IN TIE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2012/0131

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 Zahra Rahimzadegan

without holding an inquest: find that the identity of the deccased was Zahra Rabimzadegan (also known as Mandy Ahmadi) born on 6 January 1965 and the death occurred on 16 December 2011 at, 96 High Street Road, Ashwood, Victoria from: 1 (a) UNASCERTAINED

Pursuant to section 67(1) of the Coroners Act 2008, I make findings with respect to the following circumstances: ;

History of Coronial Investigation

1. Zahra Rahimzadegan (also known as Mandy Ahmadi) was killed at her home by her husband Nasir Ahmadi (also known as Nathan Ahmadi) on the afternoon of 16 December 2011.

Mr Ahmadi pleaded guilty to manslaughter and, on 5 June 2013, was sentenced by Justice Curtain in the Supreme Court of Victoria to 11 years imprisonment with a non parole period of 7 years. Following the completion of those criminal proceedings and the expiry of relevant appeal periods, a bricf of evidence was provided to this Court so that the coronial investigation, which was effectively suspended for the duration of the criminal proceedings,

could resume.

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2. It was apparent from the brief provided, and the sentencing remarks of Justice Curtain,’ that the deceased’s death was a family violence homicide. I therefore directed that further evidence be obtained, in addition to that included in the original brief, about the family violence context

within which the death occurred. I was subsequently provided with:

a. Further information from the coroner’s investigator, Detective Senior Sergeant David Butler, regarding two intervention order applications made by, or on behalf of, the

deceased against her husband;?

b. Information from the Safe Steps organisation indicating that there was no record of the

deceased having any contact with that organisation;

c, City Life Community Care records for the deceased and her family, which related to

counselling and assistance provided to the deceased in 2007, 2010 and 2011;

d. City Life Community Care policy, procedure and intake documents relating to the

provision of counselling services;

e. Correspondence from City Life Community Care dated 10 July 2015 and 10 August 2015; and

f. - Statement of Rueben Sarvananthan, a friend of the deccased who assisted her with

accommodation on past occasions when she had left her home.

3. Sub-section 52(3)(b) of the Coroners Act 2008 (Vic) (“the Act’) provides that a coroner is not required to conduct an inquest into a suspected homicide where someone has been charged with an indictable offence in relation fo the death. Section 71 provides that no findings need be made where an inquest is not held for this reason and the making of findings would be inappropriate in the circumstances. Mindful of those sections, and having considered the volume of material already available to me, I determined that there was no purpose to be served by conducting an inquest in this casc. I determined, however, that it remained

appropriate to make findings in the matter.

"The Queen v Ahmadi [2013] VSC 293 (5 June 2013) 2 Emails from Det. Snr Sgt Butler dated 12 December 2014; 15 January 2015; 23 September 2015,

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Background

The deceased was born in Tehran, Tran on 6 January 1965. She was onc of six children, with three brothers and two sisters. She completed her schooling to year 12, before commencing

English language studics and working intermittently as an English translator.*

She met her husband, Nasir Ahmadi, in Iran in 1994-1995. The deceased’s family opposed the match but, at her insistence, reluctantly accepted the relationship* and the couple were married in a religious ceremony. Mr Ahmadi is an Afghani national and did not have Iranian

identity documents. As a result they could not legally register the marriage in Iran.*

The deceased disclosed to a friend in Australia and again during a marriage counsclling

sessions that she had had a poor relationship with her father growing up, had been subjected to verbal and physical violence and that she had married Mr Ahmadi as a means of escape, rather

than out of love.®

The couple moved to Pakistan in March 1995, possibly because of their inability to formally marry in Iran,’ and were accepted as refugees. They had their first son, Kashi, in Pakistan, before migrating to Australia in 1999. Their second son, Sherri, was born the following ycar.

The family obtained Australian Citizenship in 2001.8

The family was initially successful in Australia, running a restaurant and bakery in Rowville, but when the busincsses later failed, they lost their home and faced considerable debt. A subsequent painting and decorating business also failed when Mr Ahmadi injured his shoulder in a work accident and the family came to reside with their two sons in public housing,

supported by a disability pension.’

In around 2007, the deceased, and later Mr Ahmadi, converted from Islam to Christianity and

became very active members in various church groups.

The eviderice indicates that the deccased was a.resourceful and socially confident woman who played an active role in a number of different communities in her area, including the Iranian

community, the Christian community and the volunteer community centred around the

3 Coronial Brief, p212.

• Coronial Brief, p213.

