Deceased
Hannah Ashlie Clarke, Aaliyah Anne Baxter, Laianah Grace Baxter, Trey Rowan Charles Baxter, Rowan Charles Baxter
Demographics
mixed
Coroner
Bentley
Date of death
2020-02-19
Finding date
2022-06-29
Cause of death
Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and Trey Baxter: effects of fire; Rowan Baxter: self-inflicted stab wound to chest with burns as contributing condition
AI-generated summary
Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family with petrol and set them alight, then died by self-infliction. The inquest identified extensive domestic violence and coercive control throughout the relationship. Significant missed opportunities included: failure to pursue criminal charges for strangulation and sexual assault; inadequate police training in domestic violence risk assessment; lack of coordinated multi-agency response despite Hannah being assessed as 'high risk'; insufficient resources for men's behaviour change programs; and lack of domestic violence screening by mental health practitioners. Hannah had expressed serious fear Baxter would kill her and the children. The coroner found Baxter was manipulative and not genuinely engaged with services, using them strategically. Recommendations focus on intensive police training, multidisciplinary specialist DV stations, and increased funding for perpetrator intervention programs.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Hannah Ashlie Clarke, Aaliyah Anne Baxter, Laianah Grace Baxter, Trey Rowan Charles Baxter, and Rowan Charles Baxter TITLE OF COURT: Coroners Court
JURISDICTION: SOUTHPORT FILE NO(s): 2020/741, 2020/739, 2020/740, 2020/738 & 2020/736 DELIVERED ON: 29 June 2022
DELIVERED AT: SOUTHPORT HEARING DATE(s): 21 March 2022 – 31 March 2022 FINDINGS OF: Jane Bentley, Deputy State Coroner CATCHWORDS: Coroners: inquest, killing, retaliatory filicide, intimate partner homicide, lethality risk factors, domestic violence, coercive control, service systems, police response, police training, multi-disciplinary teams.
REPRESENTATION: Counsel Assisting: Dr Jacoba Brasch QC Instructed by Mr B Jackson and Ms K Ward Mr & Mrs Clarke Ms K Hillard (Next of Kin – Hannah Clarke, instructed by Caxton Legal Aaliyah Baxter, Laianah Baxter Centre & Trey Baxter): Commissioner of Police: Mr M Nicolson instructed by QPS Legal Unit Sgt Rolf, SC Skaines, SC Kent, Ms R O’Gorman QC SC Trigg, Const Erba, Const Instructed by Gilshenan & Luton Thomas, Const Taylor, Const Solicitors Erba & QPEU: Detective Sergeant Mr C Gnech, Gnech Lawyers Derek Harris: Ms Vivian Jarrett: Mr J Moore, Thynne Macartney Lawyers
Contents
Introduction
Section 45 of the Coroners Act 2003 provides that when an inquest is held the coroner’s written findings must be given to the family of the person in relation to whom the inquest has been held, each of the persons or organisations granted leave to appear at the inquest and to officials with responsibility over any areas the subject of recommendations.
These are my findings in relation to the deaths of Hannah Ashlie Clarke, Aaliyah Anne Baxter, Laianah Grace Baxter, Trey Rowan Charles Baxter, and Rowan Charles Baxter. They will be distributed in accordance with the requirements of the Act and posted on the web site of the Office of the State Coroner.
These findings and comments confirm the identity of the deceased persons, when, where and how they died and the causes of their deaths.
Background
On the morning of 19 February 2020 Rowan Baxter killed his wife, Hannah Clarke and their three children, Aaliyah, Laianah and Trey, by dousing them with petrol and setting them alight in their car. He also killed himself.
The question that Hannah’s parents, family and friends have asked since that day is, “Why?”
Hannah was fun-loving, happy, bubbly, friendly, hard-working and loved her three children above all else. She was extremely fit and was excelling at CrossFit, which she loved. She was the only daughter of Suzanna and Lloyd Clarke and was born at the Royal Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 1 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Women’s Hospital in Brisbane on 8 September 1988. Hannah had a younger brother.
When she was 16 years old she represented the state for trampoline.
Soon after she started coaching trampoline classes at the Carindale PCYC. When she finished school she started teaching Kindy Gym at the PCYC and she also worked as a teacher in vacation care.
Aaliyah Baxter was born to Hannah on 10 April 2013 and was six years old when she was killed by her father. She was in year 2. She was a sweet, articulate, clever, well-behaved girl who was excelling at school. She loved reading and English.
Laianah Baxter was born to Hannah on 19 March 2015 and was four years old when she was killed by her father. She had just started preschool. Laianah liked to please people and make sure they were okay. When Baxter was in a bad mood Laianah would often climb onto his lap and try to placate him.
He was only three years old when he was killed by his father. He loved running and jumping and playing. He liked to be with his mother.
All three children were healthy and happy and full of life. They loved going to the beach and going to the gym with Hannah.
Rowan Baxter was born on 9 May 1977. He was 44 years old when he died after killing his wife and three children. He experienced a prejudicial childhood with his father being imprisoned for sexually Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 2 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
abusing his sisters. He did not drink alcohol or take drugs. He was fit and healthy.
At the time of their deaths Hannah and her children were living with her parents at Camp Hill as Hannah had recently separated from Baxter. There was a Domestic Violence Protection Order (DVO) and Hannah felt protected and reassured by that order.
Many people who knew Hannah and Baxter believed the image that he projected which was of a perfect, happy family.
Relationship History Hannah and Baxter
Hannah met Baxter when she was 20 years old and he was 31 years old. She was teaching Kindy Gym at the PCYC at Carindale and his son was in her class.
Baxter started working at the PCYC as a boxing instructor. Hannah was still living at home.
Baxter was living with his wife (PP) whom he met when she was 16 years old and he was 18 years old. Baxter quickly showed signs of controlling behaviour and anger issues. By the time their son was two years old PP wanted to leave the relationship, but Baxter would not accept her wishes. He would show up uninvited and leave notes on her car. He told her that he wanted his family back and that he had a hose pipe in the boot of his car and had planned how to “end it” for all three of them. PP felt she had no choice but to go back to him.
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In 2008 Baxter met Hannah at the PCYC. Although he continued to live with PP he commenced a relationship with Hannah. He then became amenable to separation with PP and they agreed on a parenting plan for their son. However, if there was ever an issue in regard to that Baxter would become aggressive and on one occasion threatened to smash her door down to get their son.
Whilst living with PP Baxter told Hannah that they were separated but living in the same house for the sake of their son. This was not true. He told a friend that he remained living with his wife because he couldn’t afford to move out and his wife knew he was having an affair, and this was making her very unhappy.
About four months after meeting Hannah, Baxter moved in with a friend.
About six months after they commenced their relationship Hannah fell pregnant. She wanted to have the baby, but Baxter told her she was too young. She aborted the pregnancy.
They moved to a townhouse at Mansfield. Hannah worked full time at The Athlete’s Foot shops at Carindale and Capalaba shopping centres. Baxter was working as a sales representative for a pharmaceutical company.
Baxter was angry that the guests did not give them more money as gifts as he wanted to use the money to fund an overseas honeymoon.
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They asked Sue and Lloyd Clarke to invest in it. They invested $18,000 and another investor contributed about $40,000. The gym did not do well and they were constantly behind in rent and bills. The Clarkes often paid their rent and bills. Hannah and Baxter would leave their unopened bills in the Clarke’s letterbox and the Clarkes would pay them.
Hannah became pregnant with Laianah. In January 2015 Hannah and Baxter opened “Integr8” Gym at Mansfield. Laianah was born in March 2015. Trey was born in December 2016.
About three years after they opened the gym at Mansfield, they moved it to another site at Mansfield.
They bought a second car. Both cars were registered in Hannah’s name as Baxter had previously failed to pay car registration bills and he owed money to the State Penalties Enforcement Register.
In early 2017 Hannah and Baxter moved to Carindale. They were co-tenants on the lease.
The gym continued to struggle as Baxter was not a good businessman – he could not project future incomings and outgoings and he found it difficult to manage money. He was blunt with potential new members and current members often left the gym.
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History of Domestic Violence and Coercive Control
At the beginning of their relationship Hannah went on a cruise with a friend. She told her mother that Baxter wasn’t happy about her going away and contacted her constantly whilst she was on the cruise.
Shortly after they started living together Baxter told Hannah that she couldn’t wear shorts, short skirts or the colour pink. She could wear a bikini on the beach but not off the beach. They shared a joint Facebook page as Baxter did not allow Hannah to have her own.
During their relationship Baxter sought to drive a wedge between Hannah and her family.
He openly criticised her mother in front of her and her brother. He made it difficult for Hannah to spend time with her parents. Baxter stopped Hannah and her children attending weekly family barbeques at the Clarkes’ house.
Baxter borrowed Hannah’s brother’s car and drove it for months – he put over 30 000 km on it and $200 in toll bills and never left any fuel in the car. When Hannah’s brother said he needed the car and Baxter could no longer drive it Baxter stopped talking to him and made it difficult for Hannah to do so.
Baxter refused to allow Hannah to spend the day with her mother on Mothers’ Day – she could only spend half a day there and then had to spend the rest of the day with him celebrating his deceased Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 6 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
mother. He stopped the family from attending the annual Good Friday family celebrations at the Clarkes’ house.
After Aaliyah was born in 2013 Baxter would not allow Mrs Clarke to look after her or have the baby stay at her house.
In 2015 when Hannah was pregnant with Laianah she told her mother that Baxter had slammed the back gate on her leg causing a bruise.
After Trey was born in December 2016, Baxter worked at the gym three days per week and rested on the other days. Hannah took numerous classes at the gym, looked after the children and was trying to do a marketing course online. She told her mother that Baxter criticised her, shouted at her that the house was a pigsty and questioned what she did all day. He often went for days without talking to her especially if she refused to have sex with him. He told her to get a second job as they needed money. She then worked at The Athlete’s Foot on Monday and Friday and worked in the gym on the other days.
Baxter was often rude to Mrs Clarke and Hannah would ask her to apologise to him as he would refuse to speak to Hannah until she did.
On 18 May 2019 Hannah phoned her mother and told her that Baxter had wanted sex and she didn’t which resulted into a huge fight.
Baxter smashed her watch and left the house. Hannah found the hose missing and was afraid he was going to kill himself. Hannah’s parents drove around Capalaba and Carindale looking for him. He came home that morning and told Hannah that he had driven to Citipointe Church carpark and tried to kill himself.
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When they had the Capalaba gym Hannah made a joke during a class that Baxter was running. He immediately stopped the class. It was usual for everyone to have breakfast together after the Saturday class. Because he was angry with Hannah, Baxter refused to let the children go to breakfast. He often punished the children by refusing to allow them to do things which were planned when he was angry with Hannah. If they did not put their toys away quickly enough, he threw them in the bin.
In September 2019 Hannah turned 30 years old and wanted to have a dinner with family and friends. Baxter planned a surprise party for her at the gym. Her friend told Baxter that Hannah didn’t want a party. He didn’t speak to Hannah for days and told her she couldn’t have a celebration.
Hannah wanted a necklace with the children’s names on it for her birthday. Baxter collected money from members of the gym and asked the Clarkes for money towards it which they gave him.
Hannah’s family ended up organising a celebration for her birthday.
Hannah asked a friend to be the third team member and Baxter said he would be the fourth member of the team but he pulled out, apparently due to injury. When he did so he expected Hannah to pull out as well.
On 6 November 2019 Hannah was driving back from a gym session and had a conversation in the car with a friend about Baxter taking over the session and being too “full on.” Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 8 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Baxter overheard this conversation (he told Hannah that Aaliyah was playing with Hannah’s phone and called him and he overheard it) and became enraged. He refused to speak to Hannah.
Baxter told an associate that the kids had somehow recorded Hannah’s phone conversation and then sent it to his phone but the associate found that unbelievable and believed Baxter had been recording her.
The first day of the competition was on 8 November 2019. Baxter made Hannah take a gym class that morning. She came home from the gym at 7am to find Baxter and the children gone from the house.
She phoned her mother crying. She said Baxter was punishing her for taking part in the competition. He had his phone turned off. She was so fearful of what he might do that she was vomiting. She asked her brother to go to the beach to see if he could find them. Baxter finally sent her a text message stating that he couldn’t believe she was competing in the competition without him. He still didn’t tell her where he was or whether he was bringing the children home.
He came home later that day and said that he had taken the children to the beach.
In relation to this Baxter told an associate that he and Hannah argued and he took the children and left the house. When he left the house he left an old phone recording in the house. He recorded and listened to Hannah’s phone calls to her mother and she was hysterical as he had taken the children and she didn’t know where they had gone and they called him derogatory names. When his associate commented that it was not right to record people Baxter swore he left the phone recording by mistake.
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It is likely that he had a listening device in their house and one in her car as he revealed to her knowledge of conversations she had in those places when he was not present.
Hannah had told Aaliyah that she would take her to watch the finals of the competition but Rowan was not allowing her to go – Hannah believed because he was angry at her. They had a huge fight when she insisted on taking Aaliyah. As she left the house Rowan grabbed her by the arm and told her they would be talking about it later. Her friend saw red marks on her arm. Hannah said there would be no more discussions and once that weekend was over she was leaving.
Hannah told her friend that she couldn’t take it anymore and that was “the final straw.”
The next week Hannah was sad and told her friend that she was “keeping her head down at home.”
Hannah told her mother that Baxter checked her phone in the middle of the night when she was asleep. When she woke up one night and asked him what he was doing he threw the phone across the room, breaking the screen. She started to think he was tracking her phone and listening to her phone calls as he had questioned why she had phoned certain people.
Baxter became suspicious that Hannah was having a relationship with Mr D. After she was speaking to him on the phone one evening Baxter “went ballistic” and accused her of having an affair with him.
Hannah started to prepare to leave Baxter and told her mother she wanted to return home with the children. Mrs Clarke started preparing for their arrival.
On 5 December 2019 Nicole, Hannah’s best friend, phoned Mrs Clarke and told her that Hannah had moved out, they had taken Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 10 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Aaliyah out of school, Hannah had only taken a few things from home and she was scared. Nicole said that they hid Hannah’s car and left her phone in her car in case Baxter had a tracking device in it.
Hannah and the children arrived at the Clarkes’ residence the next day. Baxter called her numerous times that day and told her she was hurting the children.
On 6 December 2019 Hannah went to the Carina police station. She met Senior Constable Kirsten Kent who told her that she could obtain a DVO but Hannah told her mother she was scared that doing so would aggravate Baxter.
Baxter continued to phone her on her old phone. He insisted on picking her up and taking her out. They went out and when they returned Baxter came inside and was crying and asking for help. He stayed for dinner and then Hannah said she was going home with him. Hannah told her mother she would be at the 5am gym class the next day.
The following morning Mrs Clarke attended the 5am class. Baxter took the class. After the class Hannah phoned her mother and said the children were with her and she was taking them to her brother’s house. Later that day, her brother phoned her mother and said that Baxter had been calling her telling her she needed to come home and she was hurting the children.
On 8 December Senior Constable Kent spoke to Hannah after running into her at Carindale shopping centre. She gave Hannah some advice about DV and later Senior Constable Kent contacted the Vulnerable Persons Unit (VPU) of the QPS to discuss Hannah’s case.
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A couple of days later Hannah and the children moved into her parent’s house.
A few days later Hannah took the children to visit Baxter. He asked her to come inside to show him how to cook something. At about 8.30pm Mrs Clarke became worried about Hannah and sent her a text message. She replied asking her mother to come over straight away. Mr and Mrs Clarke went to Baxter’s house and found that Baxter was putting the children to bed in his bedroom. Hannah wanted to take the children home but he refused. Baxter told the Clarkes that Hannah was crazy and making things up. When they still insisted on taking the children he cried and said that they should have helped him sooner. They left the children there and went home but were scared of the possibility that Baxter could harm the children.
Baxter brought the children home the next morning and said that he’d had a mental health assessment and Hannah should come home with the children and couldn’t understand why she would not do so.
Soon after Hannah moved into her parents’ house she was at home with the children one morning. Baxter opened the door and let himself into the house and stood outside the bedroom listening to Hannah talk to the children. She realised he was there and he had her phone in his hand. He asked her whose phone it was and she said it was her mother’s. He said it was not her mother’s phone and she told him that she had bought a new phone because he was tracking her other phone.
On 21 December 2019 Baxter had the children for a couple of days and he was supposed to take them home at 4pm. He had agreed to do so as he knew that the Clarkes had hired a van to take Hannah and the children to visit Mr Clarke’s mother in Kingaroy the next day.
At 4.30pm he sent Hannah a text saying he was running late. She Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 12 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
called him at 5.30pm and he said he was stuck in traffic. About an hour later he phoned Hannah and said he might keep the children for a few days. Hannah begged him to bring them back. Mr Clarke drove to Baxter’s house and saw him driving down the street. He followed him and saw Baxter park in a car park. Hannah told her father to come home as she was scared that Baxter would see him.
Baxter phoned a friend, Mr M, and told him that he was supposed to have the children back at 4.30pm so they could go away with Hannah and her parents to the Sunshine Coast, but he was going to keep them.
Baxter called Hannah at 8.30pm and told her she could collect the children from a service station at Cleveland if she came on her own.
She left and collected the children. When she came back, she said that Aaliyah was very upset as she knew she was supposed to have been home at 4pm.
On 22 December Baxter contacted Centrelink and applied for full parenting payments stating that he was the full-time carer of the children. They phoned Hannah who told them she was caring for the children.
On 24 December 2019 Baxter told Hannah that he was upset as he wanted to see the children for Christmas. Hannah and her father decided to allow him to visit the house for a few hours on Christmas Day. He arrived at 4.45am and stayed until 5pm. He gave the children gift cards – the Clarkes later discovered they had no funds on them when they took the children to buy toys with them.
On 26 December 2019 Baxter asked Hannah to take the children to Bulimba skatepark so the children could play with their new skateboards (purchased by the Clarkes). She agreed but as she went to leave he said he wanted to take the children home with him.
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She refused and he took Laianah and threw her in the front seat of his car, unrestrained, and drove off.
Baxter said to Hannah, “You have caused all of this, it’s your fault.”
Baxter kept Laianah for three days. He took her to the house of his friend in New South Wales. The friend sent Hannah a text message stating this was her fault and she shouldn’t keep the children.
Constable Luke Erba was on duty with Constable Shane Cobban on 26 December 2019. At about 10.30am they were driving west on Oxford Street when they were flagged down by a member of the public. The female told them that she saw a man and a woman arguing and the male jumped into a vehicle and took off with one of the children.
They continued down the street and were flagged down by Hannah who was standing opposite the Bellissimo Café. She said there had been an incident with Baxter. Constable Erba activated his body worn camera (BWC).
Hannah was crying and told the police that he took Laianah away in Hannah’s car and said that he won’t bring her back. She said Laianah was bawling her eyes out and the other two children were beside themselves. She said he called her and said she either let him take the other two children or he wouldn’t bring Laianah back.
Hannah said she had been in contact with Senior Constable Kent and the only reason she hadn’t obtained a DVO was she was worried that it would antagonise the situation but now this had happened.
Constable Erba advised Hannah that as there were no Family Court orders they couldn’t go and take Laianah back but they could ask Baxter to return Laianah. Hannah became tearful and upset.
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Hannah told them there was a lot of controlling behaviour and it had gotten worse since she left him. That was why, once she got them back on Sunday, she decided to keep the children with her.
Hannah told them that he spent the whole day yesterday with the children and then she agreed to meet with him today. He said he wanted them for the night and she refused at which time he put Laianah in the front seat and drove off with her.
Constables Erba and Cobban had a conversation during which Constable Cobban said that it was controlling behaviour and they could consider whether a DV application was warranted. They decided to contact Baxter and persuade him to return Laianah.
Constable Erba tried to phone Baxter but his phone was blocked to private numbers. He then told Hannah he would attempt to find Baxter and provide her with an update. He also offered her a referral to DV services.
Constables Erba and Cobban attended Baxter’s address but he was not home. They then entered a job on the Police LCAD system to have crews attend the address to locate Baxter and Laianah to check on her and ascertain his version of events. Constable Erba monitored this for the rest of his shift.
That night Baxter Facetimed Hannah showing her that Laianah was okay. Baxter accused Hannah of having an affair with Mr D and told her she needed to fix that before he brought Laianah home.
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On 27 December Senior Constable Kent arranged for Hannah to visit the station the next day with the intention of pursuing a DVO application.
Also, on 27 December Baxter received letter from Hannah’s lawyers (K Lawyers) on behalf of Hannah requesting return of Laianah immediately. He phoned a friend who was a solicitor, Mr E, and gave a false version of taking Laianah from the park. He appeared upset and scared by the letter. Mr E advised him to return Laianah and resolve the matter with Hannah. He drafted letter to K Lawyers proposing a return to the previous custody arrangements. K Lawyers advised that was no longer acceptable and Baxter must return Laianah immediately.
Hannah emailed the property manager requesting her name be taken off the lease. The property manager later asked Baxter if would consent to this and he said he would not.
On 28 December Baxter contacted police and advised that Hannah had taken his dog and he was scared of her coming to his house and making a scene in front of his daughter.
On 28 December Senior Constable Kent advised Hannah she was going to apply for a DVO regardless of Hannah’s intention and Hannah supported the decision and provided an affidavit. Senior Constable Senior Constable Kent was satisfied that Baxter had placed Laianah in a dangerous situation and took out PPN with conditions that Baxter not be within 100 metres of the children or Hannah’s residence until the matter was heard in court. She attempted to contact Baxter but was unable to do so.
On 28 December Baxter sent an email to K Lawyers in which he demanded 50/50 time with children and set out a proposal for the Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 16 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
next month which involved Hannah picking the children up and dropping them off at every changeover.
A friend gave Baxter $2000 to pay for counselling as he believed Baxter was going to harm himself.
That night Baxter sent a text saying Laianah was tired and going to bed early. Hannah called police and told them Baxter was at home.
Police attended at his house but he was not there. Hannah went over and opened the house as there were lights and a tv on inside.
She saw that Baxter had put up photos of her that weren’t there before.
At about 7am on 29 December Constable Justin Kersey and Sergeant Nigel Johns attended Baxter’s residence to serve him with a Police Protection Notice (PPN) and a DVO application. When they arrived Baxter was putting Laianah into the car to go out. They went back inside the house and he was served with the PPN and application.
Constable Kersey activated his BWC. He told Baxter that he was there to serve him with the PPN and the application and Baxter commenced to complain immediately and repeatedly said it wasn’t fair. He was read the conditions and said that he understood them.
He agreed with the conditions until it came to Laianah and then he started to disagree with it and said Hannah couldn’t do that.
Sergeant Johns explained that it was the police that had obtained the order, not Hannah.
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During the time the police were in the house he would not let Laianah go. He carried her and then sat her on his lap with his arms around her.
Baxter said that he rang the police the night before because he had been away at a friend’s house for three days and he thought Hannah was going to come around and take Laianah. He gave a false version about taking Laianah in the car and said that she wanted to go with him. He said he had done nothing wrong and only wanted to look after his children. He said his friends gave him advice.
He said when he got home the dog was gone and Hannah had taken his alcohol. He was worried she was going to come over and make a scene.
He said he hadn’t done anything to warrant any of this. Hannah’s solicitor asked him to bring Laianah back. When he refused, they said they were going to court. She’d been “pushed to the wall” so she’d brought this application. The police repeated that it was a police application, not Hannah’s application.
Baxter told the police that he was a great father and there are many people who would testify to that.
Sergeant Johns and Constable Kersey took Laianah back to Hannah. They told her that Baxter had been served and the next court date was 4 January 2020.
Sometime in December Hannah was speaking to a friend at CrossFit Carina and said, “I am scared that Rowan will hurt the kids to hurt me.
On 1 January 2020 Detective Sergeant Derek Harris of the Morningside Child Protection Investigation Unit reviewed a Child Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 18 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Harm Referral created as a result of Baxter taking Laianah on 26 December 2019.
Child Harm Referrals are generated by uniformed officers who attend domestic abuse incidents. They are generated regardless of any action taken by police at the time they attend. They are also created by officers who attend an address and have concerns as to child safety e.g. living conditions.
The purpose of the review of such referrals is to determine whether any further investigative response is required to address any identifiable offences committed against children. The referral is reviewed, and the information forwarded via email to the Department of Child Safety (DOCS) Brisbane Regional Intake Service. DOCS should then undertake a similar review process to determine its response.
Detective Sergeant Harris determined that no further investigation was required and that the circumstances related to a custody dispute between parents. There were no court orders in force and nothing to indicate that Baxter was not allowed to have custody of his daughter. The QPS incident log indicated that Baxter had contacted Hannah and advised that he and Laianah were in Pottsville. There was no child protection history. No offences had been committed.
At the time he undertook the review Laianah had been returned to Hannah and DV issues were being dealt with by way of a DVO application. Detective Sergeant Harris forwarded a copy of the referral to DOCS.
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• Commits act of DV;
• Expose the children to DV;
• Go within 100m of Hannah’s residence;
• Contact Hannah unless to contact the children or arrange contact with the children.
On 14 January Baxter sent an email to K Lawyers advising it was 24 hours since he saw his children. His tone was patronising, aggressive and bullying.
On 14 January police officers visited Baxter to talk about DV and offer support service referrals.
On 17 January K Lawyers sent an email to Baxter advising Hannah had organised mediation next Thursday to resolve parenting arrangements and she would continue to facilitate Facetime until there was a formal agreement in place.
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On 21 January Mr C emailed K Lawyers stating that Baxter had not seen his children for a month and wanted them dropped off at his residence at 8am on 24 January and he would return them on 26 January at 4pm.
On 21 January Baxter texted Mr M asking him to tell his lawyer that Hannah said she was only taking out the DVO to get Laianah back.
On 22 January an internal email was sent at C Lawyers indicating that Baxter instructed that he did not see the children on Christmas Day.
