Ambulance Service paramedics attended and found Ms Palhares lying in a pool of blood with extensive injuries to her face, scalp and right hand. She was still conscious but went into cardiac arrest at the scene. She was transported to the Gold Coast University Hospital where she was unable to be resuscitated. She was pronounced deceased at 5.35pm.

Autopsy An autopsy was conducted and revealed that Ms Palhares died from head injuries.

She had sustained severe head injuries with multiple fractures of the facial bones and skull, predominantly on the right side. She had bruising throughout the soft tissues of the head and neck and haemorrhage around and within the underlying brain which had resulted in swelling of the brain and diffuse traumatic injury throughout the brain. She had inhaled blood due to her facial injuries.

The head injuries were due to blunt force trauma from multiple blows to her head.

They were consistent with being caused by the head of an axe such as that seized by police.

Ms Palhares had injuries on the front of her abdomen consistent with shoe imprints.

She had bruising in the underlying abdominal wall and a tear in the mesentery of the small bowel which had caused a large haemorrhage into the abdominal cavity (at least 800ml of blood) as well as haemorrhage into the tissues at the back of the abdomen.

The injury contributed to her death.

Ms Palhares had bruising on the back of both of her hands and a cut to her right index finger. These injuries were consistent with defence type injuries.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

At the time of her death Ms Palhares was ten to eleven weeks pregnant.

History of Domestic and Family Violence (DFV) Against Ms Palhares At the time of her death there was a Domestic Violence Protection Order (DVPO) in force which included a condition preventing Mr Wall from approaching the residence of Ms Palhares.

Soon after Ms Palhares and Mr Wall commenced their relationship he became sexually jealous, controlling and verbally abusive. He constantly accused her of infidelity and called her derogatory names.

Ms Palhares ended the relationship in August 2013 when she was in Brazil, however, they later reconciled in October 2014. The relationship continued to be characterized by verbal and emotional abuse by Mr Wall. Ms Palhares became pregnant to Mr Wall in mid-December 2014 at which time the abuse escalated to physical abuse.

On 25 December 2014 Mr Wall was physically violent towards Ms Palhares. This was the first known episode of physical violence. He repeatedly punched and kicked her in the head and stomach and told her he was going to kill the baby. She crawled under a coffee table for protection and was able to flee the residence with him chasing her.

She sustained bruising to her arms, head and foot. She told her housemate that she could not walk for days after the assault. Ms Palhares did not report this assault to police.

In the days following Mr Wall hit Ms Palhares in the head and kicked her in the stomach and locked her in his apartment. She was able to obtain the keys and flee. A neighbour saw her run from the address screaming for help but did not contact police.

Ms Palhares ended the relationship on 29 December 2014 due to Mr Wall’s violent behaviour. Mr Wall attended her address that day, verbally abused her and chased her around her car. Police were called and attended and applied for a DVPO on that date.

Mr Wall remained fixated on Ms Palhares after she ended the relationship and continued to commit acts of DFV against her including:

• texting Ms Palhares’ family in Brazil and telling them that she should get an abortion;

• telling Ms Palhares that he hoped she lost the baby and threatening to punch her in the stomach to induce a miscarriage;

• threatening that Ms Palhares would be unable to take their child to Brazil to see her family;

• constantly accusing Ms Palhares of infidelity;

• destroying several of Ms Palhares’ phones;

• calling Ms Palhares and demanding that she turn on Facetime so that he could confirm her location and who she was with;

• breaking into Ms Palhares’ home to read the contents of her phone; Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

• contacting IT specialists to ‘hire a hacker’ to install e-blaster software onto Ms Palhares’ computer;

• recording videos of himself masturbating and sending these to Ms Palhares without her consent; and

• recording videos of himself with self-harm injuries (such as cut wrists and blood over his face) and sending these to Ms Palhares; and,

• threatening to kill Ms Palhares, her unborn child and her dog.

Ms Palhares was extremely fearful of Mr Wall. She slept with a shovel beside her bed.

She told friends that she was scared. She arranged for security cameras to be installed at her residence and she began to record phone conversations with Mr Wall.

History of DFV Perpetrated by Mr Wall in Previous Relationships In 2001 Mr Wall was convicted of the assault of his then partner. He pulled her out of a car by her hair, punched her several times in the jaw and kicked her in the ribs and then drove off leaving her on the side of the road. Police found her bleeding and she was treated in hospital for bruised kidneys, sore ribs and a split lip. He was sentenced to a twelve month good behaviour bond.

Between 2009 and 2014 three of Mr Wall’s former partners made applications for DVPO. All three alleged verbal abuse including derogatory name-calling, obsessive jealousy including allegations of infidelity and monitoring of social media and phones and damage to property. All also alleged significant physical violence.

In January 2009 Mr Wall commenced a six month relationship with another partner.

She stated that he committed the following acts of acts of DFV against her:

• forced sexual acts;

• threatening to harm her dog;

• physical assaults;

• destruction of her property;

• deletion of everything on her computer;

• stalking post separation;

• threatening self-harm and suicide.