4 Coronial Brief, p214.

® Coronial Brief, p222; City Life Community Care Counselling Session Notes 27 September 2010; City Life Community Care Counselling Session Notes 24 November 2011.

7 Coronial Brief, p214.

8 Coronial Brief, p721.

° Coronial Brief, p611 — 618; Coronial Brief, p721; Sentencing Remarks, R v Ahmadi [2013] VSC 293 at [6].

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Cornerstone faith mission building. As part of what she described as her ministry, the deceased established the organisation “Women’s Better World Inc”, later known as “Alpha Migrant Centre Inc”. Through this organisation, the deceased was heavily involved in providing a range of social services, particularly to refugees and other newly arrived immigrants, from Iran and Afghanistan. This included providing free haircuts, visiting immigration detention centres, assisting new arrivals to find accommodation, distributing food.

and household items and organising sporting activities.!° In addition to helping those in need, the deceased also endeavoured to introduce members of the Iranian and Afghani community to Christianity and encouraged them to attend bible study groups.'' Although Mr Ahmadi was also involved in these activities, the statements provided give the impression that the deceased

was the driving force behind promoting and expanding the organisation.’

Tt is apparent that the relationship between the deceased and Mr Ahmadi was quite unhappy and somewhat acrimonious, with the couple observed to argue openly and often.’ The deceased reportedly considered Mr Ahmadi a disappointment and failure, with poor English, a lax work ethic and limited job prospects. The deceased’s frustrations with her family’s financial fortunes in Australia, and what she perceived as her husband’s inability to adequately provide for the family, was a source of considerable tension within the marital relationship.'4 The deceased was reportedly embarrassed that the family resided in public housing and in the weeks preceding her death she argued with Mr Ahmadi about the need to

move to a larger, privately rented home.’

As noted, the deceased was Iranian, while Mr Ahmadi is originally from Afghanistan. A statement taken from a close friend of the deceased and another from a family member suggest that there was possibly a perccption amongst some of their associates that the deceased had married someone of a lower social status, and that as an Afghani, Mr Ahmadi was somehow loss educated and cultured.'® A member of the deceased’s extended family

opined in his statement that Mr Ahmadi had elevated his status by marrying the deceased and

1° Coronial " Coronia Coronia

Brie: Brie Brie

?

?

p212 -213; Coronial Brief, p219; Coronial Brief, p 248.

p223-224; Coronial Brief, p198 and 203; Coronial Brief, p83.

p219 -- 220; Coronial Brief, p195; Coronial Brief, p247 and 255,

133 Sentencing Remarks, R v Ahmadi [2013] VSC 293 at [8] and [9]; Coronial Brief, p264; Coronial Brief, p278 — 279;

Coronial Brief, p2

M4 Coronia Rueben Sai

Brie

48.251 and p255; Coronial Brief, p196 — 197 and 199; Coronial Brief, p189; Coronial Brief, p221.

p249, City Life Community Care Counselling Session Notes-24 November 2011, Statement of

rvananthan, 13 June 2012, p3; Coronial Brief, p290; Coronial Brief, p297; Coronial Brief, p262; Coronial

Brief, p255; Coronial Bricf, p196.

13 Coronia

Brie

18 Coronia

Brie

p209; City Life Community Care Counselling Session Notes 24 November 2011.

p220, 227 and 238; Coronial Brief, p295.

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therefore he did not want to let her go.'’ An Iranian friend of the deceased indicated that she

did not approve of the deceased’s choice in husband and that she was reluctant to get involved.

in family matters because Mr Ahmadi was Afghani and she didn’t have a good feeling about

him."*

13. For his part, Mr Ahmadi. was obscrved to be possessive and jealous of the deccased and, despite her objections, frequently insisted on accompanying her in her charitable, church and social endeavours.!? The evidence suggests that Mr Ahmadi struggled with the way in which the deceased dressed in Australia and interacted directly with other men. This caused tension between the couple with Mr Ahmadi claiming that the deceased’s behaviour disrespected him

and the deceased claiming that Mr Ahmadi had not let go of his Islamic beliefs.*°

14, Several statements suggest that the family dynamic was further complicated by tensions surrounding the deceased’s cldcst son’s behaviour. There is evidence to suggest that arguments sometimes ensued betwecn the deceased and Mr Ahmadi, when she sided with and attempted to defend her son in disagreements with his father.”) Equally, there is evidence that the deccased and her eldest son were themsclvcs sometimes directly in conflict, with the

deceased alleging that he had on occasions physically assaulted her.”

