Jack - Non-inquest findings

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

JURISDICTION: BRISBANE DATE: 12/07/2022 FILE NO(s): 2018/1832 FINDINGS OF: Ainslie Kirkegaard, Acting Brisbane Coroner CATCHWORDS: CORONERS: domestic and family violence related death; high risk and recidivist perpetrators; female perpetrated intimate partner homicide; ‘violent resistance’; intimate partner homicide lethality risk factors; policing response to domestic and family violence incidents; Community Corrections; information sharing; trauma informed service delivery; problematic substance use; perpetrator accountability; men’s behavioural change programs; section 304B Criminal Code; Domestic and Family Violence Death Review & Advisory Board

1. Jack was a 41 year old unemployed man who was fatally injured during a domestic disturbance on 23 April 2018. He had been living with his partner Sally on and off over the preceding six to eight months.

2. Jack’s death was reported to the coroner because he died from serious injuries.

Relationship history

3. Jack and Sally commenced a relationship in November 2017 and were together for approximately six months prior to his death. The couple had no children together though both had children from prior relationships. Sally was the primary carer of her 12-year-old son and four-year-old daughter from previous relationships. It appears Jack had no fixed address but primarily lived with Sally and her children during their relationship.

4. Records and witness statements indicate the relationship was characterised by domestic and family violence since its early stages, primarily consisting of verbal, emotional and financial abuse perpetrated by Jack toward Sally. There is some indication Jack was also physically abusive. Sally’s former partner had noticed Sally had a large scratch across her cheek around four months prior to Jack’s death. When he asked Sally what had happened, she told him that ‘Jack was violent towards her as he was accusing her of sleeping around and that he had hit her.’ It appears Sally had tried to separate from Jack on at least two occasions due to episodes of domestic and family violence.

5. At the time of Jack’s death, there was a protection order in place prohibiting Jack (respondent) from attending Sally’s (aggrieved) address, except with her written permission. This order was made by way of police application on 26 November 2017 following an incident in which Jack smashed a glass and then followed Sally home from the local pub and refused to leave. In total, police attended three domestic and family violence related occurrences between November 2017 and April 2018. Sally was identified as the aggrieved on each occasion.

6. Prior to their relationship, Jack and Sally both had extensive service system contact in relation to domestic and family violence. Extensive patterns of domestic and family violence can be observed across multiple intimate partner relationships for both Jack and Sally. In his prior relationships, Jack was the primary perpetrator of domestic and family violence, and his violence was significant. Jack exhibited numerous behaviours across his relationships that are known indicators of domestic and family violence lethality including threats to kill a prior partner, children and pets; threats with weapons (knives); non-lethal strangulation; obsessiveness; extreme sexual jealousy; and escalating post-separation violence. According to the available records, Sally was the primary victim of domestic and family violence across at least three prior relationships. While Sally also used violence within her intimate relationships, records indicate that Sally’s behaviour primarily related to name calling/verbal abuse or physical violence in retaliation, self-defence or in defence of her children.

Service system contact during Jack and Sally’s relationship

7. Jack and Sally both had extensive contact with formal services in relation to domestic and family violence, physical and/or mental health issues, harmful substance use, and criminal offending (Jack only) over the course of their relationship.

8. Jack had an extensive criminal history relating to drug and property offences, as well as for violent offences outside of the family. In the years before his death, he had extensive contact with Queensland Corrective Services having spent various periods of time in custody or on non-custodial sentencing orders for domestic and family violence and other criminal offences.

9. On 26 November 2017, Sally called police stating that Jack was refusing to leave her address.

On arrival, police officers observed Jack drinking alcohol and he was also under the influence Findings into the death of Jack

of methylamphetamine. Sally and Jack began to argue in front of police, at which point they were separated. Sally reported that she and Jack had been in a relationship for two to three weeks but were no longer together. It appears that Sally had ended the relationship earlier that evening.