• The DVO was strongly contested;
• Baxter would call two witnesses who would say that Hannah only brought the application for custody matters;
• Another witness would say that Hannah told him she was only doing it to get the kids back;
• If this is proven they would seek costs.
On 22 January Mr C represented Baxter in court in relation to the application to vary the TPO. The court made the variation as sought by Hannah.
On 23 January the mediator sent an interim parenting plan to Mr C pending court determination with the following terms:
• The children live with their mother;
• They spend every second weekend with Baxter;
• They spend every other week Thursday to Friday with Baxter;
• Holidays are shared;
• They Facetime Baxter Tuesday and Thursday at 6pm;
• Changeovers take place at the Clarke’s house.
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On 24 January Hannah agreed fo ther children to stay with Baxter for Friday, Saturday and Sunday of that weekend and the next Thursday. During that stay Baxter questioned the children about Hannah’s “friendship” with Senior Constable Kent which upset them.
On 28 January Hannah was advised by Centrelink that Baxter was to pay child support payments of $360 per month.
On 28 January Baxter posted on Facebook thanking his supporters and stating that having had his children taken from him was crippling and he would not stop fighting to have them 50% of the time.
On 29 January Baxter drafted a letter to Hannah signed from himself and the three children which seemed to be written in contemplation of his death or Hannah’s.
On the morning of 30 January Aaliyah was crying as she didn’t want to go to her father’s place that night. Hannah told a school mother that Baxter had picked up Trey and then turned his phone off. The mother told her that she saw the girls that afternoon at school and they were not their usually happy selves. Hannah texted her that Baxter was horrible to Aaliyah because she stood up to him.
Baxter had the children overnight. Hannah received a Facetime call from Aaliyah that night. She was crying and said that Baxter was driving them on a highway and she didn’t know where they were going.
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When Aaliyah arrived at school on 31 January she asked a mother if she could use her phone to call Hannah.
On 31 January Baxter returned Trey after 9am contrary to the agreement. Hannah saw explicit photos of her in Baxter’s car and grabbed them and walked away. Baxter got out of the car and followed her and grabbed her wrist. Mrs Clarke heard Hannah scream and phoned the police.
Hannah was advised by her solicitor not to continue contact and to allow phone contact only between Baxter and children until the Family Court proceedings.
Hannah reported the breach to Senior Constable Kent. Senior Constable Kent disclosed to her Sergeant that she had become friendly with Hannah. He took over as the lead officer.
On 31 January Baxter emailed Mr C advising of the photo incident but denying that he assaulted Hannah.
Baxter attended the Coorparoo police station and spoke with police regarding an application for a DVO against Hannah.
On 1 February 2020 Hannah attended a GP who diagnosed a sprained wrist which required a splint.
On 2 February 2020 Senior Constable Kent and Sergeant Rolf attended Baxter’s house and spoke to him about the assault and breach of TPO on 31 January.
Baxter said he had been told by his lawyer not to speak to the police and he didn’t wish to participate in an interview without a solicitor.
He said he had already been to Coorparoo police station as he went there as soon as the incident occurred and told them what Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 23 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
happened. He called a solicitor (a friend) who advised him to speak to Mr C.
Sergeant Rolf said if Baxter was refusing an interview he would take action that day. Baxter then said that he wanted legal advice and said he would phone Sergeant Rolf on 4 February 2020 to advise whether he would participate in an interview with police.
Sergeant Rolf told Baxter that the order was still in place and he could not breach it. Baxter said, “I’m very smart about what I do.”
Senior Constable Kent prompted Sergeant Rolf to discuss the photos with Baxter.
Baxter said: I’d rather not get into that, because that that’s, that’s stuff that’s for Court, and that was under the seat with files that she’s taken. So that’s all, they’re all part of the bigger…
He said they were in a folder which spun around. Sergeant Rolf said if Baxter had photos like that to “put them in an envelope or something.”
On 3 February Baxter emailed Mr C advising police had been around to see him re the alleged breach of DVO and it had been suggested to him that he should get a DVO against Hannah for stealing his property out of his car and losing her temper in front of Trey. He said, “I feel like a punching bag for her at the moment.”
On the same day Baxter lost a job as a personal trainer at a gym in Brisbane and believed that it was because of Hannah joining the gym the day before and members advising they would withdraw their membership if he was employed.
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On 4 February Baxter emailed Mr C asking for changeover to occur at McDonalds as he was not comfortable going to Hannah’s parents’ place.
On 6 February K Lawyers emailed Mr C advising that due to incident on 31 January Hannah would not be complying with the parenting plan and not facilitating contact until further agreement or order of the court. They advised they instructions to file an initiating application in the Federal Circuit Court. They said Hannah would continue to facilitate Facetime Tuesday and Thursdays.
On 8 February Baxter emailed Mr C. He said he was perplexed, nothing happened, she was a fraud and why wasn’t Mr C defending him. Mr C was unhappy about receiving the email and advised Mr E as such.
Mr E later emailed Mr C advising he had told Baxter he needed to be more patient given that Mr C was helping him out in return for training sessions with Baxter and noted that Baxter had not provided any sessions.
Baxter emailed Mr C and apologised for bombarding him with emails and texts. He said he was sick of Hannah pulling stunts like this and he planned to file a DVO application against her for emotional abuse of withholding the kids.
Mr C replied that they could file for a cross order but they needed sufficient grounds and they would discuss it further.
Around this time Baxter’s friends became concerned that he may kill himself.
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At about 11.15am on 9 February Sergeant Johns and Constable Kersey saw Baxter at Carindale Shopping Centre. They were aware that he was wanted for questioning in relation to Breach of the DVO on 31 January 2020. They approached him and Constable Kersey activated his BWC.
Baxter went to the Carindale Police Beat with the officers. He declined to participate in a record of interview on advice from his solicitor, Mr C, after speaking to him on the phone. Baxter asked Mr C why it was going this far.
Constable Kersey told Mr C he would have to charge Baxter and he would have to go through the watch house as it was a DV matter.
Constable Kersey then asked Sergeant Johns whether they could serve Baxter with a Notice to Appear (NTA).
Hannah found photos in the car and he grabbed her on the arm. He said they were just deciding whether Baxter could be given a NTA or whether they would have to take him through the watch house.
Constable Kersey left to make a phone call and then returned and told Baxter he was taking him to the watch house. He then issued him with a NTA in the Brisbane Magistrates Court on 2 March 2020 and told him he was free to leave.
Later that day Constable Kersey phoned Hannah and advised her that Baxter had been charged with the breach on 31 January 2020.
Mr C sent a letter to K Lawyers requesting reinstatement of the parenting plan and advising Baxter was availing himself of the appropriate courses and counselling.
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She then spoke about needing a will.
On 11 February 2020 Constable Kersey created an additional NTA for the offence of common assault that occurred on 31 January 2020 and amended the court to Holland Park.
On 13 February K Lawyers sent Baxter a letter advising that he continued to contact Hannah directly and asking that he cease but said she remained willing to continue Facetime as previously but was not willing to reinstate the parenting plan.
On 14 February Senior Constable Matthew Rogers and Constable Mahesh Joshi attended Baxter’s address and served him with the NTA for common assault.
Events of the week commencing 17 February 2022 17 February 2020
Baxter contacted Mr E and said he was being chased by a debt collection agency for payment of rent for Capalaba Gym.
At 5.40pm Baxter was recorded on CCTV entering the Bunnings Hardware store on the corner of Creek and Wecker Roads, Mt Gravatt. He browsed a number of aisles and, after initially selecting lawn mower fuel and then replacing it, purchased a green jerry can, zip ties and a bottle of methylated spirits. He arrived home at 6.12pm and took the jerry can and the cable ties from his boot into his garage.
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18 February 2020
Baxter left his house at 6.40am carrying the green jerry can which he put inside the Nissan.
At 7.27am he went to the Caltex service station at Carindale and purchased 4.6 litres of fuel which he put into the jerry can. He also purchased three “Kinder Surprise” chocolates and two bags of lollies.
He returned home at 7.35am and parked on the street and entered his house. At 7.51am he left the house and drove off in the direction of Westfield Carindale.
At 8.43am Baxter returned to his house, jogged from his car into the house and then rushed back to the vehicle a short time later.
At 3.28pm Baxter went home. He phoned Youth and Family Services (YFS) and inquired about a men’s support program.
Hannah had restricted his access following the DV breach on 31 January 2020. He said, “Everything she is doing is working.”
At 7.23pm Baxter’s aunt sent him a text message asking if she could have her car back and he replied that he, “just required it tomorrow”.
At 9.20am on 18 February Baxter transferred $920 to the property manager bringing his rent arrears up to date.
Baxter called another friend and told him he had lost everything – Hannah, the kids, he had no money and no way out and had been served with an eviction notice.
Baxter Facetimed the children that night but didn’t speak to them – he just cried. Hannah told them they could hang up if he wasn’t speaking to them. She told her mother and said, “Oh god, what if he kills himself.” 19 February 2020
Mrs Clarke went to the gym early that morning and arrived home at about 6.20am. Hannah and the children were awake and greeted her.
At 6.30am Hannah went out to get coffee for herself and her mother and then returned home. She sat on her mother’s bed drinking her coffee whilst her mother got ready for work. The girls were playing in their bedroom and Trey was watching a dinosaur show on television.
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At about 7am he went to Piccolo Coffee Co café on Samuel Street at Camp Hill. He ordered a takeaway coffee. He told the barista he was “fighting with the ex missus.”
He took his coffee and sat at a table on the footpath. He stayed there for about an hour. The barista noticed that he was on his phone and seemed to be looking at the “Maps” application.
At about 7.20am Mrs Clarke kissed her daughter and grandchildren goodbye and told Hannah she loved her for the last time and left for work.
At 8.02am Baxter was driving on Durimbil Street. At 8.12am he stopped outside a house near the Clarkes residence. At 8.17am he drove back to the Clarke’s residence and parked across the road.
Hannah was leaving home in her silver Kia. She was driving the car and the three children were in the back seat. Trey was in the middle in a car seat, Aaliyah was behind the driver’s seat and Laianah was sitting in a booster seat behind the passenger seat.
As Hannah started the car Baxter jumped in the passenger seat and told her to drive. He was holding a petrol container. Hannah screamed at him to get out of the car.
At about 8.25am, Michael Zemek was in the driveway of his house in Raven Street at Camp Hill, washing his car. Hannah pulled over in front of Mr Zemek. She screamed to him, “Call the police, he’s going to kill me. He’s poured petrol on me.” Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 30 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Mr Zemek saw Baxter in the front seat. He was physically restraining Hannah from getting out of the car. He was holding her around the arms and chest with both of his hands. She was trying to get free.
Mr Zemek noted that he didn’t seem crazy but like he was in control.
Almost immediately the car erupted in flames. Mr Zemek ran to the vehicle. He can’t remember whether he or Hannah opened the car door but she got out of the car. He sustained burns to his face from the fire. He could not return to the vehicle as the fire was too hot.
Hannah was alight when she got out of the car. Mr Zemek told her get on the ground and roll and he hosed her. When the flames were extinguished he went to the other side of the car and saw Baxter lying on the road. He was also alight so Mr Zemek hosed him as well.
Mr Zemek returned to Hannah – she was screaming something about children being in the car but he couldn’t really make sense of what she was saying. Mr Zemek ran to his house to ask his daughter to call 000. The first call to 000 was received at 8.26am.
Mr Zemek changed his hose from the tank water to the mains water and then returned to the footpath where he continued to assist. Mr Zemek was later taken to hospital and admitted to the Burns Unit with burns to his face, eye and arm which he sustained helping Hannah out of the car.
Samantha Covey was driving her children to swimming classes that morning. As she drove along City View Road at Camp Hill she saw smoke coming from Raven Street. She turned into that street and saw the car on fire. She got out of her car and went to Hannah who was lying on the grass on the side of the road.
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Ms Covey picked up the hose that Mr Zemek had been using and started hosing Hannah’s body. Hannah said she couldn’t believe what Baxter had done – she said she had a DVO. She said her babies were in the car and asked whether anyone had got them out.
Hannah told Ms Covey that she saw a man washing his car so she stopped so that he could call the police and Baxter dropped the lighter. She said she had tried to stop him and had ripped his shirt.
Kerry Fernandez who lives in Raven Street heard a woman screaming, “Call the police.”
She then heard a bone chilling scream. She went outside and saw a car drive up on the curb on Raven Street. She immediately called
She walked toward the car and saw that other people were on the phone. She hung up her phone and ran back to her house to get a fire extinguisher from her garage. As she did so she saw Baxter standing on the footpath. He was burnt. She got the extinguisher and ran to the car with it where she attempted to extinguish the flames.
The vehicle started to roll backward and people were yelling to watch out in case it exploded. Hannah stood up and said, “My kids.”
He parked his ute about 15 metres from where Mr Zemek was standing. He heard Hannah screaming and turned around and saw her pull up in the car. He heard her say, “He’s doused me with petrol, call the police.” Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 32 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
He was screaming at Hannah to get away from the car. Mr Young ran towards the car. He saw two men running to it from the opposite side of the road. They went to the passenger side and Baxter got out of the car. They grabbed him and moved him to the curb.
The car started to roll backwards and Baxter dove into the front passenger seat head first and then came straight back out.
Mr Young obtained two pieces of timber from the back of his ute and gave them to the two men who went to the back of the car to try to stop it rolling backward.
He heard one of them yell, “Get them out, get them out.”
He ran back to the car and saw a baby seat in the back seat of the burning car. The three could not get close to the car which was fully engulfed and burning.
Ms Fernandez continued to use the extinguisher on the car. She saw Baxter walking around the car aggressively. He was very badly burnt. Ms Fernandez was getting burnt from the heat of the car so she went around to the passenger side. That was when Baxter dove into the car head on and then came out again.
Reece Gourley was watching Baxter and saw that he had retrieved a knife from the car. He warned Ms Fernandez that Baxter was armed. She immediately retreated towards her house.
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Baxter sat on the grass about two metres away from the car with his head down.
Sarah Tranberg, who resided in Raven Street, came out of her house and saw Baxter kneeling on the footpath. He had the knife tip pressed against his stomach. She told him to drop the knife a number of times but then he fell forwards onto the knife. He then curled into a foetal position on his side.
Stephanie Ring, an off-duty paramedic, stopped at the scene on her way home from work. She saw Ms Fernandez with the fire extinguisher and Ms Covey hosing Hannah. She asked Hannah what happened.
Hannah said, “My babies are in the car. My ex-partner told me to pull the car over. Then he squirted petrol on us and threw a lighter at the car.”
Ms Ring gave a sitrep to the call taker on 000 and requested multiple QAS and QPS crews attend.
Queensland Fire and Emergency Service officers arrived at the scene first. Ms Tranberg ran up to the first truck and told them that Baxter was burnt and had stabbed himself.
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Senior Constable Angus Skaines, one of the first responders, activated his BWC and obtained information from Hannah. She told him that she and the children got in the car to go to school at her parent’s place. She said she had turned the car on, and Baxter jumped in the front seat. She started to scream, and he told her to drive. He said all he wanted to do was see his children. She told him to get out and he told her to drive. He had a jerry can in his hand. She saw a man washing his car, so she pulled over and asked him to call the police and Baxter poured petrol “everywhere” and “lit the car alight.”
Dereje Bushell is an Advanced Care Paramedic 2. He and his partner, Barry Twomey (also an Advanced Care Paramedic 2) attended the scene. They saw QFES hosing down a male person with a hose and also applying pressure to his chest. They saw that he was burnt and unresponsive. His partner, Officer Twomey, told him that there was a female who needed assistance and deceased children in the car.
He walked up the footpath and saw Hannah standing on the nature strip. She was being hosed down by Ms Covey.
He was unsuccessful. He asked a police officer to bring a stretcher from the ambulance. He administered 10mg of morphine intramascularly to her thigh.
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While he was treating her, Hannah stated, “I hope he survives and rots in jail for the rest of his life.”
She asked Officer Bushell if her children were ok. He told her it was important to concentrate on herself right now.
Maddison Freer, Ambulance Officer, and her partner, Robyn Carter, Ambulance Officer, arrived at the scene at about 8.41am. They saw QPS and QFES officers already present.
They were advised by their Senior Operations Supervisor, Adrian Tong, to attend to the female patient.
The ambulance officers continued to try to get IV access. Dr Rashford, the Medical Director of QAS and an Emergency Medical Specialist, arrived. He saw immediately that Hannah had suffered full thickness burns to her entire body which were non-survivable.
He instructed the crew to give Hannah 50mcg of Fentanyl via IV which had just been established via her hands.
Dr Rashford told them to put Hannah into the ambulance for rapid sequence induction (RSI) to occur i.e. the provision of anaesthetic to make her sleep. At that time Hannah could still speak but was only responding when prompted.
Officer Bushell asked Hannah how she was doing and she replied, “I am in pain.”
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Dr Linh Nguyen, an anaesthetist who lived on Raven Street, assisted the paramedics to treat Hannah in the back of the ambulance.
Dr Rashford was advised that Baxter had arrested and he left the ambulance and went to Baxter to commence a traumatic cardiac arrest resuscitation.
Officer Bushell administered the drugs to Hannah under the direction of the Critical Care Paramedics.
The HARU paramedic intubated Hannah post administration of the RSI drugs. Once she was intubated Hannah was removed from the ambulance, stripped, dried and transferred to a fresh stretcher. The Critical Care and HARU paramedics stayed in the back of the ambulance with Hannah whilst Officer Bushell drove to the hospital.
Hannah was admitted to the Royal Brisbane and Women’s Hospital where she died at 5.40pm that afternoon.
When the fire was extinguished the burnt bodies of Aaliyah, Laianah and Trey were found in the back seat of the car.
They had sustained injuries that were clearly incompatible with life.
They had been burnt so badly that they could not be visually identified.
Paramedics removed the knife from his chest and performed finger thoracostomies on each side of his chest. A “clamshell” thoracotomy was performed which revealed blood under pressure in the sac Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 37 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
around the heart (tense haemopericardium). The pericardium was opened, and the blood was evacuated. The wound to the heart was closed with staples. Internal cardiac massage was then performed, however, this was unsuccessful and he was pronounced deceased at 9.14am.
Autopsies
The autopsy carried out on Hannah revealed that she died from multi-organ failure from the effects of the fire.
Aaliyah died from the effects of the fire including smoke inhalation and burns. She had severe burns to 100% of her body. Whilst toxicology was positive for a potentially toxic blood level of carbon monoxide it is unlikely to have caused her death.
Laianah died from the effects of fire including direct thermal effects, the effects of inhalation of smoke and other products of combustion.
Trey died from the effects of fire including direct thermal effects, the effects of inhalation of smoke and other products of combustion.
Baxter died from a stab wound to the chest. At the time of his death he was suffering from burns. As they were extensive, involving 80% of his body, they may also have contributed to his death. Toxicology was negative for alcohol and drugs. He had a number of superficial sharp force injuries, which were consistent with self-infliction. He had three stab wounds, one had entered the abdominal wall only, one had entered the abdominal cavity and very superficially involved the stomach and the one near the midline had passed upwards into the chest cavity and was responsible for the injury to the heart that caused his death.
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Fire Investigation
Sergeant Padget is a scientific officer stationed at Major Crime Unit of the Brisbane Scientific Section of the QPS. He examined and tested the vehicle and surrounds and the bodies of the children.
He concluded that the fire started in the cabin of the car and progressed to the engine bay. There was minimal damage around the fuel cover which indicated that the fuel inside of the fuel tank had not started to vent and had minimal contribution to the fire.
He located the partly burnt and melted remains of a green plastic container (the petrol container) on the floor well behind the driver’s seat.
• Three items of clothing taken from the laps of the three children;
• Hannah’s clothes;
• Burnt fabric taken from the rear passenger floor well;
• The remains of the green container.
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Homicide Investigation
Detective Sergeant Derek Harris investigated the deaths and provided a coronial report. He concluded that Baxter’s conduct on 19 February 2020 was premeditated and the result of his inability to accept his loss of control over Hannah.
He concluded that it was possible that Baxter intended to force Hannah to drive to a secluded location, kill her with the knife and then burn her body but this was obstructed by Hannah pulling up in Mr Zemek’s driveway at which time he poured petrol over her and ignited it. The death of the children could have been a decision hastily made at the time to inflict trauma on Hannah. Realising what he had done he retrieved the knife and killed himself.
The Inquest
The inquest commenced in the Brisbane Magistrates Court on Monday 21 March 2022 and concluded on 31 March 2022.
Thirty-five witnesses gave evidence and a brief of evidence containing many more witness statements and exhibits was tendered. That evidence is incorporated into the information and timelines set out above.
The findings required by s. 45 (2) of the Coroners Act 2003; namely the identity of the deceased persons, when, where and how they died and what caused their deaths;
The nature and extent of any contact by Hannah Ashlie Clarke with domestic violence services or counselling prior to 19 February 2020; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 40 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
The nature and extent of any contact by Rowan Charles Baxter with domestic violence services or counselling prior to 19 February 2020; and
The appropriateness of responses to any contact by Hannah Ashlie Clarke and/or Rowan Charles Baxter with domestic violence services and the Queensland Police Service prior to 19 February 2020.
Witnesses to the Killings and First Responders
Michael Zemek, Samantha Covey, Kerry Fernandez, Reece Gourlay and Sarah Tranberg gave evidence. All were going about their normal business on the morning of 19 February 2020 when their lives were changed forever by the horror they witnessed.
All of them bravely and selflessly helped as much as they possibly could. Mr Zemek was first on the scene and was burnt when the car burst into flames in front of him but he helped Hannah out of the car and extinguished the flames on her body with his hose.
Ms Covey stopped her car when she saw Hannah’s car on fire and took over hosing Hannah from Mr Zemek. She continued to do so until Hannah was put in the ambulance.
Ms Fernandez obtained a fire extinguisher from her garage and bravely attempted to extinguish the car even though Baxter was, at that time, pacing around it. She didn’t give up until she realised that he had a knife at which time she was forced to retreat.
Mr Gourlay saw that Baxter had a knife and warned Ms Fernandez and helped her out of harm’s way.
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The witnesses who saw Hannah that morning were amazed by her bravery, her resilience and her strength.
On 22 March 2020 Stephanie Ring (an off duty paramedic), Anthony Eggins (a Senior Fire Officer), Senior Constable Skaines and Dr Stephen Rashford gave evidence.
Officer Eggins confirmed that they arrived at the fire very quickly but by the time he arrived anyone in the car had no chance of survival.
He said that in his opinion by the time they got the first call there was “no hope for the children.”
Senior Constable Skaines was the first police officer to speak to Hannah on the morning of 19 February 2020. He remains a general duties police officer at Annerley Police Station. He helpfully provided information about the training he had been given in relation to domestic violence and coercive control and current police procedures.
He said that he received training in DV at the police academy from which he graduated in 2011. The constable development programme included an elective module on DV which he chose to study. That development programme no longer exists. That involved a written assignment. Five years ago he underwent a two day face to face training programme. He undertakes annual DV training via Online Learning Programme which involves a multiple choice test which the attendee can continue to attempt until they pass. In 2022 every officer up to a certain rank had to complete an online program (OLP) in relation to coercive control which also involved answering questions in a multiple choice setting.
He has received no training in relation to the functions of the VPU and has not received any training conducted by VPU officers.
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In relation to DV matters he said that about half of his policing time is taken up by DV incidents. If a PPN is issued the paperwork involved takes about two hours to complete and then the respondent has to be served.
He said that officers of the DVU audit all DV occurrences every day and where appropriate, refer matters to the HRT. He said officers could contact DVU officers when they were on duty and could ask them for advice about referring cases to HRT. He said that there is a DV Liaison Officer (DVLO) at Annerley Station who also reviews DV matters when she has time – she also undertakes normal general duties responsibilities.
Senior Constable Skaines displayed a good understanding of the use of the DV-PAF1 and the QPS databases. However, he said it would be unusual to look at a potential respondent’s criminal history prior to attending a DV incident and he would not check CrimTrac (which contains interstate criminal histories).
Senior Constable Skaines said that it was his understanding that not all defendants charged with breach of DVO had to be processed through the watchhouse – it was discretionary based on the circumstances and they could be issued with a Notice to Appear.
Dr Rashford gave evidence that Hannah had full thickness burns to 97% of her body and such injuries are not survivable. Baxter had 80% full thickness burns which are almost never survivable but the combination of burns and the chest wound proved fatal in his case.
1 OPM 9.4.2 provides: Domestic violence protective assessment framework The Protective Assessment Framework (PAF) is a decision-making framework designed to assist officers in assessing the protective needs of an aggrieved. Identifying the presence of risk factors and assessing the aggrieved’s level of fear will assist in determining the required response. Officers are to conduct a protective assessment at all incidents or reports of domestic violence and utilise information gathered on risk factors in conjunction with their investigative skills, knowledge and experience to make an informed decision. Officers play a crucial role in identifying and responding to domestic violence and their actions and decisions can have a marked effect on future violence.
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Dr Rashford was listening to all of the events on his radio prior to arriving at the scene and he is confident that everything that could have been for Hannah was done and was done in the most timely manner. Due to the severity of her burns the priority was to cool the burns and then provide her with pain relief.
She was put to sleep as soon as possible and taken to the Royal Brisbane Hospital which has one of the best burns units in the world.
Nothing could be done to save her.
Friends and Associates of Baxter
• He was controlling and driven;
• He didn’t like to be told no;
• He always had to be the “alpha male”;
• He was very confrontational;
• His competitiveness extended to his clients at the gym and he always had to be better than them;
• If someone was better than him he accused them of cheating;
• He would lie when it suited him;
• He trained his clients extremely hard and liked to see them exhausted and even vomiting.