15. Against that background of marital and familial disharmony, the deceased reported to friends and family that Mr Ahmadi would often use physical violence and threats of harm against both her and their children.

History of Physical Vielence and Threats

16. The evidence gathered in the course of the investigation into the deceased’s death, suggests a long history of physical abuse perpetrated against the deccased by Mr Ahmadi dating back to their time in Pakistan. A friend who knew the family during their period in Pakistan recalls the deceased living apart from her husband for some weeks, after he reportedly beat her. The

deceased had bruising on her upper arms and lower back. This occurred in a context where

7 Coronial Brief, p295.

‘8 Coronial Brief, p220 and 227.

!9 Coronial Brief, p221 and 225; Coronial Bricf, p.295;

2 Coronial Brief, p197; City Life Community Care Counselling Session Notes 24 November 2011; Coronial Brief, p83; Coronial Brief, p301; Coronial Brief, p250.

1 Coronial Brief, p91; Coronial Brief, p133 and 140,

22 Coronial Brief, p76; Coronial Brief, p222; City Life Community Care Counselling Session Notes 24 November 2011; Coronial Brief, p272.

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the deceased and Mr Ahmadi were moving between homes of various Afghani people, which the deceased reportedly struggled with. A friend took the deceased in, but it became difficult

for his family and he arranged accommodation for Mr Ahmadi and the deceased elsewhere,”

The same friend, who also migrated to Australia, indicated that this physical abuse continued in Australia. Over a long period, the deceased would frequently complain to him and his wife that Mr Ahmadi was violent towards her, without providing specific details, and would show them areas of bruising that she attributed to Mr Ahmadi’s beatings.”* The deceased frequently stated to this friend and his wife, from as far back as 2003/2004, that she thought Mr Ahmadi would kill her one day. This fricnd told the deceased that she should seck counselling and that she should use the law and the police in Australia if she was having problems, however, he

felt that she was unlikely to do that.?°

In fact, in April 2007, the deceased did contact police following an alleged violent attack by Mr Ahmadi in the context of an argument about whether the deceased had paid appropriate respect and made appropriate arrangements following the death of Mr Ahmadi’s mother. At this time, the deceased had already converted to Christianity but Mr Ahmadi remained a Muslim. The deceased considered that her husband was expecting her to observe Islamic

traditions, which she refused to do.”

The deceased attended the Rowville policc station to report the attack. On receiving an account of what had occurred. from the deceased, Victoria Police applied to the Ringwood Magistrate’s Court for an Intervention Order under the Crimes (amily Violence) Act 1987 (Vic), listing the deceased and her two children as affected family members, The Application’ stated that following an argument, Mr Ahmadi punched the deceased in the face, tried to burn her leg with an iron and kicked her in the stomach. The Application noted that this occurred in the presence of the couple’s sons who tried in vain to protect their mother. The Application noted that similar attacks had occurred in the past, and that the deccased feared the level of

violence was cscalating,””

An order, of twelve months duration, was made’ on 17 April 2007 at the Ringwood

Magistrate’s Court, Mr Ahmadi was present in court and consented to the order without

28Coronial Brief, p288.

% Coronial Bricf, p289 — 291,

5 Coronial Brief, p289 — 292.

26 Coronial Bricf, p614 - 618, Knox Community Care, General Case Note dated 20 April 2007, counselling records provided by City Life Community Care,

27 Coronial Brief, p491.

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21,

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admission. The order protected both the deceased and her two children. The order prohibited Mr Ahmadi from. approaching, contacting or telephoning the deceased and their sons or

causing anyone else to do the same, and from being with 200 metres of the family home.”*

In the following weeks, the deceased and her sons resided with a friend in Ferntree Gully, notwithstanding that Mr Ahmadi was not at the family home (which was for sale at the time) and was prohibited from approaching the house. The deceased received financial assistance from Centrelink and from CityLife Community Care?’ to assist her in this crisis period, and counselling was arranged for her children. The deceased herself was offered, but did not seek

counselling,*°

As a result of this family violence incident, the Department of Human Services (now the Department of Health and Human Services) were notified of protection concerns in relation to the deceased’s two boys. A protective investigation was undertaken by Child Protection and the boys” school and CityLife Community Care were. both involved in arranging counselling

and support for the boys.

After approximately one month, following Mr Ahmadi’s conversion to Christianity?! Mr Ahmadi and the deccased were reunited. On 18 May 2007, with Mr Ahmadi present in Court,

the intervention order was revoked.

