Finding into death of MF

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 20094238

REDACTED FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, JUDGE IAN L. GRAY, State Coroner having investigated the death of MF

without holding an inquest:

find that the identity of the deceased was MF born on 20 July 1980

and the death occurred on 30 August 2009

at Narre Warren 3805

from:

1 (a) Multiple stab wounds to the neck

Pursuant to section 67(2) of the Coroners Act 2008, J make findings with respect to the following

circumstances: Summary of Circumstances and Fatal Incident

1. MF was born in the Rodrigues Islands, part of Mauritius, on 20 July 1980. She met her husband in 2002 when he was visiting the Island for a holiday with his parents. The couple married in 2004, MF moved to Australia and together had one child. MF dicd on 30 August 2009 after her husband stabbed her 12 times in the neck in their Narre Warren home. At least

some of the attack was witnessed by their child.

Focus and Scope of Investigation

2. The unexpected and violent death of a person is a devastating event. Violence perpetrated by an intimate. partner or family member is particularly shocking given the family unit is

expected to be a place of safety and protection.

3. In this finding I will explore whether any lessons can be learnt, which might prevent similar

deaths in the future. This role is one of two parallel functions of the modern coronial system.

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The first involves the findings that I must make under the Coroners Act 2008 (Vic), which requires, if possible, that I find the:

• identity of the person who has died

• cause of death (for our purposes this usually refers to the medical cause of the death) and

• circumstances surrounding the death.

4. It is the investigation I am permitted to conduct surrounding the circumstances of a death that gives rise to my ability to consider broader issues of public health and safety. These considerations form the second parallel purpose of a coronial investigation into a death. This purpose has been enshrined in the Preamble of the Coroners Act 2008 (Vic), which sets out

that the role of the coroncr should be to:

• contribute to the reduction of the number of preventable deaths and

• promote public health and safety and the administration of justice.

INVESTIGATIONS .

Forensic Medical and Scientific Investigation

5. Dr Melissa Baker, Forensic Pathologist at the Victorian Institute of Forensic Medicine (VIFM), performed an autopsy and formulated the medical cause of death as Multiple Stab Wounds to the Neck, which I accept.

Criminal Investigation

6. MF’s husband was charged with, and pleaded guilty to, the murder of MF. On 8 June 2010, he

was convicted and sentenced to 19 years’ imprisonment with a non-parole period of 16 years.

Specialist Family Violence Investigation

7. Leading Senior Constable Martin McClean prepared a brief of evidence on the circumstances surrounding the death of MF. Following a review of this evidence, I requested the Coroners Prevention Unit (CPU)' to examine MF’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD)*.

' The Coroners Prevention Unit is a specialist service for Coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety.

? The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition, the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focussed recommendations aimed at reducing the incidence of family violence in the Victorian community.

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The CPU identified the presence of two risk factors known to increase the risk of fatal family violence between intimate partners: pending separation and history of family violence.’ In addition, the CPU identificd service contacts initiated by MF proximate to her death where she

disclosed her exposure to family violence: to Victoria Police and hcr General Practitioner.

Pending Separation between MF and her Husband

A factor relevant to MF’s death appears to have been her interest in a man named ‘Dino’ with whom she was communicating via Facebook. The day before the fatal event, MF and her husband had spoken to a marriage counsellor. During this session, it was reportedly discussed.

that MF would meet Dino in order to determine if there was a future to the relationship.

Subsequent to the appointment, she had also changed her Facebook status to reflect her maiden name. It appears that separation between the couple was possible, which has been

identified as a high-risk period for intimate-partner homicide.

Evidence of History of Family Violence in MF and her Husband’s Relationship

10. The family interaction between MF, her husband, and her husband’s parents, involved

considerable conflict in the ycars lcading up to the fatal event. In connection to MF and her husband’s relationship, difficulties were reported from 2005. There was evidence of a cycle of violence that involved MF’s husband becoming increasingly threatening and frightening, leading MF to seek assistance from friends, Victoria Police and other external service providers. Various stressors were identified that may have exacerbated her husband’s family violence behaviour, including owing money to his father, being a victim of family violence

during his own childhood and self-reported mental health difficulties.

According to the evidence of MF’s step-cousin, in the wecks preceding the fatal event, MF’s husband had allegedly stated to his mother that he was going to kill MF and the couple’s fouryear-old child. MF contacted hcr step-cousin and requested that she come to the house and collect her. MF attended Dandenong Poliec Station to report her concerns and was advised that police could not do anything unless the threats continued. Her step-cousin also stated that MF was advised that she could obtain assistance from Hanover House. The following day, MF’s husband reportedly apologised for his behaviour, stated that he had a problem, and a

reconciliation occurred.