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• He was so controlling that he would record his client’s workouts at the gym and check the times they had recorded and if they had not recorded their times correctly he would ask them to leave and not come back to the gym;
• He made all the decisions in regard to his family and the gym and ignored Hannah’s suggestions and ideas;
• He “burnt bridges” by criticising others and taking advantage of his friends and business associates financially;
• He pressured Hannah’s employee to fire her because he was “his mate” and he didn’t want Hannah to have that support;
• He became obsessed with the separation and seeing his children and stopped eating and sleeping;
• He was suspicious of Hannah and wanted to know how she was spending her time;
• He painted himself as the victim always;
• Whilst he controlled Hannah he was also dependent on her to transfer him money and look after the family bank accounts and financial matters;
• After Hannah left him he reached out to associates but his aim was to “get them on his side” and give them his version of events eg the photo incident and the taking of Laianah – some of his friends recognised this – “It felt to me like he was maybe calling clients of the gym to tell his side of the story and gain support regarding the break up.”;
• He posted on Facebook that he was missing his children etc to gain the attention of friends and associates;
• He said he wanted to change to get Hannah back but in reality he had no insight and just wanted things to go back the way they were;
• He had no intention of changing;
• He controlled family life including making Hannah take gym classes when she needed time off; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 45 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• He wanted his associates to contact Hannah and tell her she should go back to him;
• He was becoming more and more paranoid about what Hannah was doing;
• He only reached out to people when he wanted something from them and contacted many of his friends and associates that he had not been in touch with after Hannah left him to garnish support and assistance;
• He was short tempered and alienated his gym members;
• He pretended to cry when he was seeking sympathy and support for his view;
• He visited Hannah at work most shifts to check up on her and continued to do so after the separation;
• He prohibited Hannah from wearing shorts to work even in hot weather and made her wear long tights when the other employees were wearing shorts;
• He was jealous of anyone else’s success;
• He was an incredibly insecure person who put on a “macho” front and only felt valued when he perceived himself to be superior to others;
• He also had a kind side and would often help people out if they needed his support and was loyal to his friends;
• He enjoyed it when people were impressed or intimidated by him;
• He became obsessed with the relationship he imagined that Hannah was having with Mr D – “he was consumed with the idea that the breakup came about due to this relationship”;
• He discussed the incident when he assaulted Hannah over the photos with numerous friends but disclosed to none that he had grabbed her and told some that she assaulted him and others that he hadn’t touched her;
• He was “infuriated” when he couldn’t see his children after the assault; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 46 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• After the police came and took Laianah back to Hannah he told his friend that if he didn’t get the 50/50 custody split that he wanted, “I’ll make sure she never sees the kids again”;
• When Baxter told one of his friends that the custody issues were all caused by Hannah that friend thought, “Why would Hannah do this if you have done nothing wrong. It didn’t make sense because Hannah was one of the nicest persons in the world”;
• He told his friends that he was upset with Hannah’s posts on Facebook after their separation because she was “parading her body”;
• He told a friend that he saw Hannah at the school, “dressed as a tart in a short skirt”;
• One of his friends stated that Baxter “was in the mindset that only in death could he be with his children”;
• Baxter sent text messages to that friend during the separation.
Baxter said that court was “disgraceful and I’m so angry”. He said that Hannah was “a joke,” “fukn disgraceful” and a “fukn cunt of a thing”. On 12 February he complained that she had stopped paying half of the rent. He said that the “kids were terrible” and “being manipulated”. He said, “Hannah has allowed them to get away with too much, they don’t want to talk anymore because they don’t do it enough.”
• Baxter told some of his friends that Hannah left him because of his controlling behaviour and that he wanted to change and get counselling;
• Baxter misrepresented the taking of Laianah to a number of friends although some of them recognised that his story didn’t ring true – “It seemed to me like he was inappropriately taking matters into his own hands by withholding his daughter. It sounded to me like it was more about exerting his power rather than seeing his kids.”;
• Baxter believed that “the whole world was against him”; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 47 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• “there was something not quite right with Rowan”;
• When a friend posted on Hannah’s Facebook page, “Glad to see you smiling”, Baxter messaged him, “Mate, thanks for encouraging Hannah’s behaviour, she has painted me as a monster and of all people I would expect you to understand.”
A friend of both Hannah and Baxter (Mr P) was a qualified occupational therapist who had worked in an in-patient mental health unit with chronically mentally ill patients and community mental health services, as an intake worker for crisis and risk assessment and a mental health team leader and senior mental health clinician and in acute care team work assessing risk and installing preventative measures. He provided a statement to police as to his observations over the three years he knew the family.
Mr P said that Hannah was warm, loving, caring and resilient. She was very tough both mentally and physically. She wasn’t one to play the victim and took responsibility for her action. She was a really great person and even after the separation she was very reasonable until Baxter started acting out and she was left with no choice but to try to protect herself and the kids.
Mr P described Baxter as loyal, intense, detail-orientated and focused on getting things right. He was a great father, caring and considerate. He was intense and couldn’t see another’s point of view.
Around Christmas 2019 Hannah told Mr P that she and Baxter had separated. She told him she wanted Baxter to have 50/50 custody of the kids as he was a good father and she wanted him to be involved in their lives.
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He met with her at the school and asked for them back and she tore them up. He went to stop her and she started screaming that he had breached the DVO.
Mr P ceased communicating with Baxter when he realised that responding to him was “feeding into his victimhood mentality.”
Mr P is of the opinion that Baxter: Didn’t have the ability to live a life that he’s not in control of. Nor would he let those who he believes are his life to live a life outside of his control. He chose to take that from them despite never having the capacity to see he was in control of, and responsible for, the situation the whole time.
He contacted family members, friends, old neighbours, ex gym members and associates that he had not been in contact with for years. He attempted to get them on side and blamed Hannah for the separation and his inability to see his children. He complained to them of his financial situation in an attempt to obtain money from Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 49 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
them. More than one of Baxter’s associates urged him to get counselling and one gave him $2000 to pay for counselling sessions.
He took it on the basis that he would obtain counselling but he did not.
Hannah’s Family and Friends
Many people provided statements to police after her death and in them there is a recurring theme that Hannah became more and more fearful for her safety and that of the children and by February 2020, she was becoming certain that Baxter wanted to kill her.
Hannah’s family and her friends were aware of the nature of her relationship with Baxter. Whilst they had concerns for her, of course, none could foresee the tragic outcome.
Mrs Clarke gave evidence of Baxter’s nature – he was controlling, verbally abusive, manipulative, and dominating. He was unsuccessful financially and could not provide for his family, relying instead on Hannah and her parents to pay rent, bills and clothe the children.
He would make himself out to be the victim and then tell the Clarkes that Hannah had mental problems and she was the cause of issues.
Hannah was always the main carer for the children and the one who fed and clothed them and did the housework. Whilst she initially was of the view that Baxter should see the children and have them stay overnight she changed her mind once he abducted Laianah.
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Although she remained fearful for herself and them she agreed to a 70/30 parenting agreement after that incident.
He didn’t like her standing up to him. After Baxter took Laianah Aaliyah had to see a counsellor because she was so angry with him and she couldn’t get over it.
Mrs Clarke witnessed the incident where Hannah saw the photos and tried to take them. She saw Baxter twist Hannah’s wrist up behind her back. Baxter made sure Hannah saw the photos as he told her that if she went to court he would use them as evidence. He wanted her to abandon the DVO.
Although Hannah was initially happy for Baxter to have the children, after the separation and when his behaviour was escalating she became afraid that he may hurt the children to punish her.
The week before Hannah died she told her mother that she needed a will as, “When he kills me, he will be in jail and who will look after the children.”
The neighbour of Hannah and Baxter identified early on in the relationship that Baxter was arrogant and intimidating and he was controlling but Hannah was so young and sweet that she didn’t realise what was going on.
Hannah lost contact with her when they fell out after she confronted Baxter about taking advantage of them in regard to the free use of their gym but she got back in contact during the separation and disclosed his behaviour. Hannah told her that she was growing up and starting to stand up for herself and Baxter didn’t like it. As the Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 51 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
separation progressed Hannah told her that it was not safe for Baxter to have the kids.
Ms Brooks saw Baxter for what he was – a controlling man who needed to win at all costs. He even competed with his children and was very rough with them. He split Aaliyah’s head open during a pillow fight and submerged Trey in an ice bath – Trey was screaming in fright – Baxter posted it on social media and thought it funny. He would tackle Aaliyah with such force that she would cry. If he didn’t get his own way he would sulk for days, not talk to the children and cancel planned outings in spite.
Hannah told Ms Brooks that prior to the separation Baxter came home from gym and put his hands around Hannah’s neck, choking her. He said, “You have no idea what I’m capable of.”
Hannah told Ms Brooks she was fearful Baxter would kill her. Ms Brooks told the police, “I’m sure he’s going to take them out.”
Aaliyah knew exactly what Baxter was like. She was so anxious about spending time with him that Hannah bought her a watch that had texting capabilities and told her that if she was afraid while she was with him she should go to the toilet and message Hannah.
Hannah told Aaliyah not to tell her father about the watch or he would throw it away.
Ms Brooks said that Baxter was most certainly not the main carer of the children. Hannah did everything for them as well as going to work and taking gym classes – she was a “supermum.”
Lynne Kershaw joined the gym in 2017 and became friends with Hannah. She treated Laianah for sleep problems and found out that she was having ongoing nightmares about her father killing her Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 52 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
mother. She later treated Aaliyah for trauma and anger after Baxter abducted Laianah.
In 2019 after the gym moved to Capalaba she saw that Baxter, who had always been moody, became worse. He walked around muttering, had angry outbursts, disagreements with members and yelled at people during workouts. He was increasingly short with Hannah and the children and yelled at her. She was involved in CrossFit by then and improving but Baxter wouldn’t train her properly or show her new moves etc because he didn’t want her getting better and he was jealous of her.
Hannah was elated when she won a place in the CrossFit competition. Baxter got in because of her. He then pulled out at the last minute and expected her to cancel the whole thing. He was unhappy when she didn’t so the morning of the CrossFit competition Baxter made Hannah take a gym class when she should have been concentrating on the competition. When she returned home he had taken the children and turned his phone off. Ms Kershaw said that Hannah was “freaking out”, terrified and even vomited she was so upset and scared for the children.
They had a massive argument that evening because Hannah had been promising Aaliyah for weeks she would take her to the CrossFit games that night to see her idol, a CrossFit champion. Because Baxter was angry with Hannah he said that they were not allowed to go. Hannah stood up to him as she was determined to fulfill her promise to Aaliyah. He grabbed her and Ms Kershaw saw finger marks on her upper arm that evening.
Hannah told her that Baxter had said that if his previous wife had left him he would have killed their son and himself.
Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 53 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Hannah told Ms Kershaw that on Friday nights Baxter would drink and then demand sex and if she refused he would often threaten to kill himself and drive off in the car. Ms Kershaw noticed that quite often he was in a bad mood at Saturday morning gym classes.
Ms Kershaw said that on at least three occasions Hannah said to her, “I know in my heart that he’s going to kill me.”
A friend of Hannah’s who knew her and Aaliyah from school saw Aaliyah upset when she had to go home with her father and Hannah told her that she was leaving Baxter as “Aaliyah can’t do it anymore.”
Another friend of Hannah’s who saw her at gym but also outside of the gym and without Baxter knew that Baxter was controlling and punished the kids if he and Hannah had a disagreement eg by cancelling outings that the children were looking forward to which would make them upset. In 2017 she said bruises on her upper arm and Hannah told her that they had been arguing and Baxter pushed her onto the bed. Hannah would often be anxious if she was out somewhere that she had to be home to Baxter at a certain time. She would become so anxious that she would be “frantic and yelling at the kids to get in the car” so that she wouldn’t upset him.
On 16 January 2020 that friend saw Baxter at Carindale. He told her that Hannah had run off with someone and she was now obsessed about getting attention and how she looks and how fit she is. He said people were “in her ears” coaching her about what to say to keep the kids from him and she was “dictating the terms on how and when he could see his kids.”
A friend who was close with Hannah said that their “marriage was a big cycle the whole time I knew them…. Hannah started to check out emotionally as she was utterly exhausted from Rowan and his manipulation and controlling behaviour.” Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 54 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
The friend said that, “Hannah would do everything from running gym classes all throughout the door, sort the kids out before and school and do dinner. He would do nothing. He would train in the back yard and expect everything to be done for him. If the house was messy, he could sometimes not speak to her for a day or more. He would lash out verbally to the kids and just ignore her.”
In relation to the killings the friend stated, “It was the ultimate act of control – he’s won and taken them all out.”
On the morning of 26 December 2019, a Brisbane doctor and her husband were riding their bicycles on Oxford Street at Bulimba. The doctor witnessed Baxter take Laianah from Hannah. She saw that Hannah, Aaliyah and Trey were distressed and screaming, “No, stop,” as Baxter carried Laianah to his car. He got into the driver’s seat whilst still carrying her and bumped her head against the car as he did so. He then drove off immediately.
The doctor was so concerned that she immediately flagged down two police officers who were parked on the road ahead and told them what she had witnessed. She was later contacted by Senior Constable Kent to whom she provided a statement.
Hannah’s employer at the Athlete’s Foot gave evidence that prior to her death Hannah asked him how to write a will as she wanted her children cared for if anything happened to her. He told her nothing was going to happen and she said, “No, he’s going to try to kill me.”
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He noticed that in the last few weeks before Hannah left Baxter he was coming into the shop every shift that she worked. One shift he came in and started helping her put stock away.
After they separated Hannah asked him to send her roster to a new email address as Baxter had access to her old one and could see when she was working. Staff commented that they saw Baxter walking past the store.
He saw officer Senior Constable Kent walk past the store many times and she came in a couple of times to speak to Hannah.
Hannah and Baxter trained with Mr D for about five years and during 2018 and 2019 and saw them four days per week and had contact with them most days. He became good friends with Hannah. He saw that Baxter was controlling and insecure. For example, Hannah sent them both a video of her completing a difficult exercise. He replied congratulating her but Baxter replied, ”Why are you wearing shorts?”
He noticed that Baxter became more insecure after Hannah started working at The Athlete’s Foot. Mr D thought this was because she was more financially independent and was making new friends.
Baxter needed her to depend on him for security and happiness.
In about October 2019 Hannah told Mr D that she thought she deserved better than Baxter. She became more and more concerned that he was tracking her phone. As she continued to confide in Mr D, Baxter became jealous and convinced they were having a relationship.
After the weekend of the Crossfit competition Hannah told Mr D she was going to leave Baxter. Mr D continued to offer her moral support.
Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 56 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
On Christmas Eve Baxter accused Mr D of getting Hannah to leave him. They talked for about three hours and he cried the whole time but “he never shed a tear.” Baxter insisted on looking at Mr D’s Instagram account and reading the text messages between Mr D and Hannah on Mr D’s phone. Baxter said that somebody was “getting in her head.”
The next day Mr D told Hannah that they should not talk as much because he was worried it would cause trouble for her. She was upset and said she was losing one of her best friends because of Baxter. After that Baxter contacted Mr D three times and again asked him if they were having a relationship. He told him they weren’t. The last contact Mr D had with Hannah was on 4 February 2020 when she sent him a text message in relation to exercising.
Police witnesses
Detective Sergeant Derek Harris investigated the circumstances of the deaths from a homicide investigation perspective. He is attached to the Child Protection Investigation Unit.
He gave evidence of the DV training he has received. He said he’d had no specific training in DV since 2009 although the Child Protection training also incorporates DV aspects but no specific DV training. He has not completed the OLP on coercive training. He is aware that there is annual refresher training on DV but could not say whether he has done it or when.
Detective Harris is a Field Training Officer i.e. an officer who is responsible for on the job training for first year constables but he agreed that there is no specific training provided to field training officers and none in relation to DV.
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He agreed that DV training could be part of the annual Operational Skills Training (OST) and considered that would be useful to officers.
Detective Harris stated that the VPU needs increased staffing levels with permanent trained officers including detectives. Front line officers need training. High risk matters require a multi-disciplinary team approach. There needs to be a more aggressive response to perpetrators including court ordered mens’ programmes and mental health responses.
Detective Sergeant Harris received a Child Harm Referral report in relation to Baxter taking Laianah. He considered that there was no imminent risk of harm to her or her siblings and forwarded the report to the Department of Child Safety (DOCS) as per relevant procedures. He could not further the matter as there had been no crime committed by Baxter. However, he agreed that children are nearly always involved in DV and their welfare should always be considered and the risk to them assessed.
He reviewed the matter on 1 January 2020 and saw that a PPN had been taken out and Laianah had been returned to her mother.
Detective Harris said that, whilst he undertook a homicide investigation in relation to the deaths he did not review the QPS response to the events prior to the death and was unaware of any such review.
In relation to the circumstances of the killings Harris concluded that Trey was seated behind the passenger seat, Laianah was in the middle of the back seat and Aaliyah was behind the driver’s seat.
Harris concluded, from the evidence of Sergeant Padgett that Baxter poured petrol over Hannah and the three children and put the petrol container in the foot well and Aaliyahs’ feet. He then ignited the Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 58 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
petrol. There was no petrol residue found on Baxter which indicates that he did not pour petrol on himself.
• At the academy in 2010 there was a two-week unit on DV;
• In 2012 she did a two-hour OLP;
• In 2013 she attended a “train the trainer” program for 2 to 3 days in relation to the DV reforms including the DV-PAF which had been recently introduced;
• In November 2013 she completed an assignment on DV for her Constable Development Programme (no longer offered);
• In 2017 she completed a two-hour OLP on DV legislation amendments;
• She undertook a two-day workshop at the academy when the PPNs were introduced;
• On 4 January 2022 she completed an OLP on coercive control.
There was no specific training offered to her in that role. It was then her duty to report on all DV occurrences once per month and provide that report to the district DVLO. She said that she suspected that the reports she submitted weren’t actually considered by anybody.
She would be allowed one shift per month to carry out her DVLO duties.
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She first met Hannah on 6 December 2019 when Hannah came into the station. She said her mum had sent her. Senior Constable Kent was the shift supervisor at that time and saw Hannah at the front counter and went out to speak to her. Senior Constable Kent confirmed that it was by chance that Hannah spoke to her and she could have been attended to by any other officer at the counter that day.
They spoke of DV in general and during that conversation Hannah disclosed that she was being sexually coerced. Senior Constable Kent immediately recognised that as a serious matter and from then on developed a rapport with her.
On 6 December 2019 Senior Constable Kent assessed Hannah’s risk as medium. She offered her a referral to DV support services.
A few days later Senior Constable Kent was rostered to work at Carindale Shopping Centre. She knew that Hannah worked at the Athlete’s Foot so walked past the shop. She waved to Hannah – Hannah immediately came out to the front of the shop and was “so fearful” that Senior Constable Kent was there because something had happened to the children who were with Baxter at the time.
Senior Constable Kent stated that she had not “seen such authentic fear from an aggrieved before.”
Senior Constable Kent contacted the VPU to obtain advice but it was confirmed that Hannah would have to get Family Court orders re the children. Hannah had calmed down by then and told Senior Constable Kent that she did not believe that Baxter would harm the children but Senior Constable Kent thought that was inconsistent with her earlier reaction.
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Senior Constable Kent phoned VPU again on 14 December 2019 as Hannah’s level of fear continued to play on her mind. From that date until 26 December 2019 Senior Constable Kent had numerous contacts with Hannah to provide her with support.
On 27 December 2019 Senior Constable Kent saw on the QPS database that Baxter had taken Laianah. She contacted Hannah and found that Laianah had not been returned. She arranged for Hannah to come to the station the next day and told her to start making notes about their history etc for a statement.
On 28 December 2019 Senior Constable Kent completed a DV-PAF and assessed Hannah as “high risk.” The outcome of that assessment was that the matter was referred to the VPU. Senior Constable Kent applied to obtain Baxter’s criminal history from New Zealand.
On 29 December Hannah went to the station again and it was decided to obtain a PPN. Senior Constable Kent warned her that this was only the first step – she knew that Baxter would fight a DVO and she didn’t want Hannah to believe that the PPN gave her any real protection.
Hannah and Senior Constable Kent discussed whether Hannah should make a complaint of stalking but it was decided it would be better to obtain a DVO in the first place.
Constable Luke Erba provided an addendum statement as to the training he has undertaken in relation to DV:
• DV training at the academy in 2016;
• It was part of his first year program from 2016 to 2017;
• He did a written exercise for his Constable Development Program in 2018 or 2019; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 61 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• He has completed about 6 OLPs in total and is currently undertaking the coercive control OLP;
• In 2017 or 2018 an officer from VPU visited the Morningside station and spoke about DV
On 29 December Senior Constable Trigg was the Acting Sergeant and Shift Supervisor in the South Brisbane VPU. She reviewed the DVO application for Hannah. At that time, she recalled hearing about the events of 26 December when Baxter took Laianah.
Her review led Acting Sergeant Trigg to conclude that Hannah and Baxter were high risk taking into account Hannah’s increasing fear levels. She created a tasking for officer from VPU to attend and speak to both parties in an attempt to engage support services. She created a file for the crew to access.
Constable Stephanie Thomas, Constable Rebecca Taylor and VPU embedded social worker, Tanya Vanderiet from BDVS visited Baxter’s house on 8 January but he wasn’t home.
Baxter phoned Acting Sergeant Trigg on 16 January 2020. He said he had found a card from the VPU in his letterbox and wanted to know why they had been to his house. Acting Sergeant Trigg explained that they visit people involved in DV to help them access support services. She tried to convince him to agree to a face to face meeting. Baxter said that he didn’t know what to do for the next court date as Hannah wouldn’t let him see the kids. He said there was no point in him seeing someone from the VPU unless they could Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 62 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
make Hannah let him see the kids. She managed to convince him to consent to her making a referral for him for legal advice and DV services but he wasn’t interested in engaging.
The job was not deemed to be one which would have been referred to the HRT and, in any event, the HRT did not operate over the Christmas period.
Acting Sergeant Trigg said that she had attended a two day training course for Brisbane HRT.
She said there is a real lack of support for and engagement with perpetrators. She said, “we won’t change DV if we only support one side.”
She said that police can’t be social workers and an aggrieved will often disclose information to a DV service that they wouldn’t disclose to a police officer. This was the case with Hannah who provide more information to BDVS than she did to QPS.
Acting Sergeant Trigg said that the VPU is not permanently staffed so officers are rotated from general duties and sometimes there are different officers rotated in every shift.
Senior Constable Thomas was seconded to the VPU on 28 December 2019. She went with Constable Taylor and Ms Vanderiet to the Clarke’s residence. The purpose of the visit was to confirm that Hannah was connected with external services to support her.
They were tasked by the shift supervisor, VPU, to ensure that QPS had all relevant information. They discussed options for alternative living arrangements but Hannah felt safe and supported living with her parents and was close to the school.
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Many women are not willing to move their children into a motel room.
She saw the three children and did not have concerns for their safety, however, she agreed that there was no real assessment of the risk that Baxter posed to the children.
On 14 January 2020 she went with Acting Sergeant Ryan to visit Baxter but he was not home.
In relation to training Senior Constable Thomas said that she undertook a module on DV at the academy. In April 2013 she attended a single day workshop as part of the First Year Constable Program. On 11 November 2015 she completed an assignment on DV as part of the Constable Development Program. She has completed the following OLPs on DV policing:
• January 2013;
• January 2017;
• February 2017;
• December 2021;
• March 2022.
Senior Constable Thomas said she had no specific training for her role at VPU – just on the job training from other officers.
She said that BDVS is embedded in the South Brisbane office but she has no idea how to share information with the service or obtain information from them. She doesn’t see the BDVS risk assessments.
Constable Kersey went with Sergeant Johns to serve Baxter with the PPN on 29 December 2019.
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He was not aware that the case had been assessed as high risk. He didn’t read Baxter’s New Zealand criminal history.
In relation to training Constable Kersey undertook a training module in DV at the Academy in 2015. In 2016 he undertook the Constable Development Program which included a DV component. He completed OLPs in December 2016, February 2017, May 2020, March 2022.
Sergeant Rolf said that he intended to charge Baxter and take him to the watchhouse and object to his bail when he went to his residence on 2 February. However, when he went there and Baxter said that he wanted to obtain legal advice he agreed to Baxter presenting to the police station on 4 February 2020.
• Training at the Academy in May 2001;
• July 2001 face to face training;
• February 2003 face to face training;
• July 2012 face to face training; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 65 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• The following OLPs:
• July 2004;
• April 2012;
• December 2016;
• March 2017;
• August 2018;
• March 2022.
Expert Witnesses and Reports Domestic and Family Violence Death Review Unit
The Domestic and Family Violence Death Review Unit is established within the Coroners Court of Queensland to provide assistance to coroners in their investigation of domestic and family violence, and child protection, related deaths to support the identification of any missed opportunities for intervention and the consideration of whether there are opportunities to prevent future deaths from occurring in similar circumstances. The Unit also provides support to the State Coroner in his position as Chair of the independent, multidisciplinary Domestic and Family Violence Death Review and Advisory Board (DFVDRAB), established to enhance the systemic review of domestic and family violence related homicides and suicides in Queensland.
Ms Susan Beattie, the manager of the DFVDRU of the Coroners Court of Qld reviewed the circumstances surrounding the quadruple homicide-suicide. The DFVDRU provides invaluable expert advice and, once again, I am grateful for the assistance provided by that Unit. This section of the findings is extracted directly from Ms Beattie’s review and I acknowledge that it is entirely the work of Ms Beattie.
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The review considers the history of DV perpetrated by Baxter towards Hannah, his previous partner and children and provides an overview of the relevant service contact and discusses issues in relation to:
• what is known about retaliatory filicide within the context of domestic and family violence;
• the apparent invisibility of the children in the service response to Rowan’s escalating risk of harm;
• risk identification and management, including a lack of referral to the High Risk team operating in the area;
• the accessibility and availability of men’s behaviour change programs and the importance of proactive and timely referrals to them; and
• perpetrator accountability within the context of mental health service provision.
The first step in any response to domestic and family violence is to recognise that it is occurring. Domestic and family violence is an enduring pattern of coercive controlling behaviour. Actual risk fluctuates over time and is influenced by a complex interplay of risk and protective factors.