On .30 July 2007, Child Protection also ceased their involvement with the family, notwithstanding the deceased’s reconciliation with Mr Ahmadi, the revocation of the intervention order and the deceased’s decision to withdraw Kashi from counsclling. Staff at Citylife Community Care and at the school were informed that they should notify Child

Protection of any protective concerns regarding the family in the future.*”

The evidence indicates that Mr Ahmadi’s angry outbursts and alleged usc of physical violence did not cease at this point. In November 2010, the deceased again applied for an intervention order, this time in the Dandenong Magistrates’ Court and without police involvement. Both the deceased and her sons were listed as affected family members. The Application alleged

that:

28 Coronial Brief, p.494-495.

29 Ty 1997, the organisation was known as Knox Community Care.

» City Life Community Care counselling records.

31 Coronial Brief, p614 — 618;Coronial Brief, p.297; “Ex-Muslim baptised into Jesus Christ at Catch the Fire Ministries” published 4 Junc 2007 on the Catch the Tire Website — accessed 15 April 2015 at http://catchthefire.com.au/2007/06/exmuslim-baptiscd-into-jcsus-christ/

3 Knox Community Care counselling records provided by CityLife Community Care.

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a. The deceased and her children had been assaulted on many occasions by Mr Ahmadi,

including one week prior;

b. Mr Ahmadi frequently threatened to kill the deceased and her children even if he ended up in jail,

c. Mr Ahmadi appeared to be suffering from a psychological disorder because he was unable to control his temper and would go into a violent rage with little or no provocation only to forget everything a few hours later;

29.33

d, The deceased wanted Mr Ahmadi “to seek medical help and help with his behaviour”; and

e. The deceased feared for her and her children’s lives.*4

An interim intervention order was issued, but the deceased filed a notice of withdrawal two weeks later and the application was struck out without a final order being made.** Although the deceased’s initial application for an intervention order alleged that Mr Ahmadi had assaulted the boys and had threatened to kill them, it did not result in any notification of protective concerns to Child Protection. The involvement of Victoria Police on this occasion was limited to serving the interim order on Mr Ahmadi, and it does not appear that Victoria Police were made aware of the substance of the allegations made by the deceased in her

application.

Throughout 2011, friends and family continued to notice bruises on the deceased. This included bruising on her neck, which the deceased said had been caused by Mr Ahmadi choking her on an occasion when he wanted her phone and she refused to give it to him.** The deceased also reported that Mr Ahmadi hit their sons and hit the family dog without cause.?” The deceased told friends that she was afraid of Mr Ahmadi, and she told her sister and mother in Iran that Mr Ahmadi had threatened her by claiming that he had killed a previous

fiancé who had betrayed him.*®

Towards the end of 2011, when friends and associates attempted to persuade the deceased to

attend marriage counselling, the deceased told them that Mr Ahmadi had an anger

3 Coronial Brief, p500-501,

4 Coronial Brief, p.500 -501

35 Coronial Brief, p.505 — 507. :

36 Coronial Brief, p215; Coronial Brief, p219 — 235; Coronial Brief, p332.

7 Coronial Brief, p333.

38 Coronial Brief, p215; Coronial Brief, p238.

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29,

management problem and that they did not understand what went on behind closed doors. She

reported that Nathan was not quiet at home but was the devil.”

The deceased had expressed a desire to leave Mr Ahmadi on a number of occasions, in part because of his physical abuse, but also because of his poor financial prospects and, what the deceased described as their complete incompatibility.° In the months before her death, the deceased commenced an intimate relationship with another man recently arrived from Tran.!

The relationship appears to have given greater impetus to her desire to leave her marriage.

Twice in the three months before her death, the deceased left the family home for a period of days and stayed at accommodation atranged through a friend. During these periods, the

deceased ‘did not disclose her location to her husband.*”

Mr Ahmadi was increasingly suspicious over this period that the deceased was having an intimate relationship with another man. The evidence indicates that Mr Ahmadi was ordinarily jealous and possessive of the deceased and followed her closely despite her repeated attempts to create more personal space for herself. The deceased frequently complained that she felt trapped and could not go anywhere without Mr Abmadi.“ When Mr Ahmadi began to suspect the deceased’s affair in the weeks before her death, he took additional steps to secretly record her-conversations and to verify her whereabouts when she

went out. *

The deceased’s extended family lived in. Iran, although they continued to be in contact with her by phone and other means. The deceased’s brother explained that, having chosen her husband over the objections of her family, the deceased was not likely to seek her family’s advice or assistance with problems encountered in the marriage.** Closer to her death, this appears to have changed. The deceased had shared with her mother and sister in Iran some of the details of Mr Ahmadi’s alleged abuse and threats and reportedly telephoned them in Iran a week before her death and told them that she was afraid of Mr Ahmadi.*” Shortly before her

% Coronial Brief, p249; Coronial Brief, p332; Statement of Rueben Sarvananthan, 13 Tune 2012.