10. According to the police occurrence, Sally said she and Jack had been at the local pub when she ‘had a go’ at Jack or looking at another girl. Jack became angry and smashed a glass on the floor in front of her. Sally then left and returned home but Jack arrived a short time later and ‘became aggressive’ toward Sally because another man was there. Sally asked Jack to leave but he refused to do so. The police occurrence indicates Sally was scared of Jack’s behaviour and, in apparent recognition of Jack’s risk to Sally, police undertook immediate action to protect her by removing Jack from the property and applying for a protection order prohibiting Jack from having any further contact with Sally. This was an example of a highquality police response to the domestic and family violence risk at this point in time, where police recognised Jack’s elevated risk to Sally and responded appropriately.

11. On 30 November 2017, a five-year protection order was granted by the Magistrates Court prohibiting Jack from having any contact with Sally or attending her residence. The order was varied two weeks later on 13 December 2017 to prohibit Jack from attending Sally’s residence, except with her written permission. It appears Sally applied to vary the order as she wanted to continue the relationship because Jack had agreed to seek help for his harmful substance use.

12. On 6 January 2018, Sally contacted police stating that over the past two days, Jack ‘has attended her residence without her permission and that the defendant [Jack] won’t stop coming around.’ Sally reported that at around 3:40am that morning she was woken by Jack who was in the house. Sally was scared because she knew Jack was intoxicated. Sally yelled at Jack to leave until he eventually did so. Sally told police she was concerned for her safety and that of her children because Jack continually attended the home without her permission. Police subsequently located Jack who participated in a voluntary record of interview. He admitted attending Sally’s address without permission and was charged with contravening the protection order. The transcript of the 000 call records Sally saying that her ‘ex-partner [Jack] just broke into my house for the second time in 24 hours.’ She stated that Jack had broken in through the back door, which she had tried to barricade with a washing machine. He was subsequently granted bail, with additional conditions specifying he was not permitted to have contact with Sally.

13. Approximately a week later Jack breached his bail (unrelated to domestic and family violence) and was remanded into custody. On 30 January 2018 Jack pleaded guilty to contravening the protection order and was sentenced to a community-based order for four months and released from custody. The order required Jack to submit to medical, psychiatric, or psychological assessment and treatment as directed by Community Corrections, and to submit to urinalysis testing and intervention for his use of illicit drugs.

14. On 1 March 2018, witnesses called police after Jack was seen being aggressive on the street where Sally lived. Jack was described as throwing punches in the air and kicking rubbish bins.

Jack repeatedly yelled ‘fuck off’ to police, who then approached Jack and advised him he was under arrest for public nuisance. Jack was aggressive and resisted arrest. Jack was injured during the arrest and transported to hospital where he was discharged the same day.

15. On 26 March 2018, Sally’s 12-year-old son called 000 from a payphone reporting that Sally was being threatened by Jack. According to the transcript of the 000 call, the operator did not seek to clarify the nature of Jack’s threats to Sally, and this was not used to inform the urgency of the police response. On arrival, police officers observed Jack standing on the veranda of his aunt’s home across the road from Sally’s address. He was noted to be intoxicated and had been questioning Sally about ‘spending all the money.’ Sally told police the money was spent on electricity and shoes for her children. Jack had become upset and angry because he wanted the money for himself. Jack then started yelling at Sally who told him to leave, and he did so.

Findings into the death of Jack

According to the police occurrence, Jack produced evidence in writing that Sally had permitted him to have contact with her. Sally’s 12-year-old son was spoken to by police and said he had made a ‘mistake’ calling them. The matter was classified as ‘DV- Other Action’ as ‘Already DV order in place where the couple have recently varied the order to contact after police requested no contact. The agg [Sally] states she is not fearful because when she tells the resp [Jack] to leave he always does.’