Although the relationship ended in June 2009, he said that Mr Wall’s stalking of her continued until 2014 when she moved address.

In July 2009 Mr Wall commenced a new relationship. By December 2009 that partner described him as highly suspicious, insecure, extremely unstable and physically and emotionally abusive. She applied for a DVPO in which she stated that Mr Wall had:

• read all her emails and logged into her online accounts;

• pushed her into a wall; and,

• kicked her in the head.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

She ended the relationship a few days later but Mr Wall continued to contact her. She became fearful of leaving her residence. She moved overseas in February 2010.

She did not hear from Mr Wall until Christmas Eve 2011 when he sent her an email (it is unknown how he obtained her email address) which stated, “Merry Christmas and I hope you die a slow and painful death you fucking cunt.” In 2010 Mr Wall commenced another relationship with a woman who was a French national. She left him in September 2011 due to his violent behaviour. She was concerned that he continued to stalk her and applied for a DVPO in November 2011.

In that application she recounted a history of repeated emotional and verbal abuse as well as physical abuse including non-lethal strangulation, repetitive hitting and pushing.

Mr Wall met his next partner on an online dating site in November 2013. They had a relationship for three months during which she said that Mr Wall exhibited obsessive jealousy. She said that in December 2013 he choked her and prevented her from leaving his residence. In January 2014 he punched, kicked and choked her and held her down on a bed. He prevented her leaving and accused her of lying and having relationships with other men. She sustained lacerations, bruising, swollen jaw, pain to her throat, difficulty speaking, headaches, blurred vision and a lump on her head.

On 27 January 2014 she reported the assault to Southport police. Officers requested that she return on 29 January 2014 with medical certificates. She did so on 29 January 2014 and police took a statement from her. The investigation was tasked to the Surfers Paradise Criminal Investigation Branch. Police did not apply for a DVPO.

She applied for a DVPO on 28 January 2014 and the order was made on 6 March 2014.

On 19 February 2014 investigating police invited Mr Wall to be interviewed in relation to the allegations of assault. He declined. In May 2014 police determined there was insufficient evidence to charge him with criminal offences.

Mr Wall also committed acts of DFV against his mother. In 2009 he was physically violent to his parents during a visit to see them. He threatened to kill them and members of his family and to burn down his parents’ house with them inside. He prevented his mother from leaving her residence. They began to “fear him terribly.” In February 2011 Mr Wall made his mother grovel and beg for forgiveness for an insulting gesture she made to him in 2009.

Whilst in prison after being sentenced for the murder of Ms Palhares, a notebook was discovered in Mr Wall’s cell in which he had written that he would love to kill his mother if he got the chance.

Service System Contacts Prior to killing Ms Palhares Mr Wall had told others that he was going to kill her. He Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

told numerous people that he did not want to be a father. Ms Palhares had contact with a number of service systems.

On 29 December 2014 Ms Palhares attended the Robina Hospital Emergency Department due to ongoing abdominal pain following the assault on her on Christmas Day. She left before being medically reviewed but she told a social worker that she had separated with Mr Wall due to escalating verbal, social and psychological abuse.

She said that his behaviour had escalated to physical violence “about 10 times” and that the most recent episode of violence had occurred on Christmas Day. Ms Palhares also stated that Mr Wall had destroyed five of her mobile phones and that she was feeling increasingly stressed and anxious.

Ms Palhares expressed willingness to link with domestic violence supports, however, counselling services were closed over the Christmas period and the social worker arranged to follow-up with her.

On 30 December 2014, the social worker attempted to make contact with Ms Palhares but did not initially leave a message as the number she called had a male’s voice on the voicemail. She subsequently left a detailed message on Ms Palhares’ home phone which included her contact details, advice to attend the Emergency Department if she had medical needs and to follow up with her GP in the community. While it is unknown if Mr Wall heard this message, it is unclear what risk assessment was completed by the social worker (if any) to plan for this. Ms Palhares did not have any further contact with social workers prior to the fatal assault.

In the early morning of 30 December 2014 Mr Wall drove from the Gold Coast to New South Wales. During that journey he made repeated telephone calls to friends, family members and formal supports disclosing suicidal ideation and his use of violence toward Ms Palhares.

During a call to Lifeline, Mr Wall reported that he was going to be in “heaps of shit’” because Ms Palhares’ neighbours had called the police on him. He disclosed that he had been “beating” his pregnant ex-girlfriend.

Mr Wall also contacted Surfers Paradise Police Station and asked an officer whether police wanted to arrest him because he had been “violent’” to his girlfriend. The officer explained that were no charges pending, but that he needed to be served with documents in relation to a DVPO. Mr Wall disclosed suicidal ideation and reported that he was thinking about driving into a guard rail. He provided the officer with details of his car and location and NSW police were subsequently tasked to locate Mr Wall as he had already crossed the border.