4 Statement of Rueben Sarvananthan, 13 June 2012; Coronial Brief, p197; Coronial Brief, p297; Coronial Brief, p249; Coronial Brief, p221,

4! Coronial Brief, p327-334.

® Statement of Rueben Sarvananthan, 13 June 2012.

8 Coronial Brief, p251; Coronial Brief, p308-309; City Life Community Care Counselling Session Notes 24 November

Coronial Brief, p219 — 235; Coronial Brief, p295; Coronial Brief, p332; City Life Community Care Counselling Session Notes 24 November 2011.

45 Coronial Brief, p86; Coronial Bricf, p166; City Life Community Care Counselling Session Notes 24 November 2011.

4 Coronial Brief, p213 -- 215.

• Coronial Brief, p238.

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death, the deceased had told a friend that she was keenly awaiting the release of her recently arrived brother from Australian immigration detention because she would no longer be alone in Australia. She expressed hope that her brother would protect her and that Mr Ahmadi

would not bother her anymore."

Family Counselling Services

In relation to her experiences of family violence, the deceased’s most significant recorded services contact, other than with police and the courts in the contcxt of her intervention order applications, was with CityLife Community Care (CLCC). CLCC is a not for profit organisation, associated with CityLife Church, which provides community support and professional services (including counselling) to individuals experiencing hardship. The deceased was a member of the CityLife Church congregation, and on a number of occasions

the deceased, or her children, received counselling services through CLCC.

CLCC provided material and financial support to the deceased in April 2007, after the deceased had reported Mr Ahmadi’s abuse to the police and obtained an intervention order.

At this time, the service also provided counselling to the deceased’s eldest son, Kashi, who

had himself experienced and or been exposed to family violence by Mr Ahmadi.

The deccased returned to CLCC for family counselling in Jate August 2010. The intake form records that the deceased’s eldest son, Kashi, had been suspended from school as a result of his anger management issues and that family conflict, including shouting and fighting, had been escalating..It is noted on the intake form that there is past family violence. A separate

referral was made for Kashi and for the deceased and Mr Ahmadi, as a couple.

Tn his three subsequent sessions on “management of emotions”, Kashi described his father as

having violent, aggressive outbursts and states his Dad “just loses it.”

Jn the onc session that the deceased and Mr Ahmadi attended as a couple in 2010, the deccased reported that there was grcat tension and dysfunction in the family. The deceascd stated that she had marricd Mr Ahmadi to escape her physically violent father, only to discover that Mr Ahmadi was also physically and verbally violent. The deceased described her family situation as toxic. The deceased stated that she need Nathan to admit his anger. The

following session, the deceased did not attend, then the couple cancelled, then Mr Ahmadi

48 Coronial Brief, p227,

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37,

39,

40,

attended alone again. As a result no further sessions were scheduled. There were no referrals

or follow up.

The deceascd’s final contact with the counselling services of CLCC was in November 2011.

This appears to have occurred as a result of the intervention and persuasion of a fricnd, or a number of friends, that the deceased had met through the church community, and who had been supporting and collaborating with the deceased on her ministry work. These friends appear to have repeatedly counselled the deceased to suspend her ministry work, and to focus

instead on addressing her family and relationship issues.’?