Coercive control is an ongoing, relentless pattern of behaviour that is designed to exert dominance and control over another person (usually an intimate partner), taking away their right to think and act independently of the perpetrator.2 Coercive control often includes physical and sexual violence as well as verbal and emotional abuse such as belittling, humiliating, and/or threatening behaviour, as well as attempts to isolate the victim from informal and formal supports.
It is evident that Rowan used coercive controlling violence towards Hannah and his former partner, Ms PP. Across both relationships, Rowan displayed similar abusive behavioural patterns towards both partners that escalated post-separation. This is consistent with research indicating that 2 Stark, E. (2007). Coercive Control: How men entrap women in personal life. Oxford University Press Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 67 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
post-separation violence is often more serious, more obsessive, and more likely to lead to homicide (including filicide) as the perpetrator perceives a loss of control over the primary victim and family unit.3 Rowan exhibited a high level of coercive controlling behaviour towards Hannah from early in the relationship. According to witness statements, Hannah became pregnant to Rowan in mid-2009 (around six months into the relationship). Hannah wanted to have the baby, but Rowan said, ‘she was to [sic] young and lived at home and [was] unable to care for the child’.
Hannah ‘ended up having a termination and she was very upset about it’.
It appears that Rowan was still living with PP and their son (S) at the time, but that he and Hannah moved in together towards the end of 2009 and Rowan and PP formally separated.
Shortly after these events, Rowan told Hannah that PP had previously attempted to leave him. In response, Rowan said that he drove to where PP and I were staying ‘with a rope in his car, his plan was to kill them both and himself’.
Prior to her death, Hannah repeatedly reported to services that this had always played on her mind and made her feel controlled by Rowan and fearful about what he was capable of. Hannah felt that she needed to ‘make sure he never gets to that level with our children’.
It is apparent from review of the available records and witness statements that Rowan attempted to control every aspect of Hannah’s life, such as by:
• controlling what she could wear (e.g. Rowan prohibited Hannah from wearing shorts, skirts above the knee, or the colour pink);
• controlling what Hannah ate (e.g. criticising her about eating ‘unhealthy’ food or telling Hannah that she could not eat certain foods); 3 Johnson, H. & Hotton, T. (2003). Losing Control: Homicide Risk in Estranged and Intact Intimate Relationships.
Homicide Studies, 7(1), 58-84. https://doi.org/10.1177/1088767902239243.
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• attempting to isolate Hannah from her family and friends (e.g.
by prohibiting Hannah from seeing friends and criticising her family members);
• being verbally abusive and/or aggressive towards Hannah if the house was messy;
• belittling Hannah and putting her down for her achievements;
• prohibiting Hannah from having her own Facebook page;
• hacking into Hannah’s Instagram account to read her messages/content;
• reading Hannah’s text messages while she slept;
• watching Hannah from outside when she did not know he was home, or sneaking into the house to catch her unawares;
• hiding recording devices around the house and in Hannah’s car; and
• timing Hannah’s movements and constantly calling and/or messaging her to see where she was or who she was with.
Hannah described feeling as though she ‘couldn’t do anything without him knowing where I was at all times, what I was wearing and who I was talking to’. Hannah also reported to multiple friends, family, and support services that she frequently experienced sexual violence from Rowan, often in the context of coercive control. Hannah stated: I would be forced into having sex with him every night. If I refused Rowan wouldn’t talk to me for days and would yell and be aggressive with us all...he would make our lives hell...I had to do it to keep the peace and keep my kids safe from his temper.
Hannah further disclosed experiencing physical violence and non-lethal strangulation from Rowan during sex and/or acts of sexual assault. Rowan would ‘put his hands around her [Hannah’s] neck during sex without her consent and would not remove them...at times she would have to physically defend herself from the attacks’.
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During one episode of violence that occurred around May 2019, Hannah reported that Rowan ‘was trying to have sex with me and getting quite physical...he was holding me down and I kept saying just stop it and he wouldn’t get off [me]’. Rowan eventually let go of Hannah after she grabbed at his ear as an act of self-defence. Rowan then took a garden hose and drove away intoxicated, threatening to suicide. Hannah was concerned for Rowan’s safety and called her parents who went looking for Rowan, but they were unable to find him. He returned home the next day and ‘acted like nothing ever happened’.
Witness statements indicate that Rowan physically assaulted Hannah on at least two other occasions, and this involved:
• Rowan pushing Hannah which caused her to fall into a wall and then onto the ground; and
• Rowan slamming a gate on Hannah’s leg during a verbal argument which caused ‘massive bruising’ up her thigh. Both assaults appear to have occurred while Hannah was pregnant with Laianah.
Rowan was also known to use impression management techniques to control how others saw him. This included:
• posting photos on Instagram indicating he had not seen the children for periods of time when in fact the children were with him.
• calling his ex-partner PP, crying, to tell her that he and Hannah had separated, and he had not seen the kids for 30 days. PP was concerned he may attempt suicide, but Rowan advised her that he was seeing a counsellor weekly (which was not true) and that he had a good support network around him;
• creating Instagram posts suggesting that Hannah was keeping the children from him; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 70 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• advising PP that Hannah had taken out a ‘stalking application’ against him, stating that he was worried they would accidentally run into each other, and he would get into trouble for it;
• telling PP about rental debts he had accumulated since Hannah had left the marriage and sending her a screenshot to show there was only $21 in his bank account. PP and her husband gave Rowan money to clear his rental debts;
• Rowan told colleagues and friends that Hannah was cheating on him and lying to him;
• telling friends and family that Hannah was drinking heavily; and
• telling friends that Hannah was preventing him from seeing the children, and that his lawyers were charging him $2000 upfront, before they would agree to look at his case.
Perpetrators utilise image management as a means to avoid detection by being selective about when and where they use abusive tactics to control their victims. This includes such behaviours as a perpetrator choosing to wait and attack a victim privately at home, or to humiliate her in front of friends and family, so that their behaviour is not seen by others, the victim’s sense of self is undermined, and their public/outward facing image is protected.
It is apparent that Rowan would also frequently use the children to control Hannah, such as by:
• being aggressive towards the children or otherwise punishing them (e.g. confiscating toys and cancelling plans with them) if Hannah refused to comply with his demands, including sexual demands (behaviour that amounts to sexual coercion and rape);
• making repeated threats to take the children away from Hannah; and
• taking and/or trying to take the children from Hannah and not telling her where they were.
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It is clear that these behaviours frightened Hannah. She reported to police in December 2019, three months before the deaths, that she was ‘terrified’ of leaving Rowan because of ‘his reaction and what that would mean for our children’.
A friend of Hannah’s, Ms B, also expressed concerns regarding Rowan’s behaviour towards the children. Ms B stated that Rowan would post on social media that ‘just weren’t normal and they worried me’. She reported to police: Rowan would post videos of him tackling the kids where it would look like he had hurt them...One post he put the kids in an ice bath and the little boy [Trey] was crying hysterically. He just seemed to like overpowering Hannah and the kids.
Another friend reported to police following the deaths that she thought Aaliyah (the eldest child) had begun to fear Rowan because she ‘had seen and heard what Rowan had put Hannah through’.
Towards the end of 2019, records and witness statements indicate that Rowan’s controlling behaviour towards Hannah was escalating. Rowan exhibited extreme sexual jealousy and perceived that Hannah was having an affair with a male friend of hers. There is no information from the records available to suggest that Hannah and the friend had commenced an intimate relationship.
At the time Hannah expressed concerned that Rowan had been stalking her, reading her messages, and listening in on her private conversations.
For example, according to the witness statement of Hannah’s friend, Hannah discovered that Rowan had left a recording device in her car, and that (previously) this ‘was the only time she thought she could talk to her friends freely’.
Following separation, Rowan continued to exhibit possessive and controlling behaviour that escalated in frequency and severity towards Hannah. Many of these behaviours are identifiable as indicators of Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 72 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
domestic and family violence lethality, including acts of stalking, making repeated threats not to return the children to Hannah’s care, and making ‘suggestive comments about the children’s safety’.
The DFVDRU has adopted the coding system developed by the Ontario Domestic Violence Death Review Committee to explore lethality risk indicators associated with intimate partner homicides. The Ontario Coding system is the most comprehensive available and has been developed based on reviews of intimate partner homicides. It has also been adopted due to similarities in basic population demographics between Queensland and Canada.
According to the Domestic and Family Violence Death Review and Advisory Board’s 2020-21 Annual Report, there are an average of 12 lethality indicators for intimate partner homicide cases in Queensland.
Twenty-nine of 39 domestic and family violence lethality indicators were identifiable in this case based on the relationship between Hannah and Rowan.
The lethality indicators present in this case include:
choked/strangled victim in the past Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 73 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
perpetrator was abused and/or exposed to domestic and family violence as a child
Service System Contact In the four months before the homicide-suicide, Hannah, Rowan and the children had contact with, or were known to, a range of services in relation to their experiences of domestic and family violence and other related concerns. These included:
• Queensland Police Service (Hannah, Rowan)
• Department of Child Safety (Hannah)
• Centre for Women and Co (Hannah)
• Vision Psychology (Rowan)
• Brisbane Domestic Violence Service – Micah Projects (Hannah and the children)
• Family mediation (Hannah and Rowan) Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 74 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• General Practitioner at Thornlands Surgery (Hannah)
• General Practitioner at Kempsie Road Medical Centre (Rowan)
• Relationships Australia (Hannah and Rowan, although neither attended an appointment)
• Men’s Legal Service (Rowan)
• Mensline (Rowan) On 26 November 2019, Hannah attended the Centre for Women and Co (The Centre) at Capalaba, stating she wished to leave her controlling husband but did not know how to do it safely, as she believed Rowan was monitoring her. A safety plan was developed with Hannah. Notes state that it was not safe to call or text Hannah, but that she had the contact details for the The Centre, if she needed further support. A warm referral was made to the Brisbane Domestic Violence Service (BDVS) because Hannah did not live within the Capalaba catchment area. It does not appear that a risk assessment was done by The Centre at this stage as Hannah reported that she was seeking information only.
The safety plan developed between The Centre and Hannah included that she should:
• advise her parents of her intentions to leave Rowan;
• attend Friday dinner with her parents with the children (as per their routine), then return home without them to tell Rowan that she is leaving to ensure the children were safe with her parents and Rowan could not take them from her;
• have her parents either wait in the car with the children, or attend after an agreed upon time, in case Rowan’s behaviour escalated; and
• take important documents and belongings to her parent’s house slowly over the course of the following week.
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It was also noted that Hannah ‘knows to call police if at all threatened or feeling unsafe, knows this is not an ‘over reaction’ and ‘their job is to keep her safe.’ On 4 December 2019, Rowan contacted Relationships Australia, and was offered an initial telephone intake session on 10 December 2019. Rowan did not confirm his attendance prior to this appointment and it was subsequently cancelled. Hannah also contacted Relationships Australia on 4 December 2019, was offered an appointment for 24 December 2019 and was placed on a waitlist in case an earlier appointment became available.
The following day, on 5 December 2019, Hannah contacted The Centre to advise she was leaving Rowan that day and believed he was monitoring her. Hannah advised that she was staying with a friend and Rowan didn’t know where they lived. Hannah also stated she had turned her phone off and parked her car somewhere else. No new mobile phone or alternative was offered to Hannah, no risk assessment or safety plan was completed at this contact however a message was given for intake to follow up with Hannah.
The next day, on 6 December 2019, after attempting to contact Hannah and being unsuccessful, The Centre contacted Ms B, who advised them that Hannah had left Rowan, was going to her parent’s house and would turn her phone on when she got there. Ms B advised The Centre that it might be best to send Hannah a text message before attempting to call her.
That same day, Hannah attended Carina QPS station seeking advice on a ‘domestic violence situation.’ She spoke to Senior Constable Kent the Domestic Violence Liaison Officer (DVLO) at the station. It was documented in the police occurrence that Hannah ‘wishes to leave the resp [Rowan] and he is displaying controlling behaviours’. Hannah ‘divulged enough information’ for Senior Constable Kent to form an opinion that she was the victim of domestic and family violence Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 76 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
perpetrated by Rowan, but Hannah ‘did not provide enough specific information’ for police to proceed with a protection order application.
According to Senior Constable Kent’s statement, Hannah was not supportive of a protection order application at that time but wanted ‘some advice and clarification about what constitutes Domestic Violence’. Senior Constable Kent advised Hannah ‘to keep in touch’ and let police know if ‘anything happens, as well as the usual advice of calling 000 if a situation escalated’. This contact was recorded as a “Domestic Violence – Other”4 occurrence with it being noted that Senior Constable Kent:
• discussed protection orders with Hannah, and what the application process involved as well as implications; noting that Hannah reportedly stated she did not want to apply for a protection order at that time;
• formed the opinion that more investigation was warranted;
• advised Hannah to keep in touch with her and let her know if anything else happened; and
• completed a referral to the BDVS for Hannah.
That same day on 6 December 2019, the The Centre contacted Hannah who confirmed that she was thinking of applying for a protection order but had concerns that this may cause Rowan’s behaviour to escalate. The notes state that the ‘worker discussed this with her and advised that she could complete an application and if she felt as though he was escalating could apply for a TPO (temporary protection order).’ The Centre worker advised Hannah that there were court support workers at the Brisbane Magistrates Court that could assist her with her application. Notes also indicate that: ‘[Hannah] stated that she feels comfortable to call police and will not make [Rowan] aware that she is staying at her mother’s. [Hannah] stated that she will get her phone 4 DV Other Action is recorded on the QPS database when police make a referral to a DV support service but take no other action i.e. do not issue a PPN or apply for a DVO on the basis that there is insufficient evidence of DV or no need to protect the aggrieved or the aggrieved is not in fear.
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checked and continue to use her mother’s phone in the meantime.
[Hannah] stated that the property is locked and secure.’ A few days later (the exact date is unclear), Senior Constable Kent happened to be working at Carindale police beat and saw Hannah while she too was working at Carindale. Senior Constable Kent stated ‘[Hannah] was frightened by my presence and told me she thought something had happened to her children as [Rowan] had them.’ Later that day, Hannah visited the police beat during her lunch break to speak with Senior Constable Kent who stated: ‘[Hannah] was upset, she so was so pent up with fear and was so relieved that I wasn’t delivering bad news about the children. [Hannah] said she was afraid that something had happened to the children while they were in their father’s care.
[Hannah] explained that early in their relationship, [Rowan] had disclosed that when his relationship with his eldest son’s mother ended, he attended the home and sat outside in the car with a rope and had contemplated killing them and himself. [Hannah] explained that this had always stuck in her mind.’ This information was not formally recorded in QPS systems by Senior Constable Kent at the time.
Following this interaction, Senior Constable Kent contacted the Vulnerable Persons Unit (VPU) to confirm if any other options were available to Hannah. Hannah was present while this call was made however the outcome of this call is not recorded. Following the deaths, Senior Constable Kent reported in her statement that the conversation she had had with Hannah played on her mind and she again contacted the VPU via email (on 14 December 2019) requesting further advice. Senior Constable Kent stated that she was aware that after speaking with Hannah, she had enough information to apply for a ‘mandatory (protection) order’ but ‘wanted to apply for something that would provide [Hannah] and the children more protection than mandatory good behaviour’.
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Three days later on 9 December 2019, Hannah contacted BDVS to discuss the two previous referrals (by QPS and the Centre). She advised that she had left Rowan on 5 December 2019 and was linked with a QPS officer at Carina station. She also indicated that the situation with Rowan had escalated, resulting in a long argument whereby Rowan was emotionally and psychologically abusive and had threatened to take the children.
BDVS encouraged Hannah to end her lease without any financial or other penalty; and liaised directly with RE/MAX via correspondence strongly advocating for Hannah’s lease to be ended pursuant to s312 of the Residential Tenancies and Rooming Act. The BDVS worker provided additional information on the benefits and unintended consequences of protection orders and advised Hannah to seek information from Women’s Legal Service drop-in sessions regarding family law.
Hannah advised BDVS that she was currently staying with family on the Gold Coast and planned to return to Brisbane to stay with other family.
Hannah stated that she had previously contacted the QPS and the officer she had been speaking with agreed that Hannah had enough evidence for a protection order but Hannah had wanted to speak to Rowan before investigating this option.
It is from this date forward that BDVS became Hannah’s support service.
It appears from reviewing all case notes provided by BDVS that the goal for Hannah was ‘for my known safety risks to be identified and managed’.
No structured risk assessment or safety planning was done by BDVS at this stage.
On 14 December 2019, Rowan attended a GP appointment and discussed that he had a controlling nature and within the last few years this had gotten worse. Notes state: ‘Wife and kids moved out about 4 days ago, temporarily, some personal issues. Married for 7 years. Together for 11 years. Has 3 children. Works in a factory, runs gym together. Some financial strain. No sleeping. Not eating well. Has counselling from a Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 79 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
pastor last month. [Patient] states he had controlling nature. Last few years got worse. Had bad upbringing, was close to his mother. Cut off lot of people in his life. No abuse situation. [On examination] today teary but regrets his behaviour.’ On 16 December 2019, Rowan attended the same medical centre, for the preparation of a mental health care plan. He was also prescribed Temazepam. No follow up was done after this point by the GP and this was the last contact that Rowan had with them.
On 20 December 2019, Rowan attended his first appointment with a psychologist, Ms Jarret, who advertises herself as having special expertise in treating ‘Domestic violence – making changes to protect you and your family.’ According to notes made by Ms Jarrett following the deaths, Rowan reported having marital problems, that he wanted help to control his feelings of jealousy, that Hannah was angry over his controlling behaviour and he was feeling terrible because he had not realised she saw things this way. The session focused on strategies to overcome ‘overwhelming feelings’, such as through utilising breathing techniques.
Rowan hoped to ‘save the relationship’ he had with Hannah and was provided handouts in relation to ‘how to be supportive of each other [and] how to hold a relationship meeting to sort out problems logically’.
No structured risk screening or assessment for domestic and family violence was done by the psychologist. A mental health assessment undertaken at the time indicated that Rowan was feeling ‘moderately depressed and anxious’ but answered ‘never’ to all of the questions regarding risk of harm to himself or others.
On 25 December 2019, Rowan spent the day at Hannah’s parents’ house, with Hannah and the children. This was at the invitation of Hannah and her family, so that Rowan could watch the children open their Christmas presents and spend a couple of hours together. Hannah late reported to services ‘I kept my distance and Rowan was fine until it was time for him Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 80 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
to leave. He started trying to guilt me and play the manipulative games he always does but I didn’t give in.’ The following day on 26 December 2019 Rowan took Laianah from the park.
Hannah flagged down police shortly afterwards. They attempted to contact Rowan and Hannah was offered a ‘referral to assist with domestic violence and child custody issues’.
Officers attended Rowan’s address to locate him and conduct a welfare check on Laianah, though it appears that this was not reflected in police records at the time and was only reported in one of the officer’s statements following the deaths. Rowan was not at the address so police ‘entered a job’ to ‘have crews attend the address to locate Rowan and the child for the purpose of obtaining a version of events and a welfare check’. The timeline of events is unclear from review of the police records available, but it appears that the job was created and finalised on the same date without police having established contact with Rowan or Laianah.
A child harm referral was also forwarded to the Morningside Child Protection and Investigation Unit (CPIU) for their review. The outcome of the child harm referral was not documented in the police occurrence, but child safety records confirm that police forwarded concerns to the department on 1 January 2020, in relation to a witness who had seen Rowan ‘put Laianah roughly into the front seat of his vehicle, bumping her head on the vehicle before speeding off’ (the child safety response is discussed further below).
On 27 December 2019, available records indicate that one of the officers who attended the occurrence the previous day attended Rowan’s address again to conduct a welfare check on Laianah, but they were not home.
The officer entered another job to have police attend Rowan’s address ‘and conduct welfare check on child Laianah...following incident with father, Rowan.’ Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 81 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
On the same day, Senior Constable Kent was on duty and saw the job requesting a welfare check on Laianah. She contacted Hannah to ask if Laianah had been returned and was told that she had not and that Rowan had taken her to New South Wales (NSW). Senior Constable Kent arranged for Hannah to attend Carina police station the following day to commence a protection order application. In her statement made following the deaths, Senior Constable Kent reported that after reading the job details in relation to Rowan taking Laianah on 26 December 2019, ‘I formed the opinion that a DVO needed to be sought and felt I had sufficient information to proceed regardless of [Hannah’s] position and that I could also now request a DVO with sufficient conditions to protect [Hannah] appropriately.’ On 28 December 2019, almost three weeks after Hannah’s first reported Rowan’s abusive behaviours to police, they issued a Police Protection Notice (PPN) prohibiting Rowan (respondent) from approaching or attempting to approach within 100m of Hannah (aggrieved) or Aaliyah, Laianah and Trey (named persons).
The exact timeline of events is unclear, but it appears that Hannah submitted in affidavit in support of this PPN which detailed Rowan’s use of domestic and family violence against her. The PPN and affidavit clearly reflect Hannah’s fear of Rowan. She stated the following:
• Rowan would tell Hannah that she was ‘disgusting’ and that he ‘forces her to have sex nightly’ since the birth of their third child.
Rowan would tell Hannah ‘it was like having sex with a bucket’ and then become angry with her if she wasn’t ‘enjoying it’.
Hannah stated ‘If I didn’t have sex with him every night he would make our lives hell. In the end it became a chore that I had to do to keep the peace and keep my kids safe from his temper.’
• Hannah felt intimidated and dominated by Rowan for years and was starting to ‘stand up to him’ but was constantly ‘fearful he would hurt the children and himself to get back at her’. The Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 82 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
application reflects that Hannah’s fears about their safety were ‘not baseless’, as Rowan had told Hannah that when his first partner ‘took their son away he went around to where they were staying with a rope and had formulated a plan to kill them and himself’.
• This was playing ‘heavily’ on Hannah’s mind and she was agreeing to things that Rowan demanded ‘to appease him’. It was recorded in the PPN that in May 2019, Rowan had left the house after an argument and took a hose with him, admitting to Hannah afterwards that he was going to kill himself.
• Hannah did ‘not wish to keep the children from’ Rowan but wanted ‘some guarantee that she can get them back’. Hannah was seeking a family law order but, in the interim, was ‘terrified’ that Rowan would take the children.
• Post-separation, Hannah had returned to the home she had shared with Rowan to collect some belongings and discovered that Rowan had printed out three of their wedding photos, framed them and hung them on the wall of the home. Hannah stated: ‘I don’t know why he has done this now. It makes me worried and scared what he is thinking and that he is not accepting me leaving. I am really concerned for his mental health.’
• Hannah was very fearful of Rowan and he engaged in ‘subtle behaviours...which makes her greatly fear for her children’.
• Hannah felt that ‘Rowan is totally capable of killing himself and killing our children to get back at me. This scares me beyond words’.
On this same day (28 December 2019), Hannah’s solicitor (from K Solicitors) emailed Rowan to indicate that Hannah was not in support of his proposal for 50/50 custody of the children and that she was seeking the immediate return of Laianah, pending the preparation of an application for a recovery order with the Federal Circuit Court. Later that evening, Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 83 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Rowan contacted Policelink to ‘seek some advice’ on his options. During this call, he stated:
• He had split up with Hannah a month ago.
• He had one of his children, and the other two were with Hannah, noting that no court order was in place to prevent him having one of the children.
• He had been away visiting a friend for a few days with his daughter.
• He had returned to his home to find the dog missing and thought Hannah had taken it (at the end of the call, a dog is heard barking in the background).
• He had texted and called Hannah but had not received any response.
• He was scared of Hannah turning up and making a scene in front of their daughter, and trying to take her daughter off him, stating that she had keys to the house
• He was so scared of Hannah that he was currently driving around with his daughter in
• the car because he was frightened to go home.
• Hannah was trying to ‘antagonise’ him and ‘bait’ him and he didn’t want to ‘go there’.
• He was paranoid that if Hannah did show up and he threatened her or raised his voice that he would be ‘done and dusted’ and he didn’t want this to happen. He would go home and put his daughter to bed and barricade the door from the inside so that Hannah wouldn’t be able to get in.
The Policelink operator put Rowan on hold and discussed the call with her Sergeant, advising that there was a PPN in place (as of that day), but Rowan was unaware of it as it had not yet been served. The Sergeant advised that nothing could be done, that Rowan should contact a solicitor on Monday to discuss his family law matters but that if Hannah did come to the house, and Rowan was worried, he should call 000 for assistance.
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This advice was relayed to Rowan by the call operator. He was also offered a referral to Legal Aid and Mensline DV Connect for support which Rowan accepted. The Policelink operator transferred him directly to Mensline DV Connect but there is no record from that service of Rowan speaking to them on this occasion.
The following day on 29 December 2019, QPS attended Rowan’s address and served him with the PPN. Laianah was present, and police returned her to Hannah’s care. There is nothing to indicate that Rowan was not compliant with this request by officers.
On the same date, Sergeant Angela Trigg from the South Brisbane District Vulnerable Persons Unit (SBD VPU) recorded a supplementary report for the occurrence on 28 December 2019. Sgt Trigg recorded that ‘This couple has been reviewed and assessed as high risk for referral/support purpose’. Follow up with parties has been actioned by VPU...A task has been furnished to SBD VPU for management. This task will remain open until all follow up action is complete’. According to police records, Sgt Trigg tasked officers from VPU to ‘engage’ with Hannah and Rowan to:
• obtain ‘a history of DV’ from Hannah;
• discuss Hannah’s current concerns;
• ascertain if Rowan had a history of problematic substance use and/or mental illness;
• offer referrals to support services; and
• confirm current engagement with any support services According to Sgt Trigg’s statement made following the deaths, she was the Shift Supervisor for South Brisbane District VPU and, in this capacity, she was required to review all domestic and family violence related police occurrences ‘to identify couples where high and extreme risk factors are prevalent’. During her shift on 29 December 2019, Sgt Trigg reviewed the police occurrence from the day before, and ‘recalled hearing a job in the days leading up...involving the same address...This job raised my attention at the time, as it involved a male person taking a child from his Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 85 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
partner in a park’. On review of the available information, Sgt Trigg ‘deemed the couple as high risk due to concerns with [Rowan’s] pattern of behaviour and [Hannah’s] increasing fear levels’.