16. The following day, 27 March 2018, Jack and Sally were flagged by the relevant police district Vulnerable Persons Unit (VPU) as ‘RCFS [repeat calls for service] Forwarded for the information of your DVLO [Domestic and Family Violence Liaison Officer] and case management by the owning station.’ It is unclear from the records available what case management response (if any) was undertaken by local police to further assess or address Jack’s risk to Sally.

Events leading up to the domestic disturbance on 23 April 2018

17. At around 8:30am on 23 April 2018, Jack walked across the road from Sally’s house to his aunt and cousins. He asked his aunt for some advice. His cousin heard her mother tell Jack to “get off [deidentified] and get away from her.” He then returned to Sally’s house at around 9:15am.

18. At around 12:15pm, an Australia Post employee overhead a verbal argument occurring inside Sally’s house. He approached the address and saw Jack lying in the hallway in a pool of blood.

Sally told him she had stabbed Jack. The postal worker immediately phoned 000 for assistance. When police arrived, they observed Sally to be lying over Jack ‘crying hysterically.’ When the paramedic arrived a short time later, he saw Jack lying on his back in the hallway with his head towards the front door. Sally was leaning over him, crying and cuddling his upper body and kissing his lips. They moved Sally away from Jack and determined he was deceased.

Police asked Sally where the knife was located, and she stated that it was in the bedroom.

Police then seized the knife and arrested Sally. She was taken to the watchhouse where she was breath tested and determined to be under the influence of alcohol.

19. Witnesses told police they heard a lot of noise coming from Sally’s house that morning. At around 7:30am, there was yelling and screaming with Sally heard shouting “get out”. There was a loud argument back and forth between the couple. Witnesses did not think much of it at the time as the couple argued regularly. One witness told police Sally carried a hunting knife wherever she went; it was pinned to her side, and she called it ‘Kitty’.

20. Sally participated in formal police interview the following morning, 24 April 2018. She told police it was only she and Jack in the house. She said they were arguing, and Jack struck her in the face. She couldn’t remember what happened next but was aware Jack needed an ambulance.

Sally was charged with murder.

Post mortem findings

21. Autopsy revealed a single stab wound to the front of the left upper chest just below the collar bone which penetrated a major vein around the shoulder, fractured the second rib, went through the left lung and nicked the inner surface of the left 8th rib. This injury caused bleeding into the left chest cavity. The reach of the stab wound was estimated to be 16cm. Noting the stab wound had penetrated the bony part of a rib, the pathologist estimated a moderate to severe degree of force would have inflicted the stab wound. Toxicological analysis detected a significant level of alcohol and non-lethal levels of methylamphetamine (and its metabolite, amphetamine) and oxycodone. There was also evidence of cannabis use.

22. The pathologist determined the cause of death to be stab injury to the chest.

Findings into the death of Jack

Criminal proceedings

23. Sally pleaded guilty to and was convicted of manslaughter and sentenced to nine years’ imprisonment, eligible for parole after three years and nine months.

24. In sentencing Sally, the Judge took account of Sally’s timely plea of guilty, that Jack had been killed in anger, Sally’s history of alcohol and illicit substance abuse and that her adult relationships had largely been with partners who abused alcohol and illicit drugs, many of whom perpetrated domestic violence against her. The Judge accepted that given Sally’s history of repeated serial domestic violence, there was an increased likelihood of her reacting aggressively when threatened or assaulted by an intimate partner and found that Sally had stabbed Jack after he had pursued her into her home with a degree of aggressive intent and at some time after he had punched or slapped her causing a bruise and some bleeding.

25. The Judge found that: “The fact that you were such a victim of domestic violence as well as a perpetrator of domestic violence is, to my mind, sufficient to enable me to reach the conclusion that it is not reasonable in the present circumstances to treat the fact that your offending was a domestic violence offence as an aggravating feature.”

26. The Judge observed Sally had given six different accounts of the stabbing including assertions Jack had inflicted the injury himself, had armed himself with a knife and that she had hurt him to protect herself, none of which the Judge accepted.