Mr Wall was located by NSW police and ambulance services and conveyed to Maclean District Hospital, where he reported suicidal intent and depression because of “relationship crisis”. Mr Wall was unable to guarantee his own safety or that of others and was transferred to Lismore Base Hospital for involuntary mental health admission.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

Whilst in transit to Lismore Hospital, Mr Wall informed paramedics that he had been experiencing suicidal thoughts following a fight with his girlfriend on Christmas Day

2014. According to NSW health records, Mr Wall indicated that Ms Palhares had changed and “no longer wants to sleep with him on demand and he feels cheated and like she was dishonest with him.” Mr Wall referred to a DVPO being in place but stated that he didn’t give it any credence as it was yet to be served on him. Mr Wall reported that he would continue to contact Ms Palhares until she realised that he would get help for his issues, but that “she also needed to get help for hers [issues] and recognise that she had changed and his anger was caused by her.” At Lismore Hospital, clinicians assessed Mr Wall to have narcissistic and borderline personality traits in the context of a situational crises. Mr Wall reported a history of ‘explosive relationships’ where he would idolise and then devalue partners and he disclosed that he had been emotionally and physically abusive towards Ms Palhares, who was pregnant. During the mental health examination, it was noted that Mr Wall appeared transfixed on parental issues and obsessed with past traumatic events including parent-child bonding.

During his admission, Qld police officers established contact with Lismore Hospital and requested that Mr Wall not be discharged until he could be served with the DVPO.

Despite having knowledge of this and Mr Wall’s recent violence toward Ms Palhares, she was nominated as his primary carer and staff did not request that Mr Wall nominate an alternative contact.

On the evening of 30 December 2014, Mr Wall contacted Ms Palhares from the high dependency unit to let her know where he was and hospital records indicate that this call did not ‘appear to have gone well.’ Mr Wall then asked to be immediately discharged which was not possible due to his involuntary status. Mr Wall made a subsequent call to Ms Palhares and informed nurses that he could abscond from the facility if he chose to do so.

Clinical staff also spoke with Ms Palhares who reported that she did not want to speak with Mr Wall and that she was frightened for her safety. She advised that a DVPO had been taken out and that she was planning to move out of her house but she did not want Mr Wall to be made aware because she was fearful of what he would do.

On 31 December 2014, clinicians assessed that Mr Wall was no longer experiencing suicidal ideation and he was discharged with a plan to see his GP and a psychologist in the community. Mr Wall’s risk to others was considered ‘low,’ but it appears that this assessment did not take into consideration Mr Wall’s disclosure of recent violence toward Ms Palhares (who was known to be pregnant), Ms Palhares’ reported fear of Mr Wall, Mr Wall’s suicidal ideation in the context of DFV or that Mr Wall had been served with a DVPO shortly before his discharge on 31 December 2014.

Upon attending the DFV occurrence on 29 December 2014, police had made a referral for Ms Palhares through Supportlink and the Domestic Violence Prevention Centre Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

(DVPC) subsequently completed an intake with her on 31 December 2014. This included a safety assessment.

DVPC identified that Ms Palhares had been subject to physical, verbal, emotional, financial and social abuse by Mr Wall. Ms Palhares disclosed that she was pregnant and that Mr Wall had non-lethally strangled her, threatened to kill her and inflicted injuries which had required medical attention. Ms Palhares reported that Mr Wall was capable of carrying out his threats and believed that the violence was escalating. Ms Palhares also disclosed that Mr Wall had threatened suicide, was known to be jealous and highly obsessive and that he would monitor / track her extensively.

As a result of Ms Palhares’ disclosures, DVPC assessed that she was at a high risk of future harm and DVPC developed a safety plan with her which included:

• remaining vigilant with external and internal home environment (eg. keeping doors and windows locked at all times);

• carrying keys, garage remote and phone on her person at all times;

• calling police upon any risk or safety concerns;

• calling DVConnect for emergency accommodation during the DVPC closure period from 1 January 2015 – 5 January 2015;

• developing a safety plan with neighbours / friends;

• being on the DVPC High Risk list and having her address flagged with QPS;

• changing passwords on email, phone and social media accounts;

• purchasing and installing CCTV; and

• developing an emergency exit strategy from her home to her car.

DVPC made further contact with Ms Palhares on 5 January 2015 to assess her safety and risk. She reported to have maintained telephone contact with Mr Wall but that there hadn’t been any physical contact. Ms Palhares reported that she was hopeful to resume some level of a relationship with Mr Wall with regard to their unborn child and shared parenting, but she acknowledged Mr Wall’s risk and unpredictability. Ms Palhares reported no immediate concerns and the counsellor reviewed the safety and emergency exit plans and arranged to follow-up with her.

DVPC contacted Ms Palhares again on 7 January 2015. She denied further violence and reported that she felt safe. Ms Palhares again disclosed a desire to reunite with Mr Wall and the counsellor discussed the cycle of violence with her.