3 Aldridge, M.L., Browne, K.D, 2003. Perpetrator of Spousal Homicide. Trauma, Violence and Abuse. 4(3):265 - 276,

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Contact with Victoria Police

There were five Victoria Police Law Enforcement Assistance Program (LEAP) entrics recorded for MF, each regarding family violonce. On 6 November 2005, Victoria Police attended a verbal dispute between MF and her husband. This reportedly involved a disagreement over her husband’s father. No violence, alcohol, or property damage were noted

and police did not have concerns for the parties’ welfare.

On 9 April 2006, MF phoned emergency services regarding a verbal argument between herself and her husband. MF ended the emergency services call, which was then traced. Police described MF as teary and upset, but no physical violence was apparent. LEAP records note that MF’s husband had epilepsy and mood changes. The police narrative describes the

incident as ‘relatively minor’ and records that police provided MF with an informal referral.

On 22 November 2007, MF and her husband attended a horror movie together, during which it is alleged that her husband stated to MF that he wanted to kill her in a manner depicted in the movie, When they arrived home, her husband left the house for a period and MF contacted police. Her husband returned while police were at the residence. Police described MF’s husband as cooperative and understanding, and noted that MF changed her position from being scared to stating she did not want police to take action. However, police charged her husband with making threats to kill and he was bailed to attended court on 29 November

2007. On 28 November 2007, LEAP records indicate MF contacted police and stated that

further action was unnecessary, as she was not concerned for her welfare and did not want a court order, When the complaint was heard on 4 December 2007, MF attended court and stated that she had overreacted and did not want the order. Subsequently, the matter was

struck out.

On 29 August 2009, the day before she was killed, MF contacted emergency services and requested police attend their home. MF was calm in her opening conversation with the emergency services operator. She stated that she wanted police assistance as there was a problem in her relationship and her husband was accusing her of having an affair. She added

that she wanted her husband to leave the house and that he needed anger management.

MF then asked the operator to wait a moment and was heard speaking to her husband. It appears that he obtained a knife, as MF was heard saying ‘stop being like this,’ and then more urgently, ‘he’s putting a knife to his neck now, he says he’s going to kill me now’. MF’s

husband then took the phone and spoke with the operator for a few seconds. He was

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immediately instructed to put MF back on the phone, and did so. The operator had a further conversation with MF, asking her if her husband had taken any drugs and if there were any court orders in placc. MF expressed the difficultics in her relationship, but was not overtly panicked. Victoria Police were requested to attend the home and was assigned ‘Priority One’

status,

Constable Abbass and Constable Vasiliu arrived at the home and observed no signs of a disturbance.* MF’s husband greeted them at the door and was described as ‘calm and welcoming’. MF and her husband were separated, and Constable Abbass spoke to MF, He requested to see her child and observed him to be watching television in a bedroom. Constable Abbass stated that he asked MF some gencral questions about her marriage and why she had contacted police. She stated that she wanted police to tell her husband she was not having an affair. Constable Abbass directly raised the issue of a knife with her, however she reportedly denied having been threatened with a knife in this way. She advised that she was unhappy in her marriage, and when questioned if she had tricd counselling, stated that she and her husband were attending an appointment later that day. Constable Abbass stated that he did not

detect any fear in MF’s demeanour.

Constable Vasiliu spoke with MF’s husband, and was advised that MF had becn corresponding with another male over the internet. Constable Vasiliu asked him why MF had.

called police, and he stated that it was to prove to him that she was not having an affair.

Constable Vasiliu also questioned MF’s husband regarding knives. MF’s husband stated that

there were knives in the kitchen drawer, but denied threatening MF with them.

The statement of Constable Abbass indicates that he encouraged both MF and her husband to

attend marriage counsclling if they wanted to maintain their relationship. Constable Abbass also explained the intervention order application process if counselling was unsuccessful. MF and her husband told Constable Abbass that they were aware of the intervention order proccss.

Constable Vasiliu described both parties as being calm and cooperative, and stated their accounts of the incident were consistent. Constables Abbass and Vasiliu subsequently determined that the incident was not family violencc-rclated and communicated via radio that

“both parties (were) calm, in regard to the knife it was a threat only, nil sighted’?