27. Sally appealed her custodial sentence as being manifestly excessive.

28. When considering Sally’s application, the Court of Appeal noted there was evidence of Jack exhibiting irrational jealousy and taking Sally’s money and property during the relationship.

There was evidence that in the month prior to Jack’s death, Sally had told an acquaintance that if Jack continued to accuse her of sleeping with others she would ‘stab him with Kitty and kill him’.

29. The Court of Appeal observed there was no obligation for Sally to provide a comprehensive, detailed account of the events of the stabbing; she had accepted unlawfully causing Jack’s death by stabbing him when she pleaded guilty.

30. While the Court of Appeal determined the sentence of nine years’ imprisonment was appropriate, it brought forward her parole eligibility date by nine months meaning she was now eligible for parole earlier.

Systemic review

31. The broader context in which Sally caused Jack’s death was examined by the Coroners Court of Queensland Domestic and Family Violence Death Review Unit (DFVDRU). This review was informed by expert input from Dr Silke Meyer, the Deputy Director of the Gender and Family Violence Prevention Centre at Monash University. It was also considered by the Domestic and Family Violence Death Review and Advisory Board (the Board) at a meeting examining female perpetrated intimate partner homicides.

32. Sally had a significant history of past abuse experiences, including in at least three former intimate partner relationships in Queensland after she had relocated from another state to escape an abusive partner. She also had a minor criminal history (unrelated to domestic and family violence) associated with her substance use and was unemployed. She had young children from other relationships for whom she was their primary carer.

Findings into the death of Jack

33. Before her relationship with Jack, police attended multiple domestic and family violence related occurrences involving Sally and three of her former intimate partners. The violence perpetrated against her was significant and included:

• multiple physical assaults (including non-lethal strangulation, and assaults perpetrated against Sally while she was holding her infant child);

• threats to kill her and/or her children;

• threats to take her children;

• threats with a weapon (knife);

• verbal abuse;

• emotional abuse; and

• destruction and deprivation of property.

34. On several occasions, Sally called police for help during episodes of domestic and family violence but was assessed to be making ‘vexatious complaints’ against her former partner.

35. On some occasions police identified Sally had used violence toward her former partner, including when she had kicked out at her partner and scratched his face. Records also indicate however that she used violence on this occasion because her partner had threatened to abduct her infant child.

36. In the year preceding Jack’s death, Sally was subjected to concurrent experiences of domestic and family violence perpetrated against her by Jack and a former intimate partner.

37. Over a ten-year period, Jack was named as the respondent in protection orders involving five intimate partners including Sally in Queensland. He frequently breached those orders. He also had prior interstate convictions for domestic and family violence convictions.

38. Jack’s documented history of intimate partner violence was significant and included:

• multiple physical assaults (e.g. slamming his former partner’s head against the ground until she became unconscious);

• non-lethal strangulation;

• verbal and emotional abuse;

• threats to suicide;

• threats to kill the victim, their children, and pets;

• threats with a weapon (knife); and

• destruction or deprivation of the victim’s property.

39. The Board observed that on multiple occasions, Jack’s use of domestic and family violence came to police attention only at the point of separation, indicating a pattern of escalating postseparation abuse across his intimate partner relationships.

40. Jack also had an extensive criminal history for other offending behaviour spanning 20 years, with multiple convictions for drug, property, and violent offences. He had also spent time in custody and under community-based sentencing orders (including for domestic and family violence related offences).

41. In the two years preceding his death, Jack had no fixed address and drifted between the households of current partners, ex-partners and extended family to avoid homelessness.