DV Connect (Mensline) attempted to contact Rowan twice on 30 December 2019, by phone and text following the earlier referral from QPS.
They also attempted to follow up on 1 January 2020 but were unable to establish contact.
BDVS attempted to contact Hannah on 30 December 2019 to complete the Intake and Risk Assessment documents however her phone was switched off.
On 31 December 2019, Rowan attended a second appointment with his psychologist, Ms Jarret. At this appointment, Rowan disclosed that he was subject to a PPN and that there was an upcoming court hearing that was ‘really upsetting him’. Rowan also stated that a ‘friend of theirs’ had admitted to him that he had feelings for Hannah’. Rowan was reportedly ‘upset about this but happy the friend was upfront and told him’.
Rowan ‘speculated that Hannah’s parents hated him’ and that they may have ‘convinced Hannah to leave him’. Rowan alleged that Hannah ‘often drank 1 bottle of wine a day as the crossfit scene was hard and she would bottle her emotions’. He ‘described that everyone thought he had the perfect family. He was unsure how it got to this point’. According to the psychologist’s notes, Rowan was ‘visibly upset by not having access to the kids’ and they ‘discussed the hardship over not seeking the children’.
Rowan alleged that Hannah was ‘making up events in the DVO’.
On 1 January 2020, an email was received by the Child Safety Regional Intake Service (RIS) from a mandatory notifier, referring to the incident in the park (where Laianah was removed from Hannah’s’ care) that occurred on 26 December 2019 whereby Rowan removed Laianah from her care in the context of domestic and family violence. No screening criteria were selected, and an assessment was made to record a Child Concern Report Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 86 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
which was approved on 13 January; almost two weeks after the initial notification.
Child Safety determined that the information did not meet the criteria for a Child Protection Notification because there ‘was no information to indicate that the child suffered significant harm of a detrimental nature as a result of the incident. A welfare check was being tasked by QPS. Furthermore, the information does not indicate there is no parent willing and able to meet their protective needs and a CCR [Child Concern Report] is being recorded.’ On 2 January 2020, the BDVS contacted Hannah and discussed ‘safety and risk, supports needed, information updated and action necessary.’ There are no records of any formal risk assessment being undertaken at this stage although Hannah did update BDVS with information of the event on 26 December 2019. There are no records to suggest that Hannah advised BDVS of the PPN in place and nothing to indicate the service took steps to seek any advice from, or raise any safety concerns with, police.
On 6 January 2020, Rowan attended a psychology session. He stated that he and Hannah had closed their gym business nine days ago and that ‘in the end they lost clients due to Hannah sharing too much emotionally and some clients wanted to keep their distance’. Rowan reported feeling worried about what others thought of him and whether Hannah had been ‘saying nasty things behind his back’. Rowan reported having a job ‘to keep things going financially’.
Discussion was held around Rowan and Hannah’s family court matters, and that Rowan wanted a 50/50 shared custody arrangement. Rowan ‘described her [Hannah] as a good mother’. They also discussed ‘mental strategies to help him through...We discussed at length that he could use this time to try out some new activities and we tossed around a few ideas...’ However, it is not specified what these strategies or ideas were.
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On 8 January 2020 the Temporary Protection Order was granted. Rowan was in court when the matter was heard, represented by a Barrister, who was the father of a friend.
That same day, officers from SBD VPU and a social worker from BDVS attended Hannah’s address. Hannah stated that she had been present in court in relation to the protection order application (earlier the same day) and was disheartened that the matter had not been finalised. However, she ‘now had all three children safe at home’. Hannah advised that she was seeking private legal advice in relation to the protection order and family law matters.
She reported being fearful of letting Rowan see the children ‘after the incident’ on 26 December 2019. Laianah was observed by police to be ‘visually suffering some anxiety from the incident’ and ensured that her mother was in eyesight at all times during the police interaction. Hannah accepted referrals for personal counselling for herself and referrals for the children to Child Aware Psychology. It does not appear that Hannah or the children attended Child Aware Psychology.
VPU officers provided advice to Hannah about how to report breaches of the temporary protection order should the contact from Rowan ‘become excessive and what the process is to request for the conditions to be varied by the court’.
The notes state that Hannah consented to a BDVS worker to call her back the following day, 9 January 2020 to ‘discuss support needs.’ No risk assessment was carried out.
Hannah had however also kept in contact with Senior Constable Kent and exchanged ‘numerous’ texts with her. Following the mention on 8 January 2020, Senior Constable Kent spoke on the phone with Hannah, and found her to be upset, overwhelmed and disillusioned. According to a statement made by the officer following the deaths, she invited Hannah to her home ‘so we could talk and I could offer some assurance for her. I don’t know why I invited [Hannah] to my home it was a split-second decision, I trusted Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 88 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
[Hannah] and I empathised with her. She was a normal girl who was going through a tough time. [Hannah] had her three young children, I thought that if they had a swim at my place [Hannah] and I could have a conversation out of ear shot from the children.’ On 9 January 2020, BDVS contacted Hannah to explore further ‘housing options, Centrelink and personal counselling’. Hannah advised that Rowan’s abuse had been ongoing for months prior to police intervention and she had previously engaged with the CFWC and eventually attended Carina Station to report the domestic and family violence. Hannah advised that she wasn’t aware what constituted domestic and family violence before she engaged with an officer at the Carina Station, but she was aware now. There is no evidence to suggest that a risk assessment or any additional safety planning was carried out at this time.
Hannah advised that she was staying at her mother’s house but trying to source public housing as well as Centrelink options including a single parent payment and family tax benefit. There is nothing to suggest that Hannah was offered assistance with this by the BDVS worker. She advised that Rowan did not have an issue with alcohol when they were together but that he was treated for ‘mental health issues’ that were ‘evident toward the end of the relationship’. Hannah advised that Rowan had been attending a psychologist from May 2019, once he became aware that Hannah intended to leave the relationship.
Hannah advised the worker that since court that morning Rowan had contacted her to inquire about when he could see the children. Hannah had been provided advice by her solicitor not to answer Rowan until she was ready. SBD VPU officers had provided advice to Hannah about how to report breaches of the temporary protection order should the contact from Rowan ‘become excessive and what the process is to request for the conditions to be varied by the court’.
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No formal risk assessment was undertaken by the BDVS worker at this contact point, although statements after the event indicate that they were undertaking informal risk assessments at each contact.
On 9 January 2020, Hannah called her solicitor to advise she had been receiving text messages from Rowan since the previous day. Hannah disclosed that Rowan appeared in Holland Park Magistrates Court (in relation to the TPO) with three lawyers disputing the episode of violence where he took Laianah. It was suggested by Hannah’s solicitor that ‘the best thing now would be to look at allowing Rowan some supervised time with the children pending mediation with Facetime at 1830 hours every evening’ suggested as an option. There does not appear to have been any clarification with Hannah or advice provided by her legal representative that she could have sought an exemption to mediation based on her experiences of domestic and family violence On 10 January 2020, Hannah’s solicitor corresponded with Rowan, identifying possible mediators and associated costs as well as instructing Rowan to correspond with themselves rather than Hannah. The correspondence reminded Rowan of the requirements of the protection order in respect of him regularly contacting Hannah by text message to see the children and that Hannah did not consent to him spending time with the children on an interim basis until mediation and a formal agreement was in place. Further, Hannah proposed that Rowan could Facetime the children at 6:30pm every Monday, Friday and Sunday; with a request that he refrain from discussing adult issues with the children during telephone calls and that all correspondence with respect to access should be made directly to Hannah’s solicitor.
On 12 January 2020, Rowan emailed Hannah’s solicitor, seeking to spend time with his children, and to contact Hannah directly in relation to business and financial matters relating to their shared business, lease arrangements and family trust arrangements. Rowan was in constant contact with Hannah’s Solicitor, and at times, multiple emails per day were exchanged regarding contact with his children.
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On 13 January 2020, Rowan contacted a solicitor stating to the receptionist that he was ‘getting pretty desperate’ and needed someone ‘batting’ for him in the upcoming court matters. He left a phone message for Solicitor [Ms J] to call him back. Rowan met with [Ms J] two days later on 15 January 2020.
On 14 January 2020, Officers from SBD VPU attended Rowan’s home to conduct follow up inquiries that arose from the statement received from the witness of the alleged abduction of Laianah. Rowan was not home, and a card was left.
On this same date, Rowan attended another appointment with his psychologist. Rowan disclosed that the protection order matter had been adjourned and that ‘he had 2 barristers and a lawyer, so he felt confident’.
Rowan was reportedly happy to ‘have facetime finally with the children’.
According to the psychologist’s notes made following the deaths: ‘It has been 18 days away from the kids. 4 Feb next DV hearing. Was teary about talking about missing the children. Planned to see family lawyer tomorrow....Hannah crossed over with him at Carindale and he felt really panicky over what she might accuse him over. He felt it was hard to keep away as all the usual places they visit he could accidentally run into her.
He was balancing up trying to keep active and trying to avoid randomly seeing her. Finding this really difficult’.
On 16 January 2020, the BDVS telephoned Hannah to complete a risk and safety assessment (some five weeks after her initial contact with this service). During this contact she made the following disclosures to her caseworker that Rowan:
• would put his hands around her neck (non-lethal strangulation) while having sex, without her consent, and would not remove them. This last happened in November 2019;
• wanted sex every night, regardless of consent and at times she would have to physically defend herself from his attack; Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 91 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
• repeatedly threatened to take the children and she was afraid of what he would do;
• had come to her parents’ home unannounced, and she was worried he would install monitoring devices; and
• appeared to know details she hadn’t told him and may have installed spyware on her phone. She again raised the need for a tech sweep of her phone.
Hannah stated she was worried Rowan would escalate and what he was capable of. When asked by the BDVS worker “do you believe that the perpetrator (Rowan) is capable of killing you?” Hannah response is recorded as – ‘Due to him (Rowan) having nothing to lose and previous threats to kill ex-partner and child, she was concerned this may happen to her’.
Together with Hannah, the BDVS completed a risk and safety assessment for Hannah and calculated her risk as ‘High’. Both Hannah’s estimation of risk and the BDVS risk and safety assessment identified the risk to Hannah and the children as high, with a score of 625. A safety plan was developed with Hannah, where she was advised to:
• Seek legal advice in relation to property and family law and keep all important documents in a safe place.
• Memorise emergency contact numbers, including for DV Connect.
• Have a passcode or fingerprint scanner on her phone, keep screenshots and records of any text messages, social media messages and emails.
• Seek further advice from specialist services if technology safety is a concern.
• Keep a diary or record of DV experiences, including photographs of physical injuries.
5 In their statement BDVS indicate that this risk assessment was conducted over two days, and that while risk assessment outcome scores of 47 and above are considered ‘high’ in the last financial year 62 was the average score in BDVS, indicating this level of risk is commonly managed by the team.
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• Keep a copy of the DVO on or near her at all times and provide copies of restraining orders to the children’s schools, trusted family and friends.
• Change her routines wherever possible, including working hours, routes she travelled to work or the children’s school.
• Keep evidence of DVO breaches, including when Rowan said inappropriate things to the children.
It was also noted that ‘due to respondent (Rowan) regularly threatening to take the children, Hannah is afraid of what he is capable of, Hannah worried respondent will escalate’.
At this time Hannah requested a technical sweep of her phone and ongoing safety planning. The referral for the technical sweep was not completed by BDVS until nine days later on 24 January 2020. There is no information to suggest that BDVS informed police about the outcomes of this comprehensive risk assessment, including that Hannah had disclosed significant high-risk indicators.
Also on 15 January 2020, Rowan met with a solicitor (Ms J) to discuss access to the children, wanting a 50/50 split to parenting, while he raised the abduction of Laianah he stated that she had said “Can you carry me dad?” which indicated to Rowan that she wanted to “come with me”.
Rowan acknowledged that he drove with her unrestrained in the car, and that he didn’t want to go home as Hannah would have come around, so he went to a friend’s place in NSW. Following this initial consult, Rowan did not actually instruct Ms J and had no further contact with her.
On 15 January 2020, Rowan contacted QPS in relation to the card left at his address the previous day and stated that he was seeking legal advice and was confused about the upcoming court processes. Rowan accepted a referral to Legal Aid and Adapt Programs On 17 January 2020, Rowan contacted the Mens Legal Service. He broke down crying, stating that Hannah had launched a campaign to remove him from the children’s lives, and he had evidence that she was planning on Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 93 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
taking the children interstate to get away from him. He stated that he took Laianah out of concern for her, and advice was given to him by a previous solicitor stated that he could legally take Laianah as there were no parenting orders in place. There is no indication that on this occasion Rowan had told the Solicitor that he had in fact taken Laianah interstate without notifying Hannah and refused to return her when asked. The Mens Legal Service worker requested that Rowan send further information to them (although the notes do not specify the information requested) and agreed to send him a client agreement.
This same day, Hannah’s solicitor corresponded with Rowan to advise that he would be contacted by a mediator for the purpose of attending urgent mediation in an attempt to resolve parenting arrangements. It was confirmed that Hannah continued to be willing to facilitate Facetime in accordance with her proposal until such time both Rowan and Hannah had attended mediation and there was a formal agreement in place.
On 19 January 2020, Rowan instructed a new solicitor, Mr C, who was a friend of a friend, and had agreed to assist Rowan with his family law and TPO matters on a pro bono basis.
On 20 January 2020, Hannah submitted an application to Holland Park Magistrates Court to vary the conditions of the temporary protection order made on 8 January 2020. Hannah requested that Rowan be prohibited from locating or attempting to locate her, or from approaching within 100m of her, amended from attending to within 100m of where she resided.
In her application to vary, Hannah articulated concerns that Rowan was stalking her, noting that he would attend the same coffee shops at the same time, and happened to be in shopping centres when she was there and ‘reacted to me walking past him and then proceeded to follow my dad and kids to escalator’. On another occasion, Hannah was having coffee with a friend when Rowan again walked past and then ‘looked her up and down’ and then ‘shook his head’. Hannah stated that she worked inside a Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 94 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
shopping centre and was feeling ‘constantly anxious and scared’ that Rowan would come into the store while she was at work.
Hannah strongly believed these events were not a coincidence and expressed concerns that Rowan had put a tracking device on her phone.
Hannah requested that the original no contact conditions of the PPN be reinstated as she was fearful for her safety. The condition was varied to include that Rowan must not come within 100m of where she lived, or approach within 20m at any place she was. The next mention was listed for 29 January 2020.
On 21 January 2020, Rowan attended an appointment with his psychologist. He stated that he ‘couldn’t believe they were now accusing him of being mentally unstable to try to prevent him from seeing his kids’.
He stated that the temporary protection order ‘had nothing about the kids and [sic] there and that he was a great parent’. Rowan was reportedly worried that Hannah ‘might make up stories about him to try stop him from having access to the kids’.
On the same date, Rowan’s psychologist, Ms Jarret, completed a letter of support for Rowan in relation to his upcoming family court matter. The letter reflects that the psychologist was supportive of Rowan’s contact with Aaliyah, Laianah and Trey. The psychologist stated: “Mr Baxter has been stressed over his wife leaving him suddenly but has been coping remarkably well given the situation. He has been very open and sincere in our sessions. I have no concerns regarding his mental health. Contact with his children would be ideal and after reviewing his parenting strategies, all seems in order for him to regain contact”.
It appears that this assessment was based solely on the information provided by Rowan. There is no information to suggest that the psychologist undertook any collateral checks (e.g. with Hannah or police) in relation to why the order was in place or the conditions of the order; the details of Rowan’s use of domestic and family violence towards Hannah and/or the children; or the risk to the children in this context. No risk Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 95 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
assessment or screening was undertaken by the psychologist in relation to domestic and family violence or child harm to inform this letter of support.
On 22 January 2020, BDVS notified court support workers and asked them to watch for Hannah as she was appearing at the Holland Park Court (with respect to Hannah’s application to vary the protection order). The temporary protection order was varied, and additional conditions were imposed prohibiting Rowan from having any contact with Hannah or the children unless necessary for the parties to attend an agreed conference, counselling, or mediation session, or when having contact with the children as set out in a written agreement between the parties. The amended order also prohibited Rowan from approaching within 20 metres of Hannah at any place. The matter was adjourned for 29 January 2020 and then adjourned for 26 February 2020 (following the deaths).
On 23 January 2020, BDVS attempted to contact Hannah to discuss device security, following Hannah’s concerns that Rowan was tracking her, but Hannah’s phone was turned off. This same day, mediation was completed between Rowan and Hannah and an interim agreement was reached. A parenting plan was signed, consenting to the children living with Hannah and that the children spend time with Rowan as may be agreed between the parties. It was understood that it was Rowan’s intention to commence proceedings in the Federal Circuit Court seeking parenting orders for the children to spend equal time with both parents.
On 24 January 2020, BDVS forwarded a referral to Concentric Concepts and requested a technical sweep of Hannah’s phone. The referral noted that Rowan was likely tracking Hannah’s phone as he had made a Facebook post several days previously, containing private information that was discussed between Hannah and Rowan’s adult son.
On 26 January 2020 Baxter drafted a letter (which may have been amended later) in which he set out that he had been victimised by Hannah and he stated: Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 96 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
You had this planned and it’s disgusting. I’m sorry Hannah I’m finishing your game I don’t want to play anymore this was never ever my intention but you need to realise you can’t fuck with someone’s life like this and expect for them just to take it. I’m glad the advice you have been getting is working for you , but I can tell you no more Hannah no more ….
I will never go through my life not seeing my children again and with how unpredictable you are and the bullshit you are doing I’m not risking my happiness anymore. For me not to see them for 40 plus days has killed me inside and out. You have absolutely no idea what you have put me through & the tormenting Facebook posts. They are my children and their (sic) will be no legal representation or you telling me how many time I can see my children. Do you know how hard it is to go to bed every night without your children? Do you know how hard it is to watch your children wave at you from the car when you haven’t seen them for 12 days because you put a DVO on me and then to hear from them that you told them it wasn’t daddy it was someone who looked like daddy.
Hannah you have focussed all the shitty stuff before you left but out life has been filled with plenty of good things in it especially with the children.
I wish you had of just tried … I have told the kids that you loved them and they will miss you I’m sure.
You have destroyed my life & I can not move on. I hope all this was worth it for you and your family. I still have never said a bad word about you Hannah. In fact I feel sorry for who you have become.
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Enjoy your life and freedom now that you have no one to apparently control it. Your (sic) a strong girl you will be fine.
Row, Aaliyah, Laianah and Trey xo On 29 January 2020, Hannah contacted BDVS to advise she had more evidence that Rowan was tracking her phone and listening to her calls.
Hannah again requested a technical sweep of her phone. Also on this date the TPO was heard in the Holland Park Courthouse where Rowan appeared with his Barrister to contest the conditions of the order.
On 31 January 2020, Rowan attended Hannah’s address to drop off Trey as per their parenting agreement. Rowan parked in the driveway and stayed in the car. When Hannah went to the back of the car and opened the door to remove Trey, she observed printed intimate photographs of her in her underwear that had been sent to Rowan while they were still together. The photographs were on the floor of the vehicle. Hannah grabbed the photos and said to Rowan, “why do you have photos of me in your car?” and “my children are in this car and they don’t need to see that.” Hannah scrunched up the photographs and then Rowan reached around and ‘grabbed Hannah by the wrist and twisted it’. Rowan said to Hannah, “put them down, they’re mine, they’re for court”. Hannah yelled for Rowan to let her go and Hannah’s mother came out of the house. She said to Rowan ‘you’re breaching [the temporary protection order], I’m calling the police’. Rowan let go of Hannah and she went inside. Hannah was holding Trey when Rowan grabbed her. Rowan left the address in his car and called her mother a ‘mole’.
Hannah and her mother attended Carina police station provided statements to officers. Hannah had a minor red mark on her wrist which was photographed. Hannah also provided QPS with the photographs of her from Rowan’s car. The matter was initially recorded as a breach of the protection order and Rowan was flagged for questioning. On 2 February 2020 the offence of assault occasioning bodily harm was added to the Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 98 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
occurrence and it was documented in the occurrence that Hannah wished to make a complain of assault against Rowan (due to Rowan grabbing Hannah’s wrist and twisting it).
Hannah also contacted her solicitor on 31 January 2020 to advise that Rowan had assaulted her, and disclosed she was scared to allow Rowan access to the kids as his abuse was escalating and he was no longer willing to comply with the parenting plan. She also requested that mental health assessment be conducted to ensure that he was safe around the children. Hannah’s solicitor agreed to contact Rowan’s solicitor and advise that proceedings would be initiated, and Hannah would no longer be complying with the parenting plan.
That same day, Rowan attended the counter of Coorparoo police station for ‘advice in relation to a minor incident’ that had occurred earlier. Rowan stated that he was dropping Trey back to Hannah when she entered the rear of his vehicle and removed A4 printed photos from the footwell. The officer noted that a temporary protection order was in place that listed Rowan as the respondent and Hannah the aggrieved. Police records reflect that the officer provided ‘advice’ to Rowan, but the nature of the advice was not recorded. There was no indication that Rowan was referred to counselling or a men’s behaviour change program.
According to the statement of this officer following the death, Rowan disclosed on this occasion that he had attempted to snatch his photographs back from Hannah but denied ‘the situation escalated any further’ and he was concerned that Hannah might report him for breaching the temporary protection order in place. The officer advised Rowan that police would contact him if a breach was reported.
On 1 February 2020, Hannah attended her GP relating to a wrist injury sustained the previous day when she was assaulted by Rowan. Hannah suffered a sprained wrist, requiring a wrist splint. Hannah disclosed ‘ongoing DVA issues with police involvement’ to her GP. The GP noted in records that the police had been notified about the incident.
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That same day, it appears that an officer from the SBD VPU reviewed the occurrence from 31 January 2020 and requested that the responding officers follow up with Rowan to offer him a referral to a support service.
SBD VPU did not re-assess the matter as ‘high risk’ (or as an ‘extreme’ risk as per the DV-PAF), despite information to suggest that Rowan’s behaviour was escalating and there were clear indicators of a heightened risk of harm and indeed criminal offences (including non-lethal strangulation, sexual violence, and stalking).
According to the statement of the officer who oversighted this occurrence she did not consider further action was required as Hannah had been offered advice and support from both SBD VPU and BDVS.
On 2 February 2020 the offence of assault occasioning bodily harm was added to the occurrence and it was noted that Hannah wished to make a complaint of assault against Rowan. Senior Constable Kent continued to monitor Hannah’s matter and once aware of this additional report, she attended Rowan’s address in relation to the assault and breach of the protection order. Rowan was provided with his rights and cautions, and he agreed to participate in an electronic record of interview the following week once he had sought legal advice.
On 3 February 2020, Rowan attended another psychologist’s appointment. Rowan disclosed to the Psychologist that on 31 January 2020, he was dropping Trey back to Hannah when ‘she grabbed [intimate] photographs from inside his car’. According to the psychologist’s notes, Rowan intended to use the photographs to show that Hannah ‘was enjoying their relationship, especially their sexual relationship’. Rowan stated that he ‘went to grab the paper back but then she [Hannah] accused him of breaching the DVO and assaulting her’. Rowan discussed that given how ‘difficult’ Hannah was being, he was ‘losing hope that she might change her mind and come back’ to him. Rowan made allegations that Hannah was becoming ‘unwell’ and stated that she had previously bitten her arms and banged her head on doors when stressed.
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On 4 February 2020, Hannah attended BDVS. Hannah explained that she has been directed by her solicitor to withhold the children from going to Rowan’s that weekend as he was not abiding with the parenting agreement set out in mediation. It was noted that Hannah expected that Rowan would ‘escalate significantly as a result.’. Hannah also noted that she remained on the lease for the family home and wanted to change this as it had been one of the reasons Rowan had sought to challenge the no contact condition of the TPO.
They discussed BDVS providing a support letter to assist in having her removed from the lease where Rowan continued to reside. The staff member and Hannah discussed the unintended consequences of this action. Hannah indicated that she would be very open to this support letter. Hannah also made an application to QCAT to have herself removed from the lease. The following Safety Plan was developed:
• A representative from Concentric Concepts would be completing a Tech Sweep of Hannah’s device on Friday.
• Hannah was reminded to turn off location settings on her phone, and not share plans or her whereabouts on social media in the meantime.
• Hannah was to keep the house locked up and call police if she saw Rowan near the property.
• Hannah was to ensure the school was aware of the current temporary protection order however the school had already advised Hannah that they were unable to stop Rowan taking the kids as there were no family court orders in place.
On 6 February 2020, Hannah’s solicitor wrote to Rowan’s solicitor (“C” Lawyers) to advise that following the incident on 31 January, Hannah would no longer be complying with the parenting plan. On 9 February 2020, Rowan was charged by police in relation to breaching the protection order on 31 January 2020 and was given a notice to appear on 2 March
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By 7 February 2020 Rowan was becoming frustrated and angry. He phoned Hannah’s brother’s ex-wife and told her that “he was so angry he wanted to and kick her in the head. He wanted to go over, kick the door down and smash her head in.” On 10 February 2020, Rowan contacted Mensline expressing an interest in completing a men’s behavioural change program. Records indicate he was ‘given services to use moving forward’. This appears to have been prompted by considerable correspondence between Rowan and Hannah’s Solicitor regarding access to his children. His own Solicitor also strongly suggested Rowan attend a men’s program.
On 11 February 2020, a consultant visited Hannah at home to perform the technical sweep on her phone, following the referral from BDVS. Hannah was provided with a new phone by the security consultant and advised to leave her initial phone fully activated with no changes, so Rowan could ‘continue to communicate with the children whilst managing any escalation potential.’ The security consultant also walked through the home with Hannah, to ‘ensure Hannah had a safety plan in place should the respondent’s behaviour escalate.’ The technology sweep identified a suspicious email that enabled the sender to access Hannah’s phone. She was instructed to change email addresses and all passwords.