Police did not complete a Victoria Police Family Violence Risk Assessment and Risk

Management Report (L17), which appears to have been an oversight in accordance with the

• Statements of Constable Abbass Inquest Brief, p.117.

5 17,3 of audio file of Radio communications.

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‘Victoria Police Code of Practice for the Investigation of Family Violence." A Victoria Police Ethical Standards Department (ESD) investigation into this incident acknowledged that police members attending the home on 29 August 2009 did not complete the Form L17 as required.

It is not open to conclude that failure to complete and submit the Form L17 was causally connected to MF’s death. However, J note the importance of this process as it allows for the collection of information, identification of risk factors, assessing the risk to victims and providing a record of violent incidents. It is also possible that some of the immediate risk factors pertaining to MF’s situation would have been afforded greater significance. Similarly, the provision of referral information to a family violence service or Mcn’s Referral Scrvice

could have been an opportunity to receive specialist assistance.

It is important to note that in this caso, despite Form L17 not being completed and submitted, Victoria Police members did assess risk, and indecd their statements reflect that attention was given to a range of factors described in the Victoria Police policy and procedural framework.

This included directly asking. MF about the threat with the knife, observing her level of fear

and asking her if there had been previous violence.

Contact with General Practitioner

MF’s medical records were obtained from her two most recent General Practitioners. A review of thesc records revealed disclosures of family violence and evidence of many of the generalised symptoms associated with women experiencing family violence who present in general practice settings, These include feeling tired, dizzy, having trouble sleeping, and

recurrent back pain.°

On 22 December 2008, MF presented to her Gencral Practitioner and expressed feeling stressed, weak and down. During this consultation, she stated thc she was experiencing problems with her father-in-law, and that he had threatened to use his mafia links to kill her and her husband. It is noted ‘had a plan to commit suicide together as they were living on the streets.’ This statement appears to be consistent with information outlincd in the statement of Pastor Stephen Kane.’ MF requested to sce a counsellor or psychiatrist, and stated she also wanted her husband to attend, She was given the names and phone numbers of psychologists

and it was noted that she would return for a Mental Health Care Plan.

§ Hegarty, K., O’Doherty, L. 2011 Intimate partner violence: identification and response in general practice. Australian Family Physician 40(1 1):852 — 856, T Statement of Stephen Kane, Inquest Brief, p.86,

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From early August 2009, increasing pressures in MF’s and her husband’s relationship were

documented by the General Practitioner. On 13 August 2009, the medical records noted:

Distressed +++, (MF’s husband) has not attended anger management. Has left the surgery today because I kept him waiting. Has been quite violent in the past. Intervention order taken out against him by police. Police have told (MF) that if she calls them again they will put him in gaol. (MF) does not want that on her conscience, (MF’s husband) very paranoid and possessive, Checking on her all the time. (MF) hates herself for not having the courage to leave, Knows (her husband's) parents will blame her if she leaves. (MI’) does not feel she is protective her son. Feels life would not be

worth living if not for her son.

MF returned to the General Practitioner on 26 August 2009. The notes from this consultation

include the following:

Feels she has to get out of this relationship. Scared. Has been to police Station to get intervention order against parents-in-law...Still feels like ending her life, though. Feels she can’t leave her husband, because he has nowhere to go. I will ring Dandenong CCAT tomorrow. Tried tonight, but could not get through.

On 27 August 2009 it is recorded that the General Practitioner spoke to the Crisis Assessment Treatment Team (CATT), following a call to MF, The General Practitioner was advised that MF was not actively suicidal or psychotic, and therefore did not qualify for CATT services. It was suggested she be provided a referral to a psychologist. On 27 August 2009, three days before she died, the General Practitioner phoned MF. The entry states ‘she will ring to make

an appt for a Mental Health Care Plan.’

It is evident that MF expressed ongoing family violence concerns, involving both her fatherin-law and husband, to her General Practitioner. The General Practitioner’s notes indicate that he was making efforts to seek further assistance for her, which seemingly focused on mental health supports. Further to this, there is no reference to a referral for family violence services being provided. It is relevant that the General Practitioner recorded several risk indictors for violence, such as pending separation, previous suicidal ideation by both parties, a past history of violence, controlling and possessive behaviour by MF’s husband, as well as possible

reference to his mental health involving paranoia. It can not be determined from the notes

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whether the General Practitioner was alerted to the significance of thesc in respect to escalating violence. However, MF was clearly secking support from him, and he appeared to have been making efforts to assist with her mental health condition and issues with her

husband and extended family.