42. Jack died in the context of domestic and family violence perpetrated primarily by him toward Sally. Although they were only in a relationship for a short time, the violence he perpetrated against Sally was significant and included:

• multiple physical assaults and verbal abuse;

• financial abuse (e.g. stealing money from Sally, leaving her unable to afford her rent);

• emotional abuse; Findings into the death of Jack

• sexual proprietariness (e.g. becoming aggressive and violent if Sally had contact with other men,

• interrogating her and searching for ‘evidence’ of infidelity);

• social isolation; and

• escalating post-separation violence (e.g. breaking into Sally’s home and stalking her).

43. Sally had tried to separate from Jack on at least two occasions because of his violent and controlling behaviours.

44. The abuse perpetrated by Jack towards Sally after the couple had separated was reflective of an ongoing pattern of escalating post-separation violence that he had mirrored across multiple prior relationships; and that this violence was increasing in frequency and severity over time.

45. Jack was well known to Queensland Corrective Services. His mental health, substance use, and domestic and family violence were repeatedly identified as criminogenic needs requiring intervention or monitoring. In particular, the risks associated with his use of alcohol and other drugs were routinely identified by Community Corrections as significant, with problematic substance use noted as a key contributing factor to his use of violence, including domestic and family violence.

46. As a result, Community Corrections staff identified there was an ongoing need to intervene in these areas by:

• monitoring Jack’s relationships;

• addressing his use of domestic and family violence through requiring him to participate in a men’s behavioural change program; and

• engaging in safety planning and treatment to prevent relapse into substance use.

47. While Community Corrections staff explored the opportunity of referring Jack to a men’s behavioural change program for his use of domestic and family violence on three occasions, referrals did not eventuate due to his transience and regional location. Community Corrections staff referred Jack to a psychologist to address his mental health needs. However, Jack failed to engage regularly in treatment as required by his community supervision order, with a lack of enforcement of the conditions on the order.

48. While in custody in January 2018, Jack requested a phone call to Sally’s phone number and while he provided her current address, he listed her as his ‘friend’ and provided a false surname. He further stated that there was no protection order between them, despite an order having been issued the month before and the reason for his incarceration being a breach of this order. Records showed that a few years before, Jack had done the same thing with a previous partner despite there also being a protection order in place listing her as the aggrieved. There was no indication that custodial corrections staff took steps to confirm the presence of a protection order or to independently verify the information provided by Jack on either occasion.

49. While under community supervision in 2018, Jack repeatedly referred to his relationship with Sally in his appointments with Community Corrections and denied any issues. Despite his significant history of domestic and family violence perpetration and ongoing assessments which indicated that Jack’s relationships required constant monitoring, corrections staff appeared to take his comments at face value. There was no indication that police informed Community Corrections about the incident on 26 March 2018, despite it being noted in police records that Jack was subject to community supervision. Nor did it appear that that Community Corrections staff undertook collateral checks with police to confirm Jack’s self-reported adherence to the protection order.

50. Jack had begun to engage in psychological support in the year preceding his death as mandated by Community Corrections. He frequently missed appointments, in part due to a Findings into the death of Jack

lack of transport, but he also changed psychologists as the first one stopped servicing the area where he lived.

51. Prior to his death, Jack attended several appointments with the second psychologist. Domestic and family violence was not raised until his fourth appointment, despite this being identified as a key problem in the referral from Community Corrections. At that appointment, Jack disclosed being in a relationship with Sally and self-reported having breached the protection order listing Sally as the aggrieved (which had been in place for three months). Despite this disclosure and that the psychologist was informed by Community Corrections about Jack’s prior history of domestic and family violence perpetration, there is no indication the psychologist further explored Jack’s relationship with Sally or conducted any risk or safety screening. The psychologist’s notes document Jack as being ‘protective’ of Sally.

52. The psychologist reported back to Community Corrections that Jack was engaging well in treatment focused on his relationships. This was the last time Jack attended an appointment with this psychologist, as he failed to attend the next appointment reportedly because as he had no mobile, he did not receive a reminder text from Community Corrections. Records show Jack advised Community Corrections that he could be reached on Sally’s phone, this suggesting their relationship was ongoing.