DVPC were unsuccessful in trying to contact Ms Palhares on 12 and 14 January 2015, but established contact with her on 15 January 2015. Ms Palhares reported that she felt safe, requested to be removed from the DVPC High Risk list and declined any ongoing follow-up from the service.

On 2 January 2015, Mr Wall presented to a GP in an agitated state and expressed frustration about his ‘failed relationship.’ Mr Wall expressed ‘great remorse’ about his violence toward Ms Palhares and a willingness to engage in therapy. A Kessler Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

Psychological Distress Scale (K10) was completed and this resulted in a score of 33.

A score between 30 and 50 indicates that a person may have a severe mental disorder. The GP prescribed Mr Wall the drug Mirtazapine and referred him to a psychologist.

Mr Wall established contact with the psychologist but was advised that an appointment would not be available for another month. Mr Wall pleaded to be seen, stating that he was ‘dangerous’ and that he had beaten Ms Palhares on Christmas Day 2014. The psychologist discussed other treatment options and suggested that Mr Wall contact the psychiatrist he had seen at Lismore Hospital.

On 5 January 2015, a friend of Mr Wall contacted the Acute Care Team, Community Mental Health Service in Ashmore (ACT) and expressed concern regarding Mr Wall’s mental state. A clinician from the ACT then telephoned Mr Wall and conducted a triage assessment. Mr Wall disclosed that he had recently driven to Lismore and admitted himself into a mental health facility ‘to see what it was like.’ He reported to have been fully aware of his actions at the time and that he had felt suicidal but ‘did not have the balls to do it.’ Mr Wall believed that he suffered from borderline personality disorder, abandonment issues and anger management issues. He disclosed having been violent toward Ms Palhares which ‘he was not happy about’ and that he was upset because he believed he may not be the father of her unborn child. Despite Mr Wall’s disclosure that he was violent toward his partner, the clinician assessed that Mr Wall was at a medium risk of aggression and a low risk of suicide or self-harm. Mr Wall reported to have an appointment with a psychoanalyst and his GP and as such, the case was closed by

ACT.

On 5 January 2015, Mr Wall returned to the GP. He requested a referral to another psychologist and complained that the Mirtazapine had been causing him increased agitation. Mr Wall was prescribed Modafinil as a mood elevator and the GP provided him with a referral to another psychologist. However, records indicate that Mr Wall never established contact with her.

On 6 January 2015 Mr Wall self-referred to Spectrum, a Victorian-based service that provides treatment for people with personality disorders and focuses on those who have particularly complex needs or are at risk of serious self-harm and suicide. Mr Wall disclosed to Spectrum that he had terrible relationships and a terrible bond with his mother. He reported to have been violent toward his pregnant girlfriend and that he wanted ‘help.’ The Spectrum worker advised that he would see who was in Mr Wall’s area for assessment and then notify him via email. However, it is unclear from the records available whether the Spectrum worker followed through with this.

According to DVPC records, a staff member met with Surfers Paradise police on 6 January 2015 to discuss Mr Wall’s violence toward Ms Palhares and concerns regarding her heightened level of risk. DVPC advised police that Mr Wall had been exhibiting high risk behaviours correlated with domestic and family violence lethality, including:

• physically assaulting Ms Palhares who was pregnant; Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

• attempted non-lethal strangulation;

• threats to harm himself and Ms Palhares;

• stalking; and

• excessively tracking and monitoring Ms Palhares.

At approximately 2:15pm on 7 January 2015, police responded by flagging both Ms Palhares and Mr Wall on QPRIME (the QPS database) as a ‘High Risk DV Response.’ This was recorded as an intelligence submission with the case type recorded as ‘Case Management – Offences against the person domestic violence’ but it is unclear whether the details of Mr Wall’s domestic and family violence (physical assaults, nonlethal strangulation etc) were recorded in the occurrence. It is also unclear from the records available what case management responses (if any) police undertook to further assess or address the risk toward Ms Palhares.

Ms Palhares contacted police at approximately 9:30pm on 7 January 2015, reporting that she could hear noises outside of her window and that she was frightened it was Mr Wall. Ms Palhares reported that Mr Wall had attended her address earlier that evening and a verbal argument had ensued. Police records reflect that ‘no domestic violence breach reported’ and patrols failed to locate anyone in the vicinity of Ms Palhares’ address. It does not appear that police further investigated the alleged breach of the DVPO such as by taking up with either Ms Palhares or Mr Wall.

According to the statement of Mr Wall’s colleague, Mr Wall appeared ‘emotionally unwell’ while at work on 9 January 2015 and the colleague arranged for a counsellor from Mates in Construction (MIC) to speak with him.

Mr Wall subsequently spoke with the counsellor and reported that he had ‘lost his cool with his girlfriend and beaten her up’, admitting that it wasn’t the first time that he had used violence towards her. Mr Wall reported that he had been taking prescription medications to help with his ‘outbursts,’ but that they were keeping him awake and making him ‘edgy.’ According to the records of MIC, Mr Wall was not interested in reconnecting with his GP or another practitioner and felt that he was able to work things out on his own. He became resistant and insisted on ending the session, declining an offer for further follow up by MIC. It does not appear that MIC reported Mr Wall’s disclosures of physical violence toward Ms Palhares to police or other services.