The deceased was reluctant to undertake counselling and told one of these friends that Mr Abmadi’s anger problems could not be changed through counselling. She disclosed that she had previously obtained an intervention order and that she was afraid of Mr Ahmadi and his physical violence. The deceased accused her friend of not understanding or appreciating what

was happening and her problems behind closed doors in the family home.*°

Nonetheless, this same friend made arrangements for counselling through CLCC. He spoke to an Associate Minister at City Life Church, who in turn referred the matter to a pastor at City Life Church. The pastor met with Mr Ahmadi alone on 11 November 2011 3! Mr Ahmadi told her that the deceased had left the family home at that time. He had not seen her for a few days, that she would not answer his calls and that she had not disclosed her location to him. Mr Ahmadi requested that the pastor contact the deceased and she made several attempts to do so, eventually making contact on approximately 15 November 2011. An agreement was made to

meet with Mr Ahmadi and the deceased together on 18 November 2011.7

The mecting took place on 18 November 2011 in the pastor’s office. At this mecting, the deceased was questioned about her recent absence from the home, where she had been staying, and whether she was conducting an affair with another man. The deceased did not volunteer any information in response to these questions. The pastor discussed with Mr Ahmadi and the deceased the importance of resolving their relationship issues in the context

of continuing their ministry.*

9 Coronial Bricf, p133-135 and 141; Coronial Brief, p 199 — 201; Coronial Brief p, 249; Coronial Brief p. 309; Statement of Rucben Sarvananthan, 13 June 2012

53° Coronial Bricf, p249.

5! Coronial Brief, 249; Coronial Brief, p.308.

® Coronial Bricf, p308,

33 Coronial Bricf, p309.

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42,

44,

Following the mecting, the pastor suggested that Mr Ahmadi and the deceased needed long term couple’s counselling and, with their agreement, referred them for six counselling sessions with CLCC, An agreement to partially waive the standard counsclling fees was also

made,**

The referral/intake form completed by CLCC that day lists the presenting issue as follows: “Mandy [the deceased] left for 5 days. Nathan [Mr Ahmadi] thinks Mandy is having an affair, Mandy has not denied this. Conflict, trust issues.” There is no mention of family violence,

cither historical or ongoing as part of the presenting issue.*

_ The same pastor who organised the counselling referral had been involved with the deceased.

when she was assisted by CLCC in April 2007. As a result, she was aware that the deceased had obtained an intervention order at that time, and that Child Protection had been involved with the family, because of a history of physical violence and threats allegedly perpetrated by Mr Ahmadi against the deceased and witnessed by their children.

However, it is not apparent that this history of family violence informed the pastor’s intervention and approach in November 2011. There is no evidence that the issue of family violence, and the possibility that it may be ongoing or that the deceased may be at risk, particularly given the current status of the relationship, was overtly raised or proactively considered in arranging or conducting the meeting. What was noted was that Mr Ahmadi and the deceased were angry with each other and raised their voices. It was also noted that the

deceased had left the family home on past occasions.

The CLCC Procedure for Intake and Referral states that during the intake procedure clients will be assessed to ascertain, amongst other things, “risk or history of family violence where appropriate’. The Procedure further states that if the client is experiencing family violence, or threat of violence, they should be asked questions concerning their safety and that police

should be called where there are immediate concerns. Where there is no immediate threat,

’ questions should be asked about existing safety plans or intervention orders, and

recommendations or referrals should be made to cither services such as the Eastern Domestic Violence Service, community legal centre or Centre Against Sexual Assault, as appropriate.

The Procedure further states that it should be ascertained if children are present, and if so,

whether they have been witness to family violence. In the event that they have the Department

5 Coronial Brief 309.

% City Life Community Care, Adult Telephone Intake, 18 November 2011.

56 Coronial Brief, p306-307.

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should be contacted either directly or by supporting the client to do so, and other appropriate

referrals should be considered.*”

As noted, the counselling intake form makes no mention of the history of family violence known to CLCC from the family’s past contact with the organisation. There is no intake documentation which would suggest any clear collection and assessment of the type of information which might be required to undertake an assessment of the risk of family violence. There is no indication that, in the absence of the deceased proactively raising any fears hersclf, that any history or risk of family violence was addressed with her (including in private, away from Mr Ahmadi) at any stage. There is no: indication that the friend who initiated the meeting with the pastor, and to whom the deceased had disclosed a fear of Mr Ahmadi, was questioned about any knowledge or perceived risk of family violence at the time

he sought out assistance for the couple.

In that context, the first counselling session took place on 24 November 2011 with a husband and wife counselling team. In the record of that session, the presenting problem was cited as “marriage relationship difficulties. Mandy [the deceased] left home for 5 days recently”.

Under the heading “Client disclosure” information was recorded about the couple’s children; the circumstances of their marriage (i.e that the deccascd married Mr Ahmadi to escape her violent family life in Iran); their migration to Australia, the deceased’s depressive episode following the death of her father in Iran; their financial setbacks over the years; their conversion to Christianity; their current rental situation; and the deceased’s unhappiness and anger that because of Mr Ahmadi’s