53. Both Jack and Sally had multiple contacts with health services regarding mental and/or physical health issues associated with their substance abuse. There was no routine screening for domestic and family violence or biopsychosocial assessments undertaken in respect of either.

54. The Board’s examination identified at least 20 intimate partner homicide lethality risk factors were present at the time of Jack’s death, many of which were known to formal support services: 1.History of domestic and family violence 2.History of violence outside of the family by perpetrator 3.Prior threats to commit suicide by perpetrator 4.Escalation of violence 5.Obsessive behaviour displayed by perpetrator 6.De facto relationship 7.Presence of stepchildren in the home 8.Controlled most or all of victim’s daily activities 9.Prior destruction or deprivation of victim’s property 10.Actual or pending separation 11.Excessive alcohol and/or drug use by perpetrator 12.Perpetrator unemployed 13.Extreme minimization and/or denial of spousal assault history 14.Depression – in the opinion of family/ friend/ acquaintance - perpetrator 15.Other mental health or psychiatric problems - perpetrator 16.Failure to comply with authority - perpetrator 17.After risk assessment, perpetrator had access to victim 18.Sexual jealousy - perpetrator 19.Victim’s intuitive sense of fear of perpetrator 20.Perpetrator threatened and/or harmed children.

55. The Board noted the presence of so many risk factors indicated that Jack posed an ongoing and significant risk to Sally throughout their relationship up until the time of his death.

56. The Board’s examination identified the following themes and service system issues arising from the circumstances surrounding Jack’s death:

• Sally’s complex experiences of trauma and victimisation over her life course, and its association with her problematic substance use and other mental health concerns, meant that Sally did not present as an ‘ideal victim’ to police or other services; Findings into the death of Jack

• Jack displayed an ongoing pattern of high risk domestic and family violence, including multiple indicators of lethality across relationships, and his trajectory of violence was escalating before he commenced a relationship with Sally;

• in the two years preceding Jack’s death, he had contact with multiple services in relation to domestic and family violence, mental health issues, and criminal offending including contact with police, court services, corrections, health, and mental health services. Overall, services worked in isolation from one another and failed to examine Jack’s past use of violence and consider this in the context of the risk he represented to Sally; and

• service responses were largely symptomatic and focused on the immediate presenting issue rather than the underlying causal factors. For example, police responded to each report of domestic and family violence in isolation, rather than identifying an escalating pattern of behaviour.

57. The Board acknowledged the work currently being undertaken by the Queensland Government to create a shared language of common risk and perpetrator accountability, such as through the implementation of the Queensland Common Risk and Safety Framework and the HighRisk Teams (HRT). The Queensland Government has also undertaken legislative and policy reforms to empower government and non-government agencies to exchange information to improve responses to domestic and family violence.

58. However, the Board questioned whether more needs to be done to ensure agencies are sharing information appropriately for cases that may not meet the threshold for a referral to a HRT or are outside HRT locations to ensure that all agencies are better equipped to identify and respond to domestic and family violence.

59. The Board also questioned whether more could be done to maintain visibility of high-risk and recidivist perpetrators of domestic and family violence when they enter into new relationships or move to different service areas. Jack had a significant and documented history of serious violence in prior intimate relationships and while this information was visible to the services engaged with him, there were indications that when he relocated across districts, services appeared to ‘start again’ in their assessment of his risk. Services also failed to examine Jack’s past use of violence in earlier relationships and to consider this in the context of the risk he represented to new partners, including Sally. He represented a sustained and extreme risk to his intimate partners over time.

60. The Board considered the circumstances surrounding Jack’s death highlighted the importance of holistic and proactive service system responses to address immediate safety concerns, as well as to better respond to underlying issues that may contribute to an elevated risk of future violence perpetration or victimisation over the life course.