On 8 January 2015, Ms Palhares contacted The Hart Centre to arrange a psychology appointment. According to records from The Hart Centre, Ms Palhares hoped to engage in couple’s therapy and reported that there was a DVPO in place which required that Mr Wall be of good behaviour toward her.

However, upon attending their initial appointment at the Centre on 13 January 2015, both Mr Wall and Ms Palhares denied that there was a DVPO in place. Ms Palhares initially met with the counsellor independently and reported that she was happy to raise the baby alone but wanted to continue her relationship with Mr Wall if he engaged in counselling and changed his ways.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

At the end of the session, the counsellor provided Mr Wall and Ms Palhares a worksheet which required them to think about what was ‘wrong’ with their partner and their relationship. Follow up appointments were booked for Mr Wall separately and with he and Ms Palhares.

On 15 January 2015, Ms Palhares attended an appointment with her GP which appears to have been in relation to her pregnancy. Ms Palhares reported to have a DVPO against Mr Wall because he had physically assaulted her and that they were receiving couple’s therapy. The GP identified an increased risk of foetal abnormality, but it is unclear from the medical records whether this was linked to the domestic violence assaults. Ms Palhares’ GP provided her with a referral to the GCUH for further follow up. It does not appear that the GP proactively reported Ms Palhares’ disclosure of DFV to the GCUH, police or other services or provided Ms Palhares with a referral to a support service.

In the days following their initial appointment, Mr Wall sent a number of emails to the counsellor. On 15 January 2015, Mr Wall told the counsellor that ‘the longer this mess between Fabi and I continues the less sorry I am for my violent reactions to her… my apologies just seem to go unnoticed. I think counselling will be a waste of time… I’d love to save it but it feels like it is dead. I love her but it’s not in a healthy way and I definitely don’t trust her…’ As a result of Mr Wall’s comments, the counsellor felt that she could not guarantee Ms Palhares’ safety during sessions and cancelled all of their future joint appointments.

However, she was prepared to continue the individual sessions with Mr Wall. She did not notify police of her concerns for Ms Palhares or offer Ms Palhares a referral to another service, despite her concerns for Ms Palhares’ safety.

Mr Wall continued to contact the counsellor via text message and questioned why she had cancelled the joint sessions. On 16 January 2015, he wrote, ‘it feels like I’m being singled out as the monster in all of this. I know where I went wrong with Fabiana. I own it. Deep down inside I’d love to be with her but it’s pointless when all she does is act like she hates me… it feels like you’ve taken sides… I can tell you that there are zero safety concerns between Fabi and I and you.’ The counsellor advised Mr Wall that she was happy to discuss the matter at their next face-to-face appointment.

Mr Wall subsequently met with the counsellor on 20 January 2015, at which time he appeared to demonstrate a low opinion of women in general. According to the counsellor’s session notes, Mr Wall reported to have ‘no sense of self’ and talked about his past relationships, though it does not appear that Mr Wall disclosed his prior history of DFV. The counsellor discussed different personality disorder diagnoses and referred Mr Wall to another therapist, but it appears that a follow-up appointment was also made for Mr Wall with the counsellor. The appointment was scheduled for 3 February 2015, the day after Ms Palhares was killed.

On 21 January 2015, Ms Palhares received a call from Mr Wall who wanted to meet up to discuss their relationship and her pregnancy. Due to being fearful of Mr Wall, Ms Palhares arranged to meet him at 5:00pm in a public place.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

At around 3.45 on that date, Ms Palhares awake from a nap to find Mr Wall standing at the end of her bed reading the contents of her mobile phone. Mr Wall was trying to find out who she had been calling (an example of his sexual jealousy and male proprietariness) and Ms Palhares became concerned that he would become violent or damage property. She called out to her flatmate to contact police.

Upon the arrival of police, Mr Wall declined to be interviewed but made full admissions to jumping over Ms Palhares’ fence and entering her home without permission. Police issued him a Notice to Appear in relation to contravening the DVPO and the matter was scheduled to be heard on 16 February 2015 in the Southport Magistrates Court.

It is not clear why Mr Wall was not charged for his unlawful entry of Ms Palhares’ residence.

The responding police officers also completed the Domestic Violence Protection Assessment Framework (DV-PAF – an assessment tool designed to assist the decision making of front-line police officers in relation to the protective needs of victims of DFV). They noted Ms Palhares’ pregnancy (Category 1 risk factor) and the ongoing conflict (Category 2 risk factor) to be risk factors. They assessed that Ms Palhares was fearful and at a medium level of risk.