On 11 February 2020, officers attended Rowan’s home and charged him with common assault in relation to the episode of domestic violence on 31 January 2020. On this date, Rowan’s solicitor (“C” lawyers) also referred Rowan to another legal firm who specialised in Family Law to assist in finalising matters relating to the children.
On 12 February 2020, Hannah attended Carina police station and provided an affidavit detailing Rowan’s use of domestic and family violence towards her. This was to support the protection order application, which Rowan was contesting. In her affidavit to the QPS DVLO, Hannah detailed that she had ‘still been subjected to intimidation by Rowan’ since the temporary protection order was granted on 8 January 2020.
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Hannah detailed an episode of domestic and family violence that had occurred over the Australia day weekend when Rowan had custody of the children. Hannah stated that Aaliyah had called her from the car ‘really frightened and anxious, she was telling me “I don’t know where we’re going. I’ve asked Daddy lots of times and he won’t tell me”. Hannah stated that she tried to remain calm but was ‘petrified’ and felt that Rowan was trying to frighten her and ‘punish’ Aaliyah (as she had not wanted to go with Rowan when he picked her up). She stated that Rowan was constantly harassing her to change their parenting agreement.
Hannah also alleged that Rowan had been stalking her, reporting the events detailed above, where Rowan had been frequenting the coffee shop and shopping centre she attended and installing spyware on her phone. Hannah stated that she had contact with BDVS who ‘sent out a tech’ to go over her phone. The technician was reportedly confident that there was spyware on Hannah’s phone but ‘would need Rowan’s phone to confirm 100% however he was so sure there was something that he gave me a new phone’.
Hannah also articulated her fear of Rowan and stated, ‘he gives me this look and that makes me know if I was alone with him, he would do me serious harm or worse’. No further advice was offered to Hannah at this point, and it appears that no consideration was given to a referral to the High-Risk Team operating within the region.
On 13 February 2020, Hannah’s friend Ms B provided an affidavit to QPS in support of the protection order, describing coercive controlling behaviours exhibited by Rowan towards Hannah, such as Rowan belittling Hannah and attempting to isolate her from her family. That same day, Hannah’s solicitor again wrote to Rowan’s solicitor, Mr C, advising that on account of the assault that Rowan committed against Hannah on 31 January 2020, Hannah was not willing to reinstate the parenting plan, and would be preparing an initiating application to file in the Federal Circuit Court.
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On 14 February 2020, Rowan attended an initial consult with new solicitors, in relation to the notification that Hannah’s solicitor would be preparing an initiating application. The notes indicate that while Rowan had been instructing C Lawyers, they were not a family or criminal lawyer.
On this day, Rowan was issued with a notice to appear for the common assault charge relating to the incident on 31 January 2020.
On 17 February 2020, Rowan was observed on CCTV footage entering Bunnings, and purchasing a green jerry can, zip ties and a bottle of methylated spirits. CCTV footage provided by neighbours accessed after the deaths show Rowan arrived home, took the green jerry can and what appears to be a bundle of cable ties from the boot and carried them towards his garage.
On 18 February 2020, Rowan called Mensline. During this phone call, Rowan advised the call taker that his ‘ex-wife put a DVO on me to get my middle child back’ noting that ‘…its almost like a game to put her in a better position for family court.’ Rowan’s primary concern during this phone call was that by accepting a referral to a mens’ behavioural change program he would be admitting guilt in relation to the DVO, which he was adamant was an effort by Hannah to use the kids against him. During this phone call, in relation to the events of 26 December, Rowan stated: ‘I’m 42, I shouldn’t have to … ask for my kids. And then it got to the stage where that she was just dictating to me when I could have them, And she’s 30 so.. 32, so she’s only eight years younger, but she became very immature when it came to using the kids a wee bit, and then… we were at the park maybe Boxing Day, and my middle one wanted to come with me, and I said to her, well you can come with me then, and her mother didn’t want a bar of it. So, she still came with me, and her mother kicked up a stink.
And then the next thing, you know, I get home to… I get home and some police come and take her off me. She put a DVO on me. And then it’s just gone worse and worse and worse.’ The call taker reassured Rowan that referral to a behaviour change program or service was ‘not about any blame.’ Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 104 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
The presenting issue recorded on the call log by the service was ‘anger’ and the additional issues were referral and information. Rowan asked the telephone counsellor for information on Men’s Behaviour Change (MBC) programs and was given the numbers for two services within 20 km of his home. The notes state “caller motivated to get on a program though not sure if he needed help.” The telephone counsellor extended the search for programs to 100kms of Rowan’s home and located one additional service on the Sunshine Coast.
Rowan then contacted YFS requesting to speak to a member of the men’s behavioural change program however due to all team members being unavailable and the lateness of the day, he was only able to leave a message. The service attempted to call Rowan back on 19 February 2020 but were unable to make contact.
On 18 February 2020, Rowan was captured on CCTV footage walking from his house carrying the green jerry can in his left hand. Rowan then drove to a service station and purchased 4.6 litres of fuel, dispensed into the green jerry can. Rowan also purchased lollies before returning home and entering his residence carrying a white piece of clothing or cloth.
This same day, Rowan’s solicitor sent correspondence to Hannah’s solicitor to request that Rowan be allowed to telephone/skype/Facetime the children every weekday at 6pm, until the initiating application has been received (within the Family Circuit Court). Rowan disclosed to his solicitor that he sincerely missed his children and wanted to be able to communicate with them every day.
On this day, Hannah also texted BDVS to advise that QCAT had accepted the application and her name was no longer on the lease of the family home. She thanked them for their support but also wanted to know what would happen to the amount of money owed in rent. That same evening, Rowan contacted a friend, crying about only being able to Facetime his children on Tuesday and Thursday nights. Rowan said ‘everything she is Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 105 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
doing is working and the kids are just drifting away because they don’t get to talk to me and they don’t get to see me’.
In the evening of 18 February 2020 Rowan facetimed his children.
Hannah’s mother recalls Hannah saying, ‘he wasn’t talking just sobbing to the kids’. Hannah told one of the children to hang-up on daddy if he was not talking, just crying. Hannah mentioned to her mother that she felt bad and concerned Rowan might kill himself. Hannah, Aaliyah, Laianah and Trey were killed by Rowan the following day on 19 February 2020.
Issues for Review In the four months before the deaths, there was extensive service contact in relation to DV perpetrated by Rowan towards Hannah (and the children). This included contact with police, child safety services, specialist domestic and family violence services, legal and court services, and mental health services (Rowan only).
Relevant recommendations from the Women’s Safety and Justice Taskforce’s First Report, Hear her Voice (2021) are discussed though-out this section, given their relevance to the issues identified. While the first terms of reference of the Taskforce sought to consider how best to legislate against coercive control, broadly speaking, recommendations from this report seek to: improve primary prevention; raise community awareness and understanding of domestic and family violence and coercive control; improve service responses, primarily across the criminal justice (e.g. police, court services, legal practitioners etc) and specialist domestic and family violence service systems (men’s behavioural change programs, crisis shelters etc); better hold perpetrators to account; legislate against coercive control; and monitor and evaluate reform implementation. At the time of the completion of this review, the Taskforce’s recommendations were yet to be responded to by the Queensland Government.
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Issue 1: Retaliatory filicide within the context of domestic and family violence Between 1 July 2006 and 30 June 2021, almost one-quarter (23.7% of 375 cases) of all domestic and family homicides in Queensland were homicides of children killed by a parent or caregiver (filicide). Despite this, they are still statistically rare events. Consequently, there is a paucity of research available that specifically considers child homicides in the context of domestic and family violence (despite evidence that clearly demonstrates this as a feature in many filicides).
A contemporary framework developed by Bourget and Bradford6 has sought to categorise filicides with a greater focus on establishing intent where possible. The categories are:
• mentally ill – actions associated with mental illness, psychosis, postpartum disturbance, or other mental disturbance;
• fatal abuse – includes cases of child neglect and abuse;
• mercy filicide – intentional killing when a child has a severe or debilitating illness;
• retaliatory – intentional killing because of anger or revenge; and
• other/unknown – to be used where there is insufficient information or cases with multiple, contributing factors.
Retaliatory filicides are associated with a specific intention to kill and are committed out of revenge towards an intimate partner. The child/ren are used as tools by the perpetrator to punish their partner and this type of crime is most commonly perpetrated by male offenders.
In 2012, the Victorian Domestic and Family Violence Resource Centre published a paper that considered available research and contemporary understandings of retaliatory filicide, and underlying contributing and 6 Bourget, D. and Bradford, J. (1990) ‘Homicidal parents’, Canadian Journal of Psychiatry, vol. 35, pp 233-38 Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 107 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
causal factors associated with this type of crime.7 Salient findings about retaliatory filicides with respect to the circumstances of this case include:
• when biological fathers kill their children, it is most often in a context in which they are separated from the child/ren’s mother or they perceive there is a threat of separation;
• there may not be a history of physical violence towards the children before the event and the killing is often intentional; and
• in some cases, the children are perceived to be an extension of the mother and thus the motive for killing the children often relates to a desire to hurt the mother.
It is apparent that, in the three months before the deaths, Hannah grew increasingly fearful of Rowan and that she held significant concerns for her safety and for the safety of Aaliyah, Laianah and Trey. Hannah clearly articulated her concerns in an affidavit provided to police on or about 28 December 2019, stating, ‘I believe that Rowan is totally capable of killing himself and killing our children to get back at me [for leaving him]. This scares me beyond words’. Hannah also disclosed to BDVS that Rowan ‘had nothing to lose’ and had made ‘previous threats to kill [his] ex-partner and child’ in the context of their separation After Rowan set fire to Hannah and the children on 19 February 2020, multiple witnesses attempted to intervene and provide assistance (e.g. by trying to help Hannah who was significantly injured and initially still on fire after she escaped the car). Rowan is reported to have threatened people with a knife (while he was still on fire/significantly injured) in an apparent attempt to keep them away from the vehicle and reduce the possibility of saving the children, who remained trapped inside.
As part of the police investigation following the deaths, it was also identified that Rowan had pre-planned the homicides. This included purchasing a jerry can, zip ties, and methylated spirits on 17 February 2020, two days before the deaths. He was later captured on CCTV on 18 7 Refer to http://www.dvrcv.org.au/knowledge-centre/our-publications/discussion-papers/just-say-goodbye.
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February 2020, the day before the quadruple homicides-suicide, filling the jerry can with fuel. These events occurred prior to the Facetime call that Rowan had with the children on 18 February 2020, in which he appeared distressed, the night before he killed Hannah and the children.
Issue 2: Invisibility of the children in the service response Despite Hannah disclosing to multiple services that Rowan was using Aaliyah, Laianah and Trey to control her and that she was fearful for their safety (and for her own safety), there was limited apparent consideration of the children’s safety and welfare in any of the service responses.
Officers from SBD VPU visited Hannah on 8 January 2020, around six weeks before the quadruple homicide-suicide, in the company of a BDVS worker. On this date, Senior Constable Stephanie Thomas from the SBD VPU observed that Laianah appeared to have been suffering some anxiety from the event on 26 December 2019, whereby Rowan had removed Laianah from Hannah’s care for three days in an act of domestic and family violence. Senior Constable Thomas observed that Laianah kept ensuring that her mother was always in eyesight during the police interaction.
A discussion was held around support services for Hannah and the children on this date, with a referral to Child Aware psychology services offered for the children which Hannah accepted; however, it does not appear that she established contact with this service.
BDVS records also indicate that Aaliyah, Laianah and Trey were referred to their children and young person’s program for children who have been impacted by domestic and family violence, in the form of a one to one or group psycho-education. While on review of the available files, it does not appear that any of the children had contact with this service, only children older than six years old are able to attend which means Laianah and Trey would not have been able to engage with this service.
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Although it was not reflected within case notes BDVS have subsequently advised that ‘consideration of the children was a priority in all that Hannah was concerned about and Hannah determined staying at her parental home was the safety option at that point in time as she had to navigate further issues like family law court parental agreements.’ In response to Rowans’ escalating violence they further advised that this ‘had resulted in the school being notified and a plan for Hannah’s parents to collect the children from school.’ Child harm report On 1 January 2020, a child harm report to the Regional Intake Service (RIS) of child safety services was made by police with respect to the event on the 26 December 2019. It is unclear why this information was sent to the RIS rather than the Child Safety Services After-Hours Service, however, due to 1 January 2020 being a public holiday, the information contained within the Intake was not reviewed until 2 January 2020. An Intake was generated based upon the information provided within the initial concerns submitted by QPS.
On 13 January 2019, after considering the Structured Decision-Making Trees and subsequent assessments, and in consultation with the Senior Team Leader, the matter was finalised by way of a Child Concern Report (CCR) with Hannah being assessed as a parent willing and able to care for the children.
No consideration or assessment appears to have been undertaken of Rowan or the potential threat he posed, and no collateral information was sought by child safety services to inform this assessment within the context of the violence that Hannah was experiencing or her consistent fear that Rowan would harm the children to hurt her. There were no prenotification checks carried out to confirm the information received, assess the impact on the children, or explore if the QPS held any updated information.
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The Systems and Practice Review completed by child safety services after the homicides acknowledged that had the RIS sought and been provided with the additional information regarding Hannah’s situation, the coercive control reported to police and the referral to the SBD VPU, this information would have better informed their assessment.
In addition to seeking additional information the RIS, upon completion of the CCR, could have also made a referral to Family and Child Connect (FaCC) for both parties which would have provided an earlier opportunity for Rowan to be referred to, and engage with, specialist services (specifically a men’s behaviour change program).
Issue 3: Risk identification and management (lack of referral to High-Risk Teams) In addition to having an intuitive sense of fear of Rowan in the months leading up to the homicides, Hannah disclosed multiple other risk factors to services indicative that she was at high, and escalating, risk of harm including: non-lethal strangulation; intimate partner sexual violence; child custody concerns; sexual proprietariness (Rowan); relationship separation; mental health concerns (Rowan); suicidal threats or attempts (Rowan); (implicit) threats to kill, and other obsessive or controlling behaviours (Rowan).
While there is no tool that can accurately assess risk of future lethality within the context of intimate partner violence, national principles for effective risk assessment processes within the context of domestic and family violence have been established.8 These principles highlight that all practitioners should ensure that risk is continuously assessed, reviewed and actively managed and that: 8 As outlined within the National risk assessment principles - ANROWS - Australia's National Research Organisation for Women's Safety Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 111 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
i. the safety of victims and their children is the core priority of all risk assessment frameworks and tools; ii. a perpetrator’s current and past actions and behaviours bear significant weight in determining risk; iii. a victim’s knowledge of their own risk is central to any risk assessment; iv. to ensure the safety of victim’s and their children, an integrated, systemic response to risk assessment and management, whereby all relevant agencies work together, is critical; v. risk assessment and safety management work as part of a continuum of service delivery, and as risk factors change over time, ongoing risk assessment and management along the service continuum also changes; and vi. intimate partner sexual violence must be specifically considered in all risk assessment processes, as it is a uniquely dangerous form of domestic and family violence.
Despite the high volume of service contacts in the months leading up to the deaths, it appears that structured risk assessments were conducted infrequently by responding agencies for Hannah (although BDVS have indicated that they were (informally) considering and reviewing her risk at each contact point) and not at all for Rowan (within the context of domestic and family violence).
Hannah was flagged as ‘high risk’ by the SBD VPU on 29 December 2019 after Sgt Angela Trigg reviewed the domestic and family violence related police occurrences to identify couples where high and extreme risk factors were prevalent in her region. On review of available information, Sgt Trigg ‘deemed the couple as high risk due to concerns with (Rowan’s) pattern of behaviour and (Hannah’s) increasing fear levels’. Hannah was also flagged as ‘high risk’ by BDVS when finalising their initial risk assessment on 16 January 2020 with it being noted that ‘due to respondent (Rowan) regularly threatening to take the children, Hannah is afraid of what he is capable of, Hannah worried respondent will escalate’. When asked if Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 112 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Hannah thought Rowan was capable of killing her during this assessment, Hannah’s response was recorded as ‘Due to him (Rowan) having nothing to lose and previous threats to kill ex-partner and child, Hannah was concerned this would happen to her’.
While Hannah was identified as high risk by both BDVS and police, there does not appear to have been any consideration by either agency of the need to escalate the service response when she sought further advice and support from them, as Hannah’s engagement with services and family support were seen as protective factors. There was also limited apparent collaborative case management outside of a joint home visit in early January 2020 with statements from BDVS indicating that they saw themselves as still being at their initial stages of engagement with Hannah; with the intensity of their engagement and the supports offered reflecting this.
Similarly, on 16 January 2020, Sergeant Trigg from SBD VPU closed the task she created on 29 December 2019 indicating that the couple were high risk, as she was satisfied that VPU ‘had completed the required follow up enquiries’ to engage Hannah and Rowan with support services.
There also appears to have been no consideration by either agency of whether there was a need to refer Hannah to a High Risk Team (HRT) for management. BDVS have subsequently advised that processes to support referrals to the Brisbane HRT are based on the CRASF (although this tool was never used with Hannah by either agency) and the HRT Brisbane Operating Protocols outline that a referral to the HRT is only completed when: a. there is evidence to suggest escalating risk of serious harm or lethality to the victim, and b. existing service responses have been unable or not sufficient to manage the level of risk.
Decisions to make a referral to a HRT are also informed by whether protective factors exist for the victim (including a safety plan) that are Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 113 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
‘sufficient’ to manage the risk identified; information sharing and collaborative safety planning has occurred; and processes are in place to monitor changes in risk and escalate matters if required.
BDVS have provided advice that they did not refer Hannah through to a HRT after they had assessed her as a ‘high risk’ case as ‘the safety planning was the beginning. Many women presenting to BDVS when describing their experiences are recognised as high risk and this informs the steps that are taken with the woman in each circumstance’…’BDVS was at the early stage of formation of a relationship and planning. This is not to say if the relationship with Hannah had of occurred over more time that a referral would not have been made.’ Factors taken into account by BDVS in determining not to refer Hannah to a HRT included that:
• Hannah had a protection order and a safety plan was in place;
• she was in the process of exploring her options and choices;
• she was in ‘discussion’ with the police through the SBD VPU, they were ‘in touch’ with Hannah, and sit on the HRT (so a system response was in place);
• she had identified that staying with her parents was a safe option for her and her children; and
• there was no request made by Hannah seeking alternative accommodation.
There appears to have been a presumption from both BDVS and QPS that each respective agency would also act as an alternate escalation point to the HRT if they deemed it appropriate to do so, and indeed Senior Constable Cristaldi who was acting Shift Supervisor (SBD DFV&VPU) during the relevant time period indicated that ‘the Specialist lead agency, BDVS, would be relied upon to have had commenced safety plans and made a judgement whether the Aggrieved (Hannah) would be referred to the High Risk Team’.
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The relatively short time frame in which Hannah sought to secure safety and protection for herself and her children no doubt impacted the capacity of agencies to swiftly respond, however there were certainly opportunities for agencies to consider and reflect what else may be required for Hannah, and the children, beyond what had already been provided. Lethal risk can escalate quickly (within hours or days) within the context of intimate partner violence perpetration, and it is critical that agencies are able to rapidly identify and respond to this changing risk level.
For example, on 31 January 2020, after Hannah reported that Rowan had assaulted her and breached the temporary protection order, VPU did not re-assess the matter as ‘high risk’ (or as an ‘extreme’ risk as per the DVPAF), despite information to suggest that Rowan’s behaviour was escalating and there were other factors to indicate a heightened risk of harm to Hannah (and the children). According to the statement of Senior Constable Miranda Cristaldi, who oversighted the occurrence on 31 January 2020 as Hannah had previously been offered advice and support from SBD VPU and BDVS, she did not consider further action was required.
It is also apparent that in their safety planning, BDVS focused on ensuring Hannah and the children’s safety with limited apparent consideration given by any agency on strategies to address Rowan’s behaviours and the increasing risk he posed. For example, the link between stalking (including cyberstalking) and intimate partner homicide (and attempted homicide) is well established. When Hannah’s phone finally underwent a technology sweep (arranged through BDVS), some five weeks after Hannah had initially raised concerns, the technician indicated that Hannah’s phone had been compromised.
Currently, safety plans and strategies also tend to focus on a list of actions that victims should or should not take to keep themselves and their children safe. However, this places an unreasonable burden on victims to manage their own safety (and that of their children and/or other family members), overlooks the perpetrator’s choice to use violence, and shifts Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 115 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
the responsibility away from services to take action to ensure victim safety and perpetrator accountability.
In addition to potentially providing an earlier point of referral to a men’s behavioural change program (either through a direct referral or through the HRT), there were also opportunities to improve the intensity of interventions by police and other agencies to Rowan’s escalating pattern of abuse. Part of the intention of the HRTs is to provide a platform for each agency to openly share information in relation to the victim as well as the perpetrator and enable an accurate understanding of all risk factors and identified patterns of escalating risk, so appropriate and timely safety responses can be actioned.
Additional actions that could have been taken by agencies in response to Hannah’s disclosures about her experiences of domestic and family violence include the police commencing investigations into Hannah’s allegation of rape (reported to the police on 6 December 2019); non-lethal strangulation (which was in the TPO and reported to BDVS on 16 January 2020); and her repeated concerns that she was being stalked or intensively monitored by Rowan (disclosed to both BDVS and QPS).
Pending consideration of whether there was sufficient evidence to pursue criminal charges, investigations by police in relation to these offences may have provided an opportunity to implement strong bail conditions against Rowan that would have allowed for more intensive monitoring of him (such as GPS tracking) or other similar restrictions.
Notably responsibilities of the SBD VPU include ‘holding the Respondent accountable for their actions’ and ensuring that ‘all domestic violence and mental health intervention occurrences recorded in QPRIME are reviewed’ in accordance with relevant provisions of the OPMS with a view to ‘determining that all legislative requirements and compliances have been completed and a proper and sufficient investigation has been conducted.’ This should include reviewing each occurrence to determine Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 116 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
‘whether related criminal charges have or should have been commenced.’ Relevant to this point, the QPS Operations Procedures Manual (Chapter
• responding officers give consideration to whether there is any evidence of choking, suffocation or strangulation, and if appropriate, initiate criminal proceedings (in recognition of nonlethal strangulation being a key predictor of domestic homicide); and
• officers actively enforce legislation and make use of investigative skills and evidence gathering to identify and support the person most in need of protection and hold users responsible for their behaviour by commencing criminal charges where appropriate.
While it is acknowledged that officers did pursue criminal charges against Rowan for the assault against Hannah on 31 January 2020, it remains unclear as to whether they explored the potential to pursue charges for other offences that she had disclosed experiencing (such as sexual assault/rape or non-lethal strangulation) (noting that this information was not recorded as ‘occurrences’ on QPRIME but was still held on this system). On this point, the statement of the Officer in Charge of SBD VPU, Snr Sgt Quinlan, indicates that he was ‘not aware of whether or not consideration was given to pursuing charges for other acts when the DFV matters were initially reported’.
Common Risk and Safety Framework In its first report (2021), the Womens’ Safety and Justice Taskforce identified the need for a consistently used framework for understanding and assessing risk to strengthen a whole-of-system approach to perpetrator accountability and intervention. A common approach to Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 117 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
assessing risk would also support information sharing and collaboration to identify cases requiring urgent intervention.
While the CRASF was developed and implemented for this purpose in 2017, three years prior to the deaths, the Taskforce heard in its submissions that the CRASF has limitations in assessing cumulative patterns of risk. While the CRASF is mandated for use in High-Risk Team locations, there is no evidence that anybody working with Hannah used the CRASF, with both the BDVS and the QPS using their own agency tools to assess risk (on the occasions where an assessment was conducted).
In response to these identified issues, the Taskforce recommended that the Department of Justice and Attorney General develop a whole-ofsystem risk assessment framework to use across all parts of the domestic and family violence and criminal justice service systems. It was further recommended that this framework recognise and respond to patterns over time within the context of a relationship as a whole, and include an assessment of the safety and risk of harm for the victims, including children, as well as the risk of a perpetrator continuing to use violence.
The Taskforce also recommended that the Queensland Government establish and adequately resource an independent and integrated peak industry body for all specialist domestic and family violence services, including shelters and perpetrator intervention services.
Issue 4: Accessibility and availability of men’s behaviour change programs There were multiple opportunities in which Rowan could also have been screened and assessed for domestic and family violence perpetration and referred to a men’s behavioural change program; however, (excluding the night prior to the deaths) it appears this only occurred on 15 January 2020 when Rowan was referred to Adapt by police. Records indicate that this Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 118 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
is a court-based men’s behavioural change program, and that Rowan ultimately did not engage with this service.
It appears that Rowan engaged predominately with legal supports, and it is through his conversations with Mr C that Rowan sought access to programs following correspondence received from “K” Solicitors (Hannah’s lawyers) regarding Hannah having expressed concerns regarding Rowan’s mental health.
In correspondence to Rowan dated 12 January 2020 (approximately a month prior to the deaths), K Solicitors identified Hannah’s concerns regarding Rowan having unsupervised access to the children based upon his: ‘…deteriorating mental health, your complete disregard of the children’s emotional wellbeing, a complete disregard to the importance of the children having a relationship with our client (Hannah) and your recent irrational and unpredictable behaviour. Our client believes that you pose an unacceptable risk of emotional and psychological harm to the children’.
According to information gained during a phone call with Mensline on 18 February 2020, the day prior to the homicides, Rowan disclosed that he had previously contacted Anglicare to engage in a men’s behavioural change program and was told there was a 12 month wait list. There was however no indication as to when he had made contact with the program (or which program) or any additional context around this contact.
During this call, the Mensline operator provided numbers for two perpetrator intervention programs, specifically for YFS (Logan City) Inc and Mercy Family Services (Nudgee) (who both provide Men’s Behaviour Change programs within a 20-kilometre radius from where Rowan resided).