61. I note that in its 2019-20 Annual Report the Board made a number of recommendations relevant to the circumstances in which Jack died which have been accepted by the Queensland Government. This includes that a review be conducted of all domestic and family violence training delivered to frontline services who may come into contact with victims and their children or perpetrators of domestic and family violence, with a focus on identifying opportunities to embed trauma-awareness and trauma-informed service delivery.

62. The Board also considered use of the legal defence of killing for preservation in an abusive relationship which provides a partial defence in cases where a victim of domestic and family violence kills their abuser. The legal provision, section 304B of the Criminal Code, introduced in Queensland in 2010, operates such that the person who they have killed must have committed acts of serious domestic violence against them in an abusive domestic relationship and the person must have a reasonable belief that it is necessary to kill to preserve themself from death or grievous bodily harm. There must be reasonable grounds for the belief having regard to the abusive domestic relationship and all the circumstances of the case. The defence Findings into the death of Jack

reduces murder to manslaughter; it is not a full defence like self-defence which can result in no criminal liability and no punishment.

63. The Board expressed concern that the defence may not be operating as intended and that the operation of self defence to the particular circumstances of domestic homicide may also be in need of review. Its concern in respect of section 304B is that victims of domestic violence might be pleading guilty to manslaughter where self-defence is raised, as they do not wish to run the risk of a murder conviction, carrying mandatory life imprisonment, at trial.

64. I note this issue was recently examined by the Women’s Safety and Justice Taskforce, which was established to examine coercive control, including whether there was a need for a standalone offence, and the experiences of women across the criminal justice system more broadly.

65. The Taskforce’s First Report, Hear Her Voice (2021) noted that ‘It is clear that evidence of coercive control is not always being used by lawyers as part of a defence or excuse or as a mitigating factor on sentence. When lawyers don’t have an up-to-date and accurate understanding of domestic violence and coercive control, they cannot effectively represent the interests of their clients, especially domestic violence victims who have killed their perpetrators.

In some cases, the defence of self-defence may have been available to these victims. It is apparent to the Taskforce that the presently available defences and excuses do not reflect current knowledge about the effects of domestic and family violence and coercive control and the damaging impact these have on victims over time.’

66. In addition to making a number of recommendations that aim to improve legal practitioners’ understanding of domestic and family violence and coercive control, the Taskforce also recommended that an independent review of defences and excuses in relation to homicide, including the operation of section 304B be conducted to assess the adequacy of existing laws and whether amendments or the repeal of provisions is required. While this recommendation has been supported in principle by the Queensland Government, the actual implementation approach remains under consideration.

67. The Board also considered the lack of access to behaviour change programs in Queensland.

In this regard, I note Taskforce also recognised the need to design, establish and adequately resource a state-wide network of perpetrator intervention programs in Queensland after identifying concerns with their availability, accessibility and appropriateness. This builds on multiple previous recommendations made by the Board in previous Annual Reports which have highlighted the need to improve system responses to perpetrators of domestic and family violence to better address their support needs and help disrupt entrenched patterns of violence perpetration.

68. In its 2020-21 Annual Report, the Board also recommended that the Queensland Government explore trauma informed options to improve the accessibility, availability and acceptability of longer-term supports for victims and their children beyond the point of crisis, to help them rebuild their lives. By doing so it also recognised that there is a corresponding need to consider the longer term support needs of perpetrators of domestic and family violence to embed ongoing behavioural change and improve protective outcomes for victims and their children. I understand the Queensland Government is yet to respond to this recommendation.

69. The DFVDRU review also noted police considered Sally to be at risk one month before the homicide. On 24 March 2018, Jack and Sally were flagged by the relevant District Vulnerable Persons Unit as repeat call for service clients and were referred to the local station for information and ‘case management’. It is unclear from the records available what case management response (if any) were undertaken by local police to further assess or address Jack’s risk to Sally. This raised questions about the purpose of these flags and the effectiveness of the Queensland Police Service internal oversight process regarding the adequacy of responses to domestic and family violence episodes (whereby outcomes of Findings into the death of Jack

investigations and occurrences are reviewed by more senior officers). As at June 2022, the QPS Operational Procedures Manual (OPM) does not appear to provide clear guidelines with respect to the management of repeated domestic violence calls for service. It was noted that [location] was staffed by two police officers which this may have impacted on the ability of police to complete proactive actions to manage the domestic and family violence risk.