The officers failed to recognise the presence of multiple other risk factors which were identifiable through QPRIME records and listed in the DV-PAF, including:

• frequency and escalation of domestic violence;

• previous episodes of domestic violence attended by police;

• relationship separation;

• controlling behaviour;

• cultural considerations;

• the respondent’s mental health issues;

• the respondent’s history of violence within other relationships;

• damage or destruction of the aggrieved’s property;

• stalking;

• the respondent’s history of suicidal ideation in the context of domestic and family violence.

Although responding officers recognised that Mr Wall posed a risk to Ms Palhares, police did not seek to amend the DVPO as a means to further protect her or hold Mr Wall accountable for his continued violence. It is also unclear why police decided to deal with the matter by way of a Notice to Appear, rather than by arresting Mr Wall and taking him into custody.

On 22 January 2015, Ms Palhares proactively re-established contact with DVPC and sought assistance to vary the conditions of the DVPO. She explained that Mr Wall had broken into her home the previous day and had threatened that she would not be allowed to take the baby to Brazil to see her family.

DVPC discussed options to amend the DVPO (including non-contact conditions or that Mr Wall not approach her home address) and Ms Palhares informed the counsellor that she would be going to court to have the order varied. The DVPC counsellor Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

encouraged Ms Palhares to stay in touch for support, but this was the last contact the service had with her before her death approximately two weeks later.

Ms Palhares subsequently attended Southport Magistrates Court later that day (22 January 2015) and made an application to vary the DVPO, requesting that Mr Wall be prohibited from attending her address. In the application, Ms Palhares stated that:

• Mr Wall had been violent toward her both before and during her pregnancy;

• following one episode of violence she had been unable to walk properly for three to four days;

• Mr Wall had previously broken or damaged property including six mobile phones, her glasses, her car mirrors, her toilet seat and that he had made two holes in her bedroom walls;

• she was fearful for her own safety, the safety of her flatmate and that of her unborn child; and

• Mr Wall was ‘not mentally well.’ On 29 January 2015, three days before the death of Ms Palhares, the Southport Magistrates Court varied the DVPO to prohibit Mr Wall from approaching within 50 metres of Ms Palhares’ residence.

On 26 January 2015, the week before Ms Palhares’ death, Mr Wall was contacted by DVConnect Mensline. According to the DVConnect Mensline records, Mr Wall disclosed that he was getting help with changing aspects of his behaviour and that he was not happy with his counsellor who was going to refer him to a psychiatrist as she did not have the skills to help him.

He admitted to a having a very negative view of women and that he had some thoughts about harming all women. The call-handler strongly encouraged Mr Wall to get help from his psychologist as soon as possible and to ensure that he followed-up with seeing the psychiatrist.

Mr Wall recorded this conversation on his mobile phone. Mr Wall’s recording identifies that he had more directly expressed homicidal ideation toward Ms Palhares and made a number of other concerning comments which were not reflected in the DVConnect Mensline records.

According to the recording, Mr Wall explained to the DVConnect Mensline counsellor that he would like to be ‘taken off the face of the earth and have his brain electrocuted or something… so he can come back fresh and probably come back and fucken kill the woman that is pregnant.’ The counsellor recommended that Mr Wall speak to his counsellor, but Mr Wall dismissed her as a ‘crock of shit’ and that she was not to be trusted.

Mr Wall further told the call-handler to ‘remember this call. My name is Brock and I will be in the news one day for going off. I will be like a time bomb that is going to explode.’ He disclosed that he was ‘a very sadistic person so much that it scares me and will probably put me in jail one day’. Mr Wall stated that he got great satisfaction from revenge.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

Mr Wall’s disclosures were not recorded in the corresponding DVConnect Mensline records and the call was categorised as a standard matter. Mr Wall ended the call abruptly and no attempts were made by DVConnect Mensline to reconnect with him or to report these disclosures to police.

On 30 January 2015, an officer from Surfers Paradise Police Station called Mr Wall to advise him of the amended DVPO. Mr Wall told the officer that he would ‘go to jail over this’ and arranged for the revised documents to be sent to him.

On 31 January 2015, three days before the homicide, Mr Wall was assigned to a high risk domestic violence case management occurrence created by Gold Coast Domestic Violence Coordination Unit. It was identified that the varied DVPO had not been personally served on Mr Wall.

Mr Wall was later contacted by Surfers Paradise police at around midday on 2 February 2015, the date of Ms Palhares’ death. He advised the call-taker that Ms Palhares was not the victim but was a ‘super bitch’ and reported that he would attend the station to collect the documentation. There are no police records detailing this conversation with Mr Wall, which was only confirmed as he recorded all of his phone calls.

At approximately 12:30pm on that date, Mr Wall attended the station and was served with the DVPO prohibiting him from attending Ms Palhares’ address. Mr Wall verbalised his understanding of the conditions but reported that he was ‘very angry.’ He stated that Ms Palhares ‘is pregnant and she is not going to have that baby because she is a slut.’ The officer reiterated that Mr Wall would be arrested if he breached the order and he replied that it ‘looks like police will be coming to arrest me.’ This was the last known contact Mr Wall had with formal services prior to the homicide of Ms Palhares, which occurred around two hours later.