When the operator widened the geographical area to a 50-kilometre radius, he was unable to provide Rowan with any additional services. It was only when the operator widened his search to a 100-kilometre radius that he was able to offer Rowan a referral to a men’s behavioural change program at Maroochydore on the Sunshine Coast. During this Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 119 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
conversation, Rowan made comments to the operator such as ‘this wasn’t my idea’ and ‘at 42 I didn’t think I need to change’. Rowan said: ‘I was told to look for a 10 week Mens Behaviour Change program’.
Rowan contacted YFS to speak with a counsellor immediately after speaking with Mensline. He spoke with the receptionist, left his contact details, and was informed that a member of the team would contact him the following day (the day of the quadruple homicide-suicide).
Perpetrator Intervention Programs Perpetrator intervention programs aim to prevent violence by changing attitudes and behaviours through a range of strategies including individual counselling, case management and group work. A significant challenge to achieving positive outcomes through such interventions is the perpetrator’s motivation to change. Ultimately, interventions will not be successful if perpetrators do not believe that their behaviours need to change.
A recent national evaluation of these programs by ANROWS9 noted that the safety of women and children can be enhanced by a men’s behaviour change program, even in situations where the man does not change his behaviour. The program might, in the short-term, be able to contain the risk he poses to her and her family, and over the longer term support her attempts to untangle herself and her children from his coercive control.
The final report of the Special Taskforce on Domestic and Family Violence (2015), Not Now, Not Ever, saw an enhancement of funding allocated to specialist services, and there have been continued investments in these programs since this time. Availability, accessibility, and quality of interventions are however variable across the state, with long wait lists still 9 Evaluating behaviour change programs for men who use domestic and family violence: key findings and future directions; ANROWS, Issue 17 June 2020.
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in place for many services. As a result, programs are generally prioritised for high risk and recidivist perpetrators of domestic and family violence.
According to the approved providers and approved intervention program list, as of April 2019, there were 24 funded men’s behaviour change programs in Queensland. These programs run for between 16 to 27 weeks with many similarities in their approach. According to this published list, two programs operate specifically in the Brisbane region, being Buranda and Spring Hill, with two services providing behavioural change programs on the Gold Coast and one in the Logan/Beenleigh area.
In late 2021, the Women’s Safety and Justice Taskforce recommended that the Queensland Government design, establish, and adequately resource a network of perpetrator intervention programs. Within this recommendation, the Taskforce specifically noted the need for accessible early intervention programs for men who identify their own problematic behaviour and want to participate, and targeted programs for respondents on protection orders.
It is important to recognise however that participation in a men’s behaviour change program alone is unlikely to reduce the risk of future offending in and of itself. Perpetrator intervention programs are just one part of a broader service system response which should aim to hold perpetrators accountable for their behaviour and reduce the harm they inflict on vulnerable victims and their children.
There have been few studies that have examined the long-term effectiveness of men’s behavioural change programs, including the relationship between program completion and domestic and family violence recidivism. There are also limited consequences for men who disengage with programs, with research suggesting that some perpetrators disengage when they believe they might not achieve the outcome they want, such as reunification with their partner and/or children.
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The complexity of each perpetrator also needs to be considered and it may be that attendance at a men’s behavioural change program should be supported by intensive psycho-social counselling.
Issue 5: Perpetrator accountability within mental health settings Between 20 December 2019 and 3 February 2020, (around two weeks before the deaths), Rowan had contact with Vision Psychology and engaged with a psychologist named Vivian Jarrett. It is apparent from a review of the available records obtained from Ms Jarrett that she:
• did not conduct any screening or assessment in relation to domestic and family violence, despite Rowan indicating that he was jealous and controlling of Hannah, that he was subject to a temporary protection order, and that Hannah held concerns about him having contact with Aaliyah, Laianah and Trey; and
• demonstrated limited understanding of the dynamics of domestic and family violence and image management (including the potential for collusion with a perpetrator in such cases).
Indeed, on 21 January 2020, one month before the apparent quadruple homicides-suicide, Ms Jarrett completed a letter for Rowan in support of his attempts to obtain further contact/custody of the children through mediation. In the letter, Ms Jarrett stated: Mr Baxter has been stressed over his wife leaving him suddenly but has been coping remarkably well given the situation. He has been very open and sincere in our sessions. I have no concerns regarding his mental health. Contact with his children would be ideal and after reviewing his parenting strategies, all seems in order for him to regain contact.
It appears that this assessment was made solely on the information provided by Rowan. There is no information from the records available to Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 122 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
suggest that Ms Jarrett undertook any collateral checks to obtain further details regarding:
• when and why the temporary protection order was put in place, including details of Rowan’s use of domestic and family violence towards Hannah and the risk to the children in this context; and/or
• the conditions of the temporary protection order, including whether the children were also protected on the order and why.
From review of Ms Jarret’s notes made following the deaths, it is apparent that Rowan attempted to portray himself as a victim, stating that Hannah was ‘making up events in the DVO’ and that he was concerned she ‘might make up stories about him to try stop him from having access to the kids’.
Perpetrators of intimate partner violence often use tactics of minimisation and denial to conceal their use of violence and place blame onto the victim. This is a form of systems abuse, commonly linked to coercive control and highlights the importance of all mental health practitioners understanding the tactic’s perpetrators may use within these types of settings.
While the clinical care provided by Ms Jarret is outside the scope of this review, the expert report completed by Dr Lowry with respect to the care provided further highlights that in situations like Rowan’s, where a distressed male presents in the context of relationship breakdown reporting multiple losses (e.g. contact with children, employment, finances, and social standing), the client and situation requires close and ongoing monitoring, assessment, and recording of risk related ideation, intent, and planning, along with safety planning due to the risks associated with violence in these situations.
Over the past five years, multiple recommendations have been made by the DFVDRAB to improve the way that psychologists understand, identify, and respond to perpetrators of domestic and family violence. This recognises the important role mental health practitioners have in Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 123 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
supporting perpetrators of violence, and the corresponding need for them to be equipped to work in a domestic and family violence informed way that accords with the National Outcome Standards for Perpetrator Interventions.
• As highlighted by the Board in its 2020-21 Annual Report, psychologists (along with other support service providers) can, at a minimum, work with perpetrators of domestic and family violence and respond to risk by:
• appropriately documenting and contextualising domestic and family violence in records and sharing this information with other agencies under Part 5A of the Domestic and Family Violence Protection Act 2012 to better inform and assess domestic and family violence risk;
• work proactively with other agencies to ensure perpetrators (and victims and their children) receive tailored responses that focus on victim safety;
• making supported referrals to specialist service providers (such as a men’s behaviour change program); and
• identifying impression management tactics and systems abuse to avoid colluding with perpetrators in their efforts to excuse, minimise or justify their violence.
The position taken by the Board is also further reinforced by the Australian Psychological Society that supports psychotherapeutic approaches, including those utilising cognitive-behavioural methods to support domestic and family violence perpetrators. These typically focus on addressing the thoughts and beliefs that justify violent behaviour and incorporate problem solving and communication skills, emotional regulation, and impulse control.
the assessment made on their answers – police should not be answering the questions based on their observations. She said that the CRASF and BDVS tools are too comprehensive for frontline officers to use.
She said that information can be shared between agencies and information such as strangulation should be shared. She said escalating behaviour in a perpetrator requires a swift response including programs at an early stage and criminal proceedings.
Ms Beattie said that the following were missed opportunities to address Baxter’s behaviour:
• He could have been charged with AOBH and Breach DVO on 2 February and his bail objected to – instead Sergeant Rolf allowed him to obtain legal advice – there was no point in that because he had already refused an interview;
• There was no follow up when Baxter failed to attend the police station on 4 February – the matter was left until Constable Kersey happened to see him on 9 February;
• On 9 February he was charged with Breach DVO only although the AOBH was on the system;
• On 9 February Baxter was issued with an NTA instead of being processed through the watchhouse and the decision as to his bail was made without a proper consideration of all the circumstances;
• Constable Kersey then downgraded the AOBH to a common assault and issued a second NTA rather than re-charging him with the correct charge – there was no reason to downgrade the charge.
share information with QPS. She knew that Hannah had been in contact with police officers so would assume that they had all relevant information.
Concerningly, she said that most women she assesses have been choked or strangled.
She said that, in her experience, women have difficulty getting police to pursue criminal offences and breach charges. However, it was sometimes the case that women did not want to pursue criminal charges and some do not want to speak to police at all.
Ms V was the BDVS social worker who visited Hannah as part of the VPU team and the embedded DV social worker at the South Brisbane VPU. She said her role there was to collaborate with police officers to provide a co-ordinated response from a DV lens.
Ms V said that the purpose of the visit to Hannah was to ascertain whether Hannah needed any further supports. She told them that she was getting a family lawyer and agreed to see a specialist DV counsellor.
In regard to information sharing Ms V said that the police gave her a job sheet and she would cross reference that with information held by BDVS. She said that she could share information with the QPS.
Ms V said it was a huge red flag that Baxter took Laianah, however, taking into account that Hannah had left Baxter, had social supports and QPS and BDVS were involved, she didn’t believe that she was at imminent risk.
Hannah’s case manager at BDVS said that she completed an additional safety plan due to Baxter’s escalation which included advising Hannah to keep the house locked and having her parents Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 126 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
pick up the children from school. Hannah said that she wanted to stay with her parents. She said that, regardless of Hannah’s wishes, emergency accommodation is very difficult to obtain.
She said that Hannah was high risk but she didn’t need any further supports – the core business of the HRT is to ensure matters “don’t fall through the cracks.”
She said that BDVS shares information with the South Brisbane VPU – there is constant communication amongst the team.
Hannah’s case manager is a very experienced DV specialist social worker. She said that investigation of criminal offending is not necessarily a pathway to safety.
A senior case worker from BDVS gave evidence that the service receives over 4000 referrals per year and they are constantly considering the best way to identify the highest risk clients and better ways to work with the QPS. Even where high risks are identified they need access to a suite of interventions that are adequately funded. Short term accommodation for women and children is not suitable. Many women return to their parents’ residence because they have nowhere else to go. There is a scarcity of emergency accommodation for women. She said there are thousands of women waiting for public housing and many women don’t even put their name down due to the waiting periods. She said that what is needed are apartment blocks of high security housing. She said that 78% of their clients experience stalking. She said we need to develop a housing model that addresses the huge need for accommodation.
She said that BDVS has women phone from the cars in which they are living.
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Vivian Jarrett gave evidence at the inquest. She is a psychologist and the Director of the company, Vision Psychology. On that company’s website Ms Jarrett holds herself out as having “special expertise in treating … domestic violence – making changes to protect you and your family.”
On 20 February 2020 Ms Jarrett provided a statement to police in which she outlined that she had treated Baxter from 20 December 2019 in relation to his distress over his relationship breakdown. She said that he told her that he wanted to make changes so that his relationship could resume.
Ms Jarrett said that they discussed strategies such as breathing and strategies on how to improve his relationship through communication and problem solving. She spoke to him again on 30 December and he was upset that an order had been made. She saw him again on 31 December and discussed the DVO. She found him to be “very level-headed.” He was visibly upset about not seeing his children.
He told her Hannah was accusing him of things which weren’t true and she drank a bottle of wine per day.
Their next appointment was on 6 January 2020 when he said the breathing techniques were working well and he still had not seen his children. He said he had closed his business nine days ago and it was Hannah’s fault they had lost clients. She discussed a strategy of him visualising that he was taking part in a marathon. She said he found this helpful.
Baxter attended again on 14 January and he said the DVO application had been adjourned but he was confident. He was upset.
He was teary when speaking about his children. He said he had seen Hannah when he was at Carindale and he was worried she would accuse him of breaching the DVO.
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On 20 January Baxter sent Ms Jarrett a text message in which he said that Hannah’s solicitor sent him an email regarding his deteriorating mental health and, “I would like to cover myself with a letter or whatever you think would be best for mediation.”
He forwarded Ms Jarrett the solicitor’s email. On 21 January he attended the clinic and he “looked emotionally worn out” and “really frustrated.” Ms Jarrett evaluated whether “he could look after his children as a normal parent” and he gave her “satisfactory answers.” She then wrote a letter for his mediation which was addressed “To whom if may concern” and which relevantly stated: Mr Baxter has seen me for 6 sessions ….. Mr Baxter has been stressed over his wife leaving him recently but has been coping remarkably well given the situation. He has been very open and sincere in our sessions. I have no concerns regarding his mental health.
Contact with his children would be ideal and after reviewing his parenting strategies, all seems in order for him to regain contact.
Baxter told Ms Jarret that “he was worried that Hannah was running out of things she could blame him for.” She saw that he was “sadder” than on previous occasions. He said the break up was hitting him harder than his mother’s death.
They had a conversation about him being able to afford the sessions and Ms Jarrett told him he could cancel appointments if he had to.
At the next appointment Baxter said he was happy that he could Facetime his children but disclosed the photo incident and said he “wanted to know what was wrong with” Hannah.
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Ms Jarrett’s final statement was that she had “provided all my records, notes, texts and emails” to the statement.
Ms Jarrett attached to that statement copies of questionnaires that she said Baxter had completed on 2 January 2020, 14 January 2020, 3 February 2020, 20 December 2020, 31 December 2020 (Ms Jarrett said this was an error and the correct date was 2019), 6 January 2021 (Ms Jarrett said this was an error and the correct date was 2020), and type written notes from 20 December 2019, 31 December 2010 (obviously also an error), 6 January 2020, 14 January 2020, 21 January 2020, 3 February 2020. Those notes also included the following entry: Conclusions 20 Feb 2020 Over the course of our session, Rowan never stated, or implied that he wished to hurt anyone. He was more in dismay that others like Hannah were willing to. He was never suicidal ….. He did look upset, flat and nervous at times when we talked about the children. In my opinion he was well supported.
Given the events that occurred I wonder if there was a triggering event and that he went into a rage or ‘snapped’. None of the behaviour described online could have been predicted from our sessions. He was never enraged in our sessions, more distressed that he lost and was grieving over his family.
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Ms Jarrett produced an “Emotional Health Check Up” completed by Baxter on 20 December 2019 in which he was asked for his main concerns and stated: “Insecurities – controlling behaviour; marriage, jealousy.”
She also produced the Mental Health Care Plan which was sent to her by Baxter’s GP which also stated, “wife was unhappy with his controlling behaviour and jealousy.”
On 26 November 2021 police executed coroner’s search warrants on the offices of Ms Jarrett which required her to produce: Any and all electronic or hard copy records pertaining to Rowan Charles Baxter, including but not limited to hand-written or typed session notes, diaries, invoices, forms, correspondence, and/or audio or video recordings of psychology sessions.
Upon execution of that search warrant Ms Jarrett provided to police the text message she had received from Baxter on 20 January 2020 in relation to the email from the solicitor and in which he said: This is the response I received from my wife’s lawyer when I asked to have more time with my children. I have mediation in 2 days so would like to be able to squash anymore of their accusations.
She also produced some screen shots of the office database which showed appointment times and details of payments made by Baxter.
They showed that he had improved remarkably between 19 Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 131 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
December (when his score indicated significant anxiety and depression) and 30 December such that, according to the program: The patient is functioning in the normal range. Consider termination.
This patient is having an unusually rapid, positive treatment response and is expected to end treatment as markedly improved and maintain treatment gains for at least six months.
Ms Jarrett was unable to provide any convincing reason for her failure to provide these documents upon execution of the search warrant. Further she stated that she had more of these documents that she had not brought to court as she had not printed them out.
The improvement shown is inconsistent with her notes in relation to Baxter’s sessions. I consider it likely that the questionnaires dated after 19 December and the database readout were constructed by Ms Jarrett herself in order to justify the letter she wrote for Baxter to use in the mediation.
Ms Jarrett gave evidence that she thought Baxter may have been using her to get evidence for his Family Court proceedings.
When asked about whether she considered that Baxter may have been using coercive control and posed a risk to his family, Ms Jarrett said that she was not an expert in domestic violence. This is obviously inconsistent with her holding herself out to be such an expert on her company’s website.
I find that Ms Jarrett was an unreliable witness who most likely gave false evidence and wrote her notes after the deaths in order to justify her unsatisfactory diagnosis and treatment of Baxter and the misleading letter that she wrote for him to take to mediation.
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The content of the session notes paints a picture of a man who perceived he was being ganged up on’, humiliated, and treated ‘unfairly’ and in an unjust way. What is also apparent on review of the session notes is the multiple losses Mr Baxter perceived he was experiencing, in addition to reality-based losses as a result of the situation – loss of / change in contact with his children, loss of the business and financial impact, loss of friendships and associates, and a perception of loss of ‘role’, ‘reputation’ and ‘status’ with Mr Baxter believing he was being belittled by Ms Clarke in some manner in her communications with others. What is important here is Mr Baxter’s perception of his situation at the time and resulting feelings of betrayal, humiliation, and blame of Ms Clarke.
Further, and of significance, is that these losses and the broader situation as perceived by Mr Baxter occurred on the background of a history of mood disorder and difficulties with jealousy, insecurity and self-reported controlling, factors which can be associated with domestic and intimate partner violence and intimate partner femicide. While the documentation does not reveal Mr Baxter disclosing he was engaging in jealousy-driven controlling or coercive behaviour, this history indicates a level of characterological and personality disturbance and potential for violent behaviour in the context of relationship breakdown.
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It is not clear from the notes where Ms Jarrett was aware of these issues and the research base linking the potential for violence with certain personal traits and situational factors in relationship breakdown. It is also unclear whether Ms Jarrett had assess or formulated this risk appropriately and in an ongoing fashion, or indeed recognised the elevated baseline risk presented by Mr Baxter. It may well have been the case, as is reflected in session notes, that Mr Baxter did not present with overt anger or rage.
However, as reflected in research, there are a range of other less obvious dynamic, situational, and historical risk factors that require assessment in such situations. It is not clear from the notes whether these were assessed or considered. It should be noted however that even if they were, it is not clear that this would have had any impact on the ultimate outcome. What is also not clear from the notes is whether Ms Jarrett sought assistance or review of the case from a senior colleague or peer which may have assisted identifying potential risks.
Further there was a period of around two weeks following the last contact where Ms Jarrett had no contemporaneous information or awareness of Mr Baxter’s situation and risk profile. Sudden session cancellations in a context such as Mr Baxter’s could signal a change or potential deterioration in the situation, however, his disengagement from Ms Jarrett this was not able to be assessed further at that time. Whilst she could have made contact with him to assess his status, it could not be expected that Ms Jarrett would necessarily be able to seek this information following disengagement from therapy.
It should be said that it is uncommon for most mental health professionals, such as psychologists, … to receive comprehensive training in the assessment of violence risk in complex relationship breakdown situations… Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 134 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
… it is difficult to see that Ms Jarrett, in her role as a general treating psychologist, would have formed an opinion regarding a specified risk of harm to an identifiable person that may have met the threshold for the disclosure of confidential information. While in retrospect a number of historical, situation, individual, and interpersonal violence risk factors and associations can be identified during the period of professional contact between Ms Jarrett and Mr Baxter, there was at the time no overt identifiable risk or clear combination of factors suggesting increased violence risk.
He said other concerns were her failure to record a mental state examination (MSE) information or any details or assessment outcomes regarding risk and safety issues.
Professor Heather Douglas
Professor Douglas, an expert in the research into gender-based violence, reviewed the circumstances of the deaths and provided a report concentrating on three issues:
an overview of current academic discussion and understandings around coercive control and responses of other jurisdictions to this issue;
relevant considerations relating to the introduction of an offence of coercive control;
identifying any missed opportunities in relation to the systemic response to the DV experienced by Hannah.
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Given the recent report of the Women’s Safety and Justice Taskforce and the government’s adoption of all recommendations arising from that report, these findings do not address the first two topics.
Specifically to this case, Professor Douglas stated that had Baxter been charged with such offence his bail may have been more consideration. In this case he was given a Notice to Appear after little consideration by the police officers. The Professor said that in cases of coercive control bail should be more carefully considered by the courts or matters dealt with much more quickly that is currently the case. Bail, if granted should be on conditions closely aligned with any DVO conditions.
If perpetrators are refused bail then they should be provided with appropriate counselling, support and behaviour change support whilst on remand. The refusal of bail may also offer an opportunity for enhanced safety planning for the victim.
A coercive control offence has been introduced in the UK and a study there found that police force-wide in-person training was associated with an increase in the rate of arrest for the crime but that training only had that effect for about eight months.
The research suggests that police need targeted training on coercive control which should be refreshed regularly, at least until understanding is well-entrenched.
Professor Douglas set out a list of behaviours identified as tactics of coercive control and how Baxter’s acts aligned with them.
Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 136 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Coercive and controlling Behaviour of Rowan Baxter behaviours identified in the literature (Boxall and Morgan, 2021; Stark, 2007) Physical violence (know his Early in the relationship Clarke was injured capability to be violent) when Baxter slammed a gate against her leg A witness reported that early in the relationship Baxter had raised his fist at another women in the cinema in Clarke’s presence Baxter grabbed Clarke’s wrist causing a sprain documented by doctor (re: intimate photos in the back seat of the car) .
Clarke told a friend Baxter was physically abusive and would put her in martial arts positions to demonstrate his strength Sexual violence Excessive demands for sex If Clarke refused sex Baxter would give Clarke the ‘silent treatment’ (isolate her) Was jealous or suspicious of the Early in the relationship – Clarke went on a respondent’s friends cruise – Baxter became jealous Constantly insulted the Witness identified that Baxter would openly respondent to make them feel say that that Clarke was ‘selfish …and would ashamed, belittled or humiliated; never praise her’ or shouted, yelled or verbally abused the respondent to intimidate them Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 137 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Monitored the respondent’s time Constantly checked Clarke’s phone and made them account for their Checked alleged lover’s phone for messages whereabouts from Clarke Followed up on her attendance at the gym via
CCTV Controlled what she wore Multiple witnesses referred to Baxter not allowing Clarke to wear shorts to the gym, not allowed to wear dresses above the knee, had to cover up over her bathers when not on the beach and was not allowed to wear pink Interfered with the respondent’s Multiple witnesses identified that Baxter relationships with other family isolated Clarke and the children from family members over time Accused the respondent of Multiple witnesses recalled Baxter being having an affair (jealousy) concerned that Clarke was having an affair with a fellow gym employee Stalked the respondent online or Multiple witnesses noted that Clarke believed in person she was being tracked and stalked by Baxter or were with her when he appeared by surprise Threatened to hurt themselves Multiple witnesses thought Baxter was ‘suicidal’, at risk of self-harm, was ‘very low’, reported Baxter felt ‘empty’ and seemed ‘flat, deflated’, ‘down’, ‘depressed’, ‘broken’, frustrated, desperate and angry’ in weeks and days leading up to the fatal incident.
Just before Christmas 2019 Baxter told one friend he couldn’t go on.
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On 14/2/2020 Baxter told a friend: ’I don’t want to be on earth anymore’ One witness thought ‘he was on the verge of a nervous breakdown’.
A letter dated 12/1/2020 from Clarke’s lawyer to Baxter asking him to stay away from the children due to deteriorating mental health; irrational and unpredictable behavior .
Clarke expressed her fear that he would kill himself and was fearful about aggravating Baxter by using court processes Clarke was fearful that Baxter would try to kill her .
Tried to keep the respondent Tried to stop Clarke working at Athlete’s Foot, from doing things to help constantly called in at the shop themselves One witness reported that after Clarke started at Athlete’s Foot ‘I think [Baxter] was worried she was becoming more financially Clarke and Baxter shared a Restricted the respondent’s use of their Facebook account (B132) only phone, the internet or the family car.
after separation did Clarke set up her own account (B131).
Threatened to hurt the Some witnesses identified incident of taking respondent’s family, friends, one of the daughters from Clarke’s care as children and/or pets seeming like a hostage or abduction situation Baxter made threats about Clarke’s mother Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 139 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
He also was reported to say: ‘I want her to know what it feels like not to have the kids’ After seeing his social media posts a witness was concerned about Baxter potentially sexually abusing the children of the relationship
• His display of intimate photos to show Hannah that he still had control, if not of her body then of pictures of her’
• The newly framed photographs of Hannah in the house after separation could be understood as a form of claiming control of her or as an attempt to maintain control;
• Baxter pressured Hannah to have an abortion early in the relationship which is a form of “reproductive coercion”;
• Witnesses described Baxter as controlling, manipulative, domineering, a psychopath, volatile, had a short fuse, comfortable with lying;
• He described himself as controlling but also reported himself as a victim which is a common strategy of those who use DV.
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Professor Douglas noted that Baxter’s engagement with Ms Jarrett represented a potential moment for possible intervention but that Ms Jarrett’s assessment of Baxter’s mental health was at odds with the assessment made by his friends and family.
The Professor noted that perpetrators have a tendency to use tactics of denial, blame and have a capacity to “blame and game” the system. During the sessions Baxter shifted blame from himself and then realised that the sessions could be useful for furthering his aims i.e. he obtained a letter from Ms Jarrett stating she had no concerns about his mental health. If Ms Jarrett had recognised his blaming behaviour and manipulation of systems it may have led her to a different approach, alerting authorities or recognising the cancellation of appointments as red flags for a dangerous event.
A further possible missed opportunity for intervention occurred when Baxter phoned a DV men’s support service on 18 February. The service was not available and attempted to call him back the next day but he did not answer. A 24 hour counselling service may have been an opportunity for intervention and this illustrates the insufficient resourcing of specialist men’s domestic violence support and change services.
The Professor noted that Baxter was struggling financially and the high cost of family law legal costs has been recognised. She stated that Baxter may have benefitted from consistent legal advice and support from the outset. Without access to a lawyer it is likely that he cobbled together advice and support from a range of sources, including possibly, the father’s group he seemed to be in contact with (which was possibly a men’s rights group). This may have exacerbated his sense of disempowerment and hopelessness. The Professor stated that ideally, timely and affordable legal support should be provided in cases involving DV.