70. However, I note the Taskforce made a suite of recommendations in their First Report which seeks to build on current activities already underway to improve policing responses to domestic and family violence across Queensland, with a high number of submissions received calling for change in the approach taken by the police. This includes recommendations that seek to enact transformational change across the Queensland Police Service, build specialist expertise, deliver evidence-based and trauma-informed training, and improve risk assessment processes.

71. Further, I acknowledge the recent establishment of the Independent Commission of Inquiry into Queensland Police Service responses to domestic and family violence as recommended by the Taskforce.

Findings required by s.45 Identity of the deceased – [deidenitied] How he died – Jack died during a domestic disturbance between him and his partner Sally which culminated in Sally fatally stabbing Jack in the chest with a large knife. Sally subsequently pleaded guilty to and was convicted of manslaughter and sentenced to nine years’ imprisonment, eligible for parole after three years. The couple had been in a short relationship characterised by ongoing domestic and family violence primarily perpetrated by Jack toward Sally in respect of which police had obtained a five-year domestic and family violence protection order preventing Jack from attending Sally’s residence, except with her written permission. He breached that order just over a month later. In the months preceding his death, Jack pleaded guilty to breaching the protection order and was sentenced to a community-based order for four months. While under community supervision Jack’s perpetration of domestic and family violence toward Sally came to police attention twice during the two months preceding his death. While the second incident appears to have led to the couple being flagged by the relevant police district Vulnerable Persons Unit as repeat calls for service requiring local case management, there is no evidence of any local case management response by police in the month leading up to the fatal incident on 23 April 2018.

Systemic review of the broader context in which Jack died has identified many factors common to the context in which victims of domestic and family violence may kill their abusive male partners. It has also identified multiple missed opportunities by the formal services including the Queensland Police Service and Queensland Corrective Services involved with the couple, particularly Jack, during their short relationship, to have responded holistically and proactively to assess and address both immediate safety concerns and also better respond to underlying issues contributing to the escalating risk of violence perpetration by Jack toward Sally.

Jack and Sally’s relationship demonstrated the different way in which men and women use physical violence within their intimate partner relationships; women are more likely to use violence in self-defence and in the context of violence being perpetrated towards them. This is known as violent resistance. It can result in services perceiving victims to be ‘the problem’ meaning that victims may be less likely to receive the assistance they need. It can also result in criminal justice system contact that may compound the perception of the victim as ‘the problem’. This is why it is critically important that the person most in need of protection, and Findings into the death of Jack

the person most likely to inflict harm, are correctly identified at every point of contact with formal services.

In its 2020-21 Annual Report, the Domestic and Family Violence Death Review Board again noted issues around the misidentification of the person most in need of protection in cases where the primary female victim had used resistive violence in self-defence or for selfprotection. The Board made a number of evidence informed recommendations including the creation of clear guidance for police and courts, that consideration be given to the need for potential legislative amendments to strengthen existing provisions, as well as the development of a triage and case management approach for domestic and family violence related cases before the courts to identify those that are complex, high risk or that involve cross applications for protection orders. These issues were similarly considered by the Women’s Safety and Justice Taskforce who made additional recommendations for change in this area in alignment with those made by the Board.

Place of death – [deidentified] Date of death– 23/04/2018 Cause of death – 1(a) Stab wound to the chest I close the investigations.

Ainslie Kirkegaard Acting Brisbane Coroner

CORONERS COURT OF QUEENSLAND 17 June 2022 Findings into the death of Jack