Criminal Proceedings Mr Wall was charged with Murder (domestic violence offence), Breach Domestic Violence Order and Unlawful Assault of a Pregnant Female (domestic violence offence).

Mr Wall was remanded in custody. He pleaded guilty to the charges in the Supreme Court at Brisbane on 26 July 2018 and he was sentenced to life imprisonment.

Concerns and Improvements DVConnect Mensline Mr Wall told DVConnect Mensline that he was going to kill Ms Palhares on 26 January Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

2015. They did not take any action or record the call on their system.

On 22 September 2020 DVConnect Mensline advised that the organization has undertaken a number of continuous improvement activities since the death of Ms Palhares including:

• Implementing a more robust and practice-based recruitment process for counsellors;

• Improvements to induction and training;

• Introduction of call recording and quality monitoring (including real-time review);

• Creation of a new Quality, Training and Development Specialist;

• Implementation of a file auditing and call review process;

• Implementation of a call coaching framework;

• Enhancement of their risk assessment framework to improve risk mitigation strategies;

• Upgrades to their database;

• Development of an enhanced relationship with QPS;

• Implementation of a client death review plan.

In addition to the improvements as outlined above, the organization has been through three Human Services quality Framework audits, receiving 100% compliance.

Relevantly, DVConnect Mensline has enhanced the practice framework to include specific practice guidelines around disclosures of potential suicide or homicide. The guidelines specify an evaluation checklist to assist in gauging whether the risk of suicide or homicide and includes information gathering such as their location and identifying features (for emergency services) and willingness to comply with emergency procedures. Where a risk of homicide is identified the caller is asked about history of violence, current homicidal feelings, any current plan for violence and details to identify the target.

In cases where there is a potential homicide the mandatory escalation process includes immediate notification to emergency services, and notification to the team leader who must assess the risk and created an alert on the system.

The upgrade of the Client Management System (iCare) enhances communications and efficiencies between the service and QPS. It centrally captures history of contacts with a person the Mensline are engaged with, risk factors, needs identified, involvement with police, mental health and other relevant information. The system of recording of case notes has been improved.

DVConnect Mensline has improved its relationship with QPS in relation to information sharing and positive working relationships between team leaders and local police.

Police are able to contact DVConnect Mensline immediately on a direct line without having to wait on hold.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

Queensland Police Service Between 29 December 2014 and the death of Ms Palhares on 2 February 2015, Mr Wall and Ms Palhares had at least seven contacts with police. Recurring issues identified with respect to the police response are:

• the failure of police to appropriately document, identify, respond to and investigate reports of domestic and family violence (DFV); and;

• an insufficient understanding and recognition of the dynamics of DFV by police.

A total of twenty-six lethality risk factors were present for Ms Palhares and most of these risks were known to responding officers or were reported to police previously and, therefore, accessible through review of the Queensland Police Records and Information Management Exchange (QPRIME) records (on average, 11.2 lethality risk factors are present for culturally and linguistically diverse intimate partner homicide victims in Queensland).

It appears that police responded to each report of DFV in isolation, rather than as an escalating pattern of behaviour. For example, on 21 January 2015, less than two weeks prior to the death of Ms Palhares, Mr Wall entered Ms Palhares’ bedroom and read the contents of her phone (an example of his obsessive behaviour, male sexual proprietarieness and escalating post-separation violence). While the responding police officers noted the ongoing conflict and Ms Palhares’ pregnancy were risk factors, they failed to recognise the multiple other risk factors (at least ten) which were identifiable at the time or through review of QPRIME records. These factors were relevant for officers to consider in their assessment of the risk Mr Wall represented to Ms Palhares and their consideration of appropriate responses. This is notable as the death occurred less than two weeks later.

While officers recognised there was some risk to Ms Palhares on 21 January 2015, the responding officers did not seek to amend the DVPO (issued on 29 December

2014. as a means to further protect Ms Palhares or to hold Mr Wall accountable for his continued use of violence. This placed the onus on Ms Palhares to manage her own safety, and she proactively contacted the DVPC on 22 January 2015 to seek assistance to vary the conditions of the DVPO and prevent Mr Wall from attending her home.

It appears police also failed to appropriately document some contacts with Ms Palhares and Mr Wall on QPRIME, which was in contravention of the requirements of police under the QPS Operational Procedures Manual (OPM). If information is not appropriately documented on QPRIME, officers responding to future events are less likely to identify behaviour as a continuing or potentially escalating pattern of DFV.

For example, according to the police application for the DVPO made on 29 December 2014, it appears Ms Palhares initially reported Mr Wall’s violence to police sometime before 29 December 2014. As this event was not recorded on QPRIME, it is unclear when Ms Palhares had contact with police or what disclosures she made in relation to her experiences of DFV. However, it appears that she was ‘given advice to take out her own Domestic Violence application due to previous violence and damage to property,’ indicating that police did not appropriately document or investigate her allegations as required under Chapter 9 of the OPM. As a result, Mr Wall was not held Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

accountable by police for his violence and this placed the onus on Ms Palhares to manage her own safety.