Family violence has been associated with a wide range of physical and mental health difficultics. Given that many victims (and perpetrators) of violence have contact with health care professionals, particularly the general practice setting, the potential contribution for this

sector to identify and respond to family violence has increasingly been recognised,

The central elements for providing victims of family violence with quality health care responses include: offering a safe and supportive environment to facilitate disclosure; ensuing ongoing access to medical care; assessing risk and safety for victims and their children; recognising and naming violent behaviours; engaging in non-judgemental and respectful communication through the various stages of contemplation and action; and appropriately directing victims to relevant resources and support (including specialist sexual assault and family violcnce services).® To achieve this, health care professionals need to be cquipped with sufficient knowledge about the nature and dynamics of family violence; it’s estimated prevalence among patient populations; relevant risk and contributory factors; and the potential for positive intervention to be provided in these settings. Further, familiarity with best practice guidelines for assisting victims, coupled with a sound understanding of the range of specialist

and mainstream services that can provide further support, is essential.

CONCLUSION

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MF experienced ongoing family violence in her relationship with her husband and had raised the possibility of separation. The couple had multiple contacts with Victoria Police over the course of their relationship in relation to family violence incidents perpetrated by MF’s husband against her. In addition, MF made disclosures to family members and her General Practitioner about incidents of family violence and fears she held for her safety and that of her

young child,

These are recurrent themes in family violence homicides that come before this Court and ongoing monitoring of these deaths continue to occur at an alarming frequency. Despite acknowledgement that family violence is unacceptable and ongoing efforts and enhancements

to government and non-government initiatives to raisc awareness, support victims and

• Heparty, K., O’Doherty, L, 2011 Intimate partner violence: identification and response in general practice, Australian Family Physician 40(11):852 — 856.

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perpetrators and hold perpetrators accountable, this is a complex phenomenon that requires ongoing multifaceted and multi-sectoral prevention-focussed approach. This is particularly

important when family members and services are aware of ongoing family violence incidents.

This appears to be increasingly recognised since the death of MF. This is evidenced by material | was provided to assist my investigation into the death of Barbara Lubik’, another

family violence homicide that occurred in the same year and in similar circumstances to MF.

Victoria Police have recently implemented the Enhanced Family Violence Service Delivery 2011-2014 model, designed to provide a more effective response to recidivist perpetrators and high risk victims of family violence. This strategy recognises that some victims may not leave violent relationships at the first intervention. I understand that this strategy includes a casemanagement component for both perpetrators and victims, while aiming to improve referral and collaboration with other services to address the underlying causes of violence. It could be argued that MF and her husband could have bencfited from such an approach to violence

prevention,

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment connected with

the death:

Given the frequency with which members of Victoria Police encounter family violence in the course of their duties, there is a need for the organisation to continually consider approaches and ways for effectively responding to this issue. The introduction of the approach described above appears to be one such cxample, and it would be of great benefit to determine the impact of this approach on reducing family violence via a formal program evaluation in duc

course,

Similarly general practice is a setting where persons expericncing physical and mental health treatment for injuries and illnesses resulting from family violence and where disclosures about exposure to family violence are frequently made. These and other health services serve as an important pathway for referral to specialist family violence support services. It is vital that general practitioners are equipped to identify symptoms of family violence, assess risk, provide advice about referrals to specialist serviccs and in what circumstances legal

intervention is required. Clinical guidelines addressing these issues has been available via the

° Court Reference Number 20090394

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Royal Australian College of General Practitioners since 2008 and is now in it’s third edition.’°

While this work is acknowledged ongoing efforts are required to strengthen the identification

and response to family violence within thc health care sector,

37. Lwish to convey my sincere condolences to MF’s family.

Pursuant to section 73(1) of the Coroners Act 2008, I ordcr that the names not be published on the internet.

I direct that a copy of this finding be provided to the following for their information: MF’s Senior Next of Kin

Chief Commissioner of Victoria Police Ken Lay APM

Professor Morton Rawlins, Chair, Royal Australian Collcge of General Practitioners

Ms Katy Haire, Department of Human Service, - Co-Chair Violence Against Women and Children

Interdepartmental Committee

Detective Superintendant Rod Jouning, Victoria Police - Co-Chair Violence Against Women and

Children Interdepartmental Committec

Signature:

Foe

ra ai

ian fay

Judge Ian L. Gray Date: 2/ 7/ Bf bp

‘© Royal Australian College of Gencral Practitioners, 2008 Abuse and violence: Working with our patients in general practice (white book) available from http://www.racgp.org.au/guidelines/abuseandviolence

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