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Education and support for community members that make the connection between threats of self-harm and suicide with danger to others in the context of DV may be worth further consideration.
Professor Douglas’ oral evidence at the inquest reinforced the need for more and more regular police training.
She said housing is a real issue and secure housing for women needs human security as well as technical security.
She said that a multi-disciplinary DV police station should certainly be trialled. She said that in this case the risk assessment by police officers was not consistent. She noted that no police officers were asking victims the questions in the DV-PAF and they should be doing so.
She said that the current criminal law could be used more often to hold perpetrators accountable. The Professor noted that 50% of men charged with choking are not released on bail. In this case there was a potential stalking offence.
Ian Leavers is the General President of the Queensland Police Union of Employees (QPUE). He was a serving police officer and continues to hold the rank of Sergeant. He is also the President of Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 142 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
the Police Federation of Australia which represents over 65,000 police officers.
Mr Leavers has advocated for many years for a systemic change in the way DV matters are policed. He believes that a dedicated offence of commit DV should be enacted and perpetrators should be required to undergo treatment to break the cycles of DV. He said such programs were needed for prisoners especially those on remand. He said not providing programs in prisons is definitely a missed opportunity. He said education and rehabilitation is not being addressed and it is a necessity in dealing with DV.
The prevalence of DV and the average time taken by police to dealt with DV incidents has increased significantly in recent years. DV is currently the single most prevalent call for policing – it accounts for up to 40% of calls across the state but in some areas can account for up to 80% of police work.
One call can commonly take up to half or more of an officer’s 8 hour shift. A routine job involved police attending the scene, making enquiries, interviewing each party and any witnesses and completing the paperwork necessary to action the matter. More complicated matters involve police arresting an offender, finding emergency accommodation, arranging medical treatment, liaising with child protection officers and responding to potential violence from the respondent.
Police officers are often required to deal with competing tasks eg in the middle of a DV incident they may be tasked to attend a serious traffic accident or a homicide.
Mr Leavers is of the view that the recent creation of the QPS Domestic and Family Violence Command has led to increased Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 143 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
compliance requirements for police including more time consuming reporting.
There has been a freeze on face to face training since the pandemic.
He believes that there is a need for continued specialist training for all police and it should be face to face.
Mr Leavers explained that the QPS DV Training Plan is yet to be implemented in any meaningful way. The only item which has been delivered to every police officer is the Operational Advisory Note. He said a five day face to face program is required to be delivered across QPS to bring the QPS up to base line and then an annual refresher program is required. He agreed that such training should be included in the mandatory annual Operational Skills Training course.
Mr Leavers believes the current system requires a streamlining of operational requirements, an urgent increase in resourcing and legislative amendments. Mr Leavers suggests a scheme whereby authorised high ranking officers could issue a DVO in the form of a PPN which then becomes a final DVO if the respondent does not apply to the court to contest it. Such orders could be electronically served.
In his view multidisciplinary teams, consisting of police, social workers, child protection and mental health workers and other relevant agencies are best placed to respond to complex DV issues and need to be implemented immediately. He believes that a MDT model should be trialled in Kirwan (where 80% of incidents are DV related) and in South East Qld.
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Mr Leavers said the expansion of QPS’s high risk teams is necessary. They should be expanded across all police districts, be permanently staffed and available 24 hours per day. He said VPUs should be permanently staffed with specifically and intensively trained officers. They are now ad hoc across the state.
Mr Leavers also advocates the creation of a national register to enable the free flow of information nationally.
QPS Witnesses as to the QPS Response to DV
Acting Assistant Commissioner Mark Kelly provided a statement in which he outlined the training provided to police recruits as of January 2021. That training consists of 21 hours of facilitator led face-to-face theory training, two days scenario based training and two days scenario based assessment. He said that first year constables receive further training in understanding the dynamics of DV including identifying risk factors, conducting risk assessments, applying the law, undertaking a thorough investigation and taking appropriate action for the protection of victims and this training includes at least one day of face to face training.
Acting Assistant Commissioner Kelly said that the Vulnerable Persons training was developed in 2017 after the Not Now, Not Ever report and has been delivered by 239 train the trainers (police officers) to 11,032 officers. There are currently 16,498 QPS members including 11,867 police officers.
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A DV three hour OLP was released on 13 July 2021 and is part of the compulsory calendar for 2021/2022. As of 28 March 2022, 10,162 members had completed the OLP.
The compulsory calendar for 2022 also includes a three hour, mandatory, OLP on coercive control. As of 28 March 2022, 7,781 members had completed that training.
Face to face training on coercive control will be delivered by DV and specialist investigators (presumably police officers) in the 2022/2023 calendar. ANROWS have expressed interest in co-facilitating the training. The train the trainer package for this training should be developed by July 2022 and delivered in August 2022. The training will take place over a full day.
Acting Inspector Martain provided a statement as to the changes that have or are to be implemented within the QPS since the death of Hannah and her children. Acting Inspector Martain was appointed as Manager of the State Domestic and Family Violence and Vulnerable Persons Unit (SDFV&VPU) in February 2020. He reports directly to the Assistant Commissioner of the DFV&VPC and has responsibility for the leadership and management of the SDFV&VPU. The Unit was first established in 2015 to “guide and enhance strategic policy, process and procedure” in relation to DFV.
In March 2021 SDFV&VPU established six DFV Co-ordinators (DFVC) in Brisbane Police Communications Centre to provide near to 24 hour, seven day per week support to frontline police responding to DV across the state. Prior to March 2021 there were only two DFVC in Brisbane. They assist officers to make decisions when responding to DV incidents by interrogation of data systems including LCAD, QPRIME and interstate and domestic DV history and provision of advice.
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The QPS DV Strategy was approved by the Commissioner on 21 January 2022. The SDFV&VPC has responsibility for leading the implementation of the DV Strategy.
The QPS has a DV Action Table which outlines a number of immediate, medium and long term actions aimed at enhancing the policing of DV.
Specialist DFVC positions at the rank of Sergeant are located in each of the fifteen police districts. They are responsible for coordinating and monitoring the policing response to DV within their district. They are assisted by a Senior Constable or Constable.
They are responsible for conducting quality assurance of all DV occurrences in their districts and identify high risk cases for referral to multi-agency HRT.
There are eight District Domestic and Family & Vulnerable Persons Units (District DFVVPU) in Qld. They actively engage with victims and perpetrators of DV at a police district level. The District DFVVPUs in Logan trialled an embedded specialist DFV support service worker working alongside police. The QPS intends to have DFVVPU in all fifteen police districts. They are managed by the district and report to the OIC of the district.
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From July 2021 police across the state are now required to consistently record all DV related criminal offences in the same incident within QPRIME.
A review of QPS DV training by the Qld Centre for DV Research of CQU provided the following recommendations:
• Develop a state-wide DV education and training framework;
• Annual DV refresher training, continual education for DFVC network and development of an evaluation strategy;
• Review of delivery methods of current training programs;
• Addressing identified training gaps.
• Vulnerable Persons Training Package – developed in 2017 – delivered to all officers up to the rank of Inspector – comprises an online learning product and face-to-face workshops;
• DV Specialist Course – a five day, face-to-face course for specialists working in the area of DV such as DFVCs, DFVOs and HRTs;
• DV Culture Change Program – to promote positive cultural and attitudinal change to DV across the service through leadership and mentoring – delivered in late 2019 to selected champions throughout the 15 police districts;
• The SDFV&VPU have used key themes from the training in messaging QPS members via “Workplace” and development of “Officer in Charge Packages” to be delivered to frontline police by local OICs;
• Further Culture Change Coaching Program to be delivered in 2022;
• Recruit and first year constable training programs;
• The DV Policing Enhancement Training was released on 28 June 2021 – online training programs (OLPs) for mandatory Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 148 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
completion by all police officers up to rank of Inspector – as of February 2022 that been completed by 9,345 officers;
• A mandatory Coercive Control training OLP was released on 31 January 2022. As of 24 February 2022 4,396 officers had completed it. Future face-to-face training is to be delivered to all QPS members;
• A QPS DV training plan was developed in 2021 by SDFV&VPC outlining training over next two years.
• Consider a total of 22 Category 1 and 2 risk factors;
• Consider the victim’s fear level; and
• Provide an assessment of overall risk.
Officers are to record details at the scene in their notebook and then enter the details on QPRIME. They now have trifold information cards to assist them in their use of the tool when at a job.
The QPS has engaged external experts to explore options for a more holistic actuarial process for identifying and responding to DV.
In March 2021 the QPS Total Harm Ranking and Evaluation Tool (THReT) was piloted in five police districts as part of a “focussed deterrence” DV operation Tango Alessa. The evaluation wass anticipated to be completed in the first half of 2022.
QPS has developed the DV Predictive Model (DPM) which uses data from QPRIME to build a profile and produces a risk score between one and ten that a couple will have a severe, harmful or dangerous domestic violence incident within 12 months. A pilot of that programme will commence in two police districts in 2022.
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The QPS High Risk High Harm Dashboard (HRHH) was implemented on 1 November 2021 and is accessible by all officers and 31 training sessions have been delivered in its use.
In the first half of 2022 the QPS intends to enhance DV service delivery by a 12 month pilot of embedding a DV specialist police officer within the Brisbane DV Service and the Ipswich DV Action Centre to:
• remove barriers and increase access to justice;
• provide a safe location for victims to engage with police;
• increase reporting rates of DV to police;
• enhance satisfaction of victims;
• enhance sharing of information;
• enhance the timely provision of wrap-around services;
• reduce trauma for victims in seeking assistance of police;
• enhance the collaborative relationship between DFV support services and QPS.
In the first half of 2022 the QPS with the University of Qld intends to pilot a randomised controlled trial of a gendered service delivery model providing for a staffed mobile police facility in a high visibility location like a traditional “shopfront” police beat but with the ability to move in accordance with demand. It is intended to assess whether there is an increase in reporting when they are staffed with female officers only. UQ will evaluate the pilot.
The QPS has DV co-responder models in two police districts in partnership with DV support services. Police and a DV social worker attend a DV incident together after the initial police response.
Expansion to other districts is being explored.
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On 2 April 2020 the QPS commenced an online portal for requesting non-urgent police contact in relation to DV. Victims can specify their preferred contact method and request a specific police officer if they have had prior contact with QPS.
Frontline police are able to refer victims to external support providers at the scene via QLiTE or at a police station computer. The QPS has recently developed the capability to share DV-PAF indicators to DV support service providers which will enable finite DV service provider services to be delivered to high risk victims in a more timely manner. The sharing of DV-PAF was scheduled to commence on 4 April 2022.
Acting Superintendent Martain gave oral evidence in relation to the implementation of the DV strategy, which was approved by the Commissioner on 21 January 2022, and training which has been provided to police officers since Hannah’s death.
Although Inspector Martain’s statement referred to “specialist” DV police officers such as the DV Co-ordinators, the DV Liaison Officers and the officers of the VPU his evidence was that some of those officers have received no specialist training in DV and no training other than that offered to all police officers. The training of VPU officers, whom the QPS describes as “DFV specialists” is “ad hoc”.
Acting Inspector Martain’s statement referred to the training and education packages introduced by the QPS.
Acting Inspector Martain’s evidence as to what training had been delivered and what was intended and when it was to be introduced was not clear. However, his evidence amounted to the fact that little training has actually been provided and there is no definite timeline for introduction of some of the training intended as it depends on Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 151 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
resources. In summary, since the “Not Now, Not Ever” report of 2016, the following has occurred:
• The Commissioner sent out an Operational Advice Notice on 30 April 2021 in relation to bail for DFV offenders;
• District Chief Superintendents had a discretion to direct training in relation to “bespoke district leadership workshops” in their district if they had “capability” to do so;
• The DV policing enhancement training was introduced on 28 June 2021 – this is a two hour online training package which has been completed by about three quarters of all police officers;
• 71 officers have completed a five day face-to face DV training course;
• About 4500 officers had completed an online training program in relation to coercive control;
• 350 officers had completed a two hour face to face training program in relation to the new DV dashboard;
• It is intended that all front line police officers will be provided with a “Cultural Enhancement Program”.
Therefore, since the Not Now, Not Ever report, at the time of the inquest the only “strategy” which has been delivered to all police officers is the Commissioner’s Operational Advice Notice of 30 April
The district training is not uniform and has not been delivered to all officers. The policing enhancement training has not been delivered to all officers (although it continues to be rolled out). Only 71 officers out of about 12,000 had undertaken the five day training course. About one third had undertaken an online programme in relation to coercive control and a very small percentage of officers have undertaken training on the new “dashboard.”
All other training packages remained dependant on resourcing and had no fixed commencement date.
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None of the training packages specifically address assessing the risk of harm to children of a DV perpetrator or victim. The DV-PAF does also not address the risk of harm to children.
Acting Inspector Martain agreed that, taking into account that DV accounts for 40% of all police call outs and in some stations up to 60%, police officers have been provided with very little training in relation to it.
In relation to assessing the risk of harm to children of DV perpetrators, Acting Inspector Martain explained that police officers who attend an incident or receive a complaint where children are involved must complete a Child Harm Report which is assessed by the Child Protection Investigation Unit.
Inspector Martain said that there had been no review of the QPS response to Hannah’s contacts with the QPS conducted and the DV command did not review the matter but he could not explain why as he commenced in his role in February 2020 but after the deaths had occurred.
I accept that QPS training plans have been greatly affected by the pandemic and the huge toll that it took on police resources and that the QPS continues to deliver training and implement new strategies.
Findings and Comments The scope of the Coroner’s inquiry and findings
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The focus is on discovering what happened; not on ascribing guilt, attributing blame or apportioning liability. The purpose is to inform the family and the public of how the death occurred and, in appropriate cases, with a view to reducing the likelihood of similar deaths.
As a result, a coroner can make preventive recommendations concerning public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in future. A coroner must not include in the findings or any comments or recommendations, statements that a person is or may be guilty of an offence or is or may be civilly liable.
Proceedings in a coroner’s court are not bound by the rules of evidence. That does not mean that any and every piece of information however unreliable will be admitted into evidence and acted upon. However, it does give a coroner greater scope to receive information that may not be admissible in other proceedings and to have regard to its origin or source when determining what weight should be given to the information.
A coroner should apply the civil standard of proof, namely the balance of probabilities. However, the more significant the issue to be determined, the more serious an allegation or the more inherently unlikely an occurrence, then the clearer and more persuasive the evidence needs to be for a coroner to be sufficiently satisfied it has been proven.
If, from information obtained at an inquest or during the investigation, a coroner reasonably suspects a person has committed an offence, the coroner must give the information to the Director of Public Prosecutions in the case of an indictable offence and, in the case of any other offence, the relevant department. A coroner may also refer a matter to the Criminal Misconduct Commission or a relevant disciplinary body.
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Findings
He forced his way into Hannah’s car when she was leaving her parent’s house to take the children to school. He had with him a container of petrol, a knife and a lighter. He told her to drive. She stopped at the intersection of Durambil and Raven Streets at Camp Hill and decided to turn into that street. It is likely that Baxter poured petrol on her and the three children at that time.
Hannah saw Mr Zemek hosing his car in his driveway and stopped the car. She told him that Baxter had put petrol on her and asked him to call the police. She was screaming. Baxter physically restrained her so that she could not get out of the car by holding her in a bear hug and then he ignited the fuel with a lighter. The car immediately exploded in flames.
The children died almost immediately from inhalation of fumes and burns. Hannah got out of the car and so did Baxter. Mr Zemek extinguished the flames on Hannah and also assisted Baxter to extinguish his burning clothes. Although Baxter was walking around he made no effort to retrieve the children from the car or extinguish the fire. He hindered others who were trying to do so. When the flames in the car had been extinguished sufficiently, Baxter dove back into the car – not for his children (although they had already died) but to retrieve a knife which he then used to stab himself in the heart on the footpath. He died from that wound and his burns.
Hannah died later that day in hospital from burns.
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After Hannah left him and he realised that she had obtained support and did not intend to give in to him and his demands, he began to rally support from friends he had not seen for years and professionals he considered could advance his cause. He received funds and support from a number of friends and family members who believed his lies that Hannah was treating him badly and that he was being victimised by her.
Baxter made numerous appointments for counselling and with doctors. All of these actions were designed to assist him to contest the DVO and get what he wanted from the Family Court process. He did not have any real wish to obtain counselling or address his problems. He manipulated doctors and psychologists.
When Baxter concluded that he had totally lost control over Hannah he killed her and her three children. He planned the deaths in the days prior.
Baxter understood the extent of the atrocities he had committed. He did not want to live with the public denunciation and punishment he would receive so, when he was sure his plan had been carried out, he killed himself in a final act of cowardice.
Baxter’s actions affected not only family and friends but those who were forced to witness the horrendous outcome of his actions.
Persons who lived in the street where the killings took place and those passing by who stopped to assist have been irrevocably affected. Those people did all they could to assist Hannah (and Baxter).
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He considered the safety and well being of the public and junior police officers by limiting their exposure to trauma as much as possible and keeping them away from Hannah and the children in the car. He set up a crime scene to protect evidence. He obtained a comprehensive statement which would have been indispensable had Baxter lived and been prosecuted. His professionalism in the face of horror is highly commendable.
The majority of the statements provided by friends and associates of Hannah and Baxter provide an insight into the controlling nature of Baxter’s personality and how it led to the deaths. However, it is of great concern and reflective of the attitudes that continue to pervade our community that even after Baxter had killed Hannah and the children, a number of his friends and associates (both men and women) gave statements to police in which they stated that Baxter loved his wife and children, he was a great father and that his actions were somehow excused or explained by the fact that he was “losing everything”, he was victimised by the process and that Hannah should not have kept his children from him. The inescapable fact is that, Hannah, who knew him best, was initially in favour of him having contact with the children but became fearful for their safety as she (correctly) perceived that he was becoming more dangerous. Even when Hannah was extremely fearful of him she continued to facilitate safe contact between Baxter and the children via Facetime.
Hannah’s expressions of fear were not concocted to assist her in the custody process (as was alleged by some of Baxter’s friends). Her fears were genuine and realistic and ultimately confirmed in the very worst way.
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QPS response
There were missed opportunities to hold Baxter accountable for his actions – for example, he was not charged and put on bail for the breach of the DVO and the assault occasioning bodily harm but given a NTA for the breach and a common assault. However, overall, I find that Hannah was dealt with appropriately by the police officers with whom she had contact.
Senior Constable Kent is to be commended for her dealings with Hannah. She identified that Hannah was a victim of DV when Hannah had not recognised that herself and did everything she reasonably could to protect and assist Hannah. She supported Hannah at a time when Hannah needed professional support.
At the inquest it was put to Sergeant Rolf that he completed the DVPAF on 31 January 2020. He denied that he did so. He was cross examined strenuously on that point. Further information confirmed that, in fact, Sergeant Rolf did not complete the DV-PAF and his evidence on that issue was true and correct. It is regrettable that his honesty and integrity were questioned during his evidence.
Training
Although QPS has introduced new roles of DV Co-ordinators and a policy of auditing DV incidents, it is uncertain how effective these new roles can be when the officers are auditing information input by front line officers who are not adequately trained to obtain relevant information.
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The majority of front-line police officers who are dealing with DV constantly and who are responsible for assessing risk and gathering the information on which the “specialist” officers audit their decisions had, at the time of this inquest, received one online “refresher” training program in the last five years.
I am satisfied that Mr Leavers is an expert in how DV incidents are impacting police officers and its effect on policing in Qld. I agree with him that immediate comprehensive training is urgently required to bring all police officers up to date with amendments to DV legislation and the latest studies in relation to identification and policing of DV and that annual refresher training is then required.
Acting Inspector Martain said that the “gold standard” of policing would be a multi-disciplinary team of police, social workers, child safety workers etc who could properly assess the risk of harm to victims of DV including children. Mr Leavers agreed that a multidisciplinary team approach to DV is required.
Service System Contacts
It is clear that there is a significant lack of counselling, programmes and support for perpetrators. However, in this case, I am satisfied that, even had it been available, Baxter was not interested in engaging unless it furthered his cause i.e. unless his engagement would result in Hannah agreeing to his wishes.
Hannah was spoken to by DV services and the services provided to her were adequate and appropriate, however, there was a failure by all agencies to recognise her extreme risk of lethality – probably due to the fact that Baxter had not been physically violent, had no relevant criminal history and it was considered that she had the support of family. There was a failure to recognise the risk of intimate Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 159 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
partner homicide which results from separation in a coercive controlling relationship.
Risk to the Children
I find that there was no real assessment of risk of harm to the children by QPS or Child Safety Officers – the only assessment was that Hannah was able to care for them.
The Women’s Safety and Justice Taskforce released its first report in December 2021, which made far-reaching recommendations to improve responses to coercive control in Queensland, did not specifically consider the risks to children in the context of domestic and family violence.
The Domestic and Family Violence Death Review and Advisory Board (DFVDRAB), chaired by the State Coroner, is responsible for the systemic review of DV deaths in Qld. The establishment of the board was a key recommendation from the “Not Now, Not Ever” report. The Board’s functions include:
• Analyse data and apply research to identify patterns, trends and risk factors relating to DV deaths in Qld;
• Conduct research to prevent these types of deaths;
• Write reports to identify key lessons and elements of good practice in preventing DV deaths in Qld;
• Make recommendations to the minister about improving legislation, policies, practices, services, training, resources and communication to prevent or reduce the likelihood of DV deaths in Qld.
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The DFVDRAB has however made multiple recommendations to improve the way systems and services understand and respond to the risks to children in the context of domestic and family violence since its establishment.
For example, in 2017-18, the DFVDRAB recommended that the Queensland Government consider what services or programs are available to support children who witness or experience domestic and family violence, with a view to expanding their availability and accessibility. This recommendation was accepted in principle, and, according to the most recent implementation update (September 2021), the Department of Justice and Attorney General has undertaken a review of current investment to identify programs funded and available to support families and specifically children and young people who experience domestic and family violence.
The DFVDRAB also recommended in 2018-19 that the (former) Department of Child Safety, Youth and Women amend the Common Risk Assessment and Safety Framework (CRASF) to incorporate evidence-based questions that specifically assess for risks to children exposed to domestic and family violence64. This recommendation was accepted in principle and in September 2021 the Department of Justice and Attorney General provided an update indicating the CRASF had been re-evaluated to consider diverse populations including children. According to the implementation update, the revised CRASF was expected to be implemented in early 2022.
In this case the Department of Child Safety assessed only whether the children had a parent who was willing and able to care for them.
They obviously did have such a parent in Hannah, however, the assessment did not go further to assess the risk they faced from their father and how Hannah could be assisted to protect her children.
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Recommendations
I have been much assisted by the considered and reasonable submissions of the parties.
I accept that the QPS continues to attempt to address the ever increasing demands associated with the scourge of DV and its training programmes and resources have been severely impacted by the global pandemic.
The Women’s Safety and Justice Taskforce report which was released this year contained 89 recommendations. The Queensland government has recently agreed to implement all recommendations and has commenced an inquiry to examine the widespread cultural issues within the Queensland Police Service. Whilst this inquest has reinforced the need for those recommendations to be implemented my role is narrower – it is to make recommendations in relation to the specific circumstances surrounding the deaths of Hannah and her children. It has become clear that certain matters require immediate attention in order to attempt to prevent similar deaths occurring in the future and in that regard I make the following recommendations:
The Qld government fund QPS to provide a five day face to face DV training program for all specialist DV police officers as a matter of urgency;
The QPS include in the annual Operational Skills Training a face to face module on DV which is mandatory for all police officers;
The Qld Government provide funding to trial a multi-disciplinary specialist domestic violence police station for a period of 12 months (preferably in the Logan or Kirwan district which have Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 162 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
the highest numbers of DV incidents) and the station includes at least the following: a. Specialist DV police officer/s including a detective to investigate criminal offences; b. Specialist DV support worker; c. A child safety officer from Department of Child Safety to assess risk of harm to children of families impacted by
DV; d. An employee from Qld Department of Housing to provide advice and assistance on accommodation for victims; e. an employee from Qld Health to assess mental health, drug and alcohol issues and the wellbeing of children; f. a lawyer to provide legal advice to police and victims.
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Findings required by s. 45 Identity of the deceased – Hannah Ashlie Clarke, Aaliyah Anne Baxter, Laianah Grace Baxter, Trey Rowan Baxter and Rowan Charles Baxter.
How they died – Hannah died from multi-organ failure due to or as a consequence of the effects of fire, inflicted on her by Rowan Baxter when he entered the car being driven by her, doused her in petrol and set her alight.
Aaliyah, Laianah and Trey died from the effects of fire, inflicted upon them by Rowan Baxter when he entered the car they were seated in, doused them in petrol and set them alight.
Rowan Baxter died from a self-inflicted stab wound to the chest with burns as a significant contributing condition.
Place of death – Hannah Clarke: Royal Brisbane Women's Hospital
HERSTON QLD 4006 AUSTRALIA Rowan, Aaliyah, Laianah and Trey Baxter: Raven Street, CAMP HILL, QLD 4152
AUSTRALIA Date of death– Hannah – 5.40pm 19 February 2020 Baxter – 9.14am 19 February 2020 Aaliyah, Laianah and Trey – approximately 8.25am 19 February 2020 Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 164 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
Cause of death – Hannah died from multi-organ failure due to or as a consequence of the effects of fire.
Aaliyah, Laianah and Trey died from the effects of fire.
Baxter died from a self-inflicted stab wound to the chest with burns as a significant contributing condition.
I am grateful for the assistance of my counsels assisting, the assistance of all of the counsel and solicitors who appeared at the inquest and those who generously shared their expertise and knowledge.
I close the inquest.
Jane Bentley Coroner
BRISBANE Findings of the inquest into the deaths of Hannah Clarke, Aaliyah Baxter, Page 165 of 165 Laianah Baxter, Trey Baxter and Rowan Baxter
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