There also appear to be inconsistencies between the QPRIME records and what transpired during at least three contacts that Mr Wall had with police in the days and hours preceding the homicide event on 2 February 2015. During these contacts Mr Wall referred to Ms Palhares in a derogatory manner and indicated to two different police officers that he intended to breach the DVPO and cause further harm to Ms Palhares. Most notably, Mr Wall had contact with an officer on the morning of Ms Palhares’ death and suggested that ‘police will be coming to arrest’ him for breaching the order. Indeed, this was two hours before Mr Wall killed Ms Palhares.

On the available information it does not appear that the responding officers treated Mr Wall’s threats with sufficient seriousness, as they did not adequately document his disclosures or take other action to hold him accountable and protect Ms Palhares. This is particularly salient, as Mr Wall had a documented and significant history of DFV within prior relationships and had been flagged on QPRIME as a ‘High Risk DV Respondent’ on 7 January 2015 in relation to his violence toward Ms Palhares.

Changes Implemented by the QPS 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 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

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

These recommendations collectively focused around changing culture to promote and embed bet 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; Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

• 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 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 nongovernment entities to improve victim safety and perpetrator accountability.

An amendment to the Criminal Code (Qld) 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.

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

Section 169F of the DFVPA states a police officer may refer person to specialist DFV service provider: (1) A police officer may give referral information about a person to a specialist DFV 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 Queensland Police Referrals system allows police officers to refer DFV victims or perpetrators with or without their consent.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

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 recognised it was vital to understand the multi-faceted and complex nature of vulnerability to efficiently formulate preventative strategies, implement evidencebased interventions and identify appropriate referral pathways for 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 DFVCs 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 is 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, nonconsensual 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.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

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 Central Queensland University to conduct an audit and review of training. Their final report, “Evidencebased 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;

• annual DFV refresher training, continual education opportunities for the DFV Coordinator (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 to 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 – 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;

• The 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; Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

• 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;

• 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.

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 Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

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 districts 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.

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)

• 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 made by frontline police, hospital emergency staff and social workers. QPS DFVCs and/or District DVLOs and/or HRT members are referred to as Level Two referrers. Level Two referrers review DFV occurrences, including the Domestic Violence-Protective Assessment Framework (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 should additional information come to light or a new incidence of DFV occur.

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

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

Operation Sierra Alessa The aim of Operation Sierra Alessa is to identify and target DFV perpetrators, through applying focused deterrence strategies to disrupt the offending cycle. It also aims to reposition DFV 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 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 operate for two months each.

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;

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

Case Management Teams The QPS is represented on integrated case management teams including:

• Suspected Child Abuse and Neglect (SCAN) There are approximately twenty teams operating in Queensland; o

• Domestic Violence Cross Agency Meetings (DV-CAM) Which includes members from local DFV service providers (NGO) and o other government departments;

• the Prosecutions Review Committee Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

the role of which is to examine the processes, policies and procedures o involved in matters before the Magistrates Court to seek to identify areas for improvement

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

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 DFVrelated) 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 Palhares died from injuries inflicted on her by Mr Wall. The attack that resulted in her death was the culmination of a long period of domestic and family violence inflicted on her by Mr Wall which included verbal, emotional and physical abuse (including non-lethal strangulation), coercive control, threats to kill her and her family and their unborn child.

The history of DFV by Mr Wall revealed numerous risk factors which were not identified or acted upon by QPS.

Mr Wall revealed to DVConnect Mensline that he was going to harm Ms Palhares but the call taker did not record this information or notify any person or agency of the threat.

Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.

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

However, I accept that since the death of Ms Palhares and the Not Now, Not Ever report there have been significant improvements throughout QPS in relation to procedures surrounding identifying and preventing DFV.

I also accept that DVConnect Mensline has made significant changes subsequent to Ms Palhares’ death in relation to the procedures for dealing with information.

Taking into account the initiatives and improvements implemented by QPS and DVConnect Mensline I am satisfied that an inquest into the death of Ms Palhares 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.

Findings Pursuant to s.45 of the Coroners Act 2003 Identity of the deceased – Fabiana Yuri Nakamura Palhares How she died – Ms Palhares died from head and abdominal injuries she sustained when she was struck with an axe and stomped on by Brock Wall.

Place of death – Gold Coast University Hospital SOUTHPORT QLD

4215 AUSTRALIA Date of death– 2 February 2015 Cause of death: 1(a). Head injuries Other significant conditions

2. Abdominal injuries I close the investigation.

Jane Bentley Deputy State Coroner

CORONERS COURT OF QUEENSLAND - SOUTHERN REGION Findings into the death of Fabiana Yuri Nakamura PalharesError! Reference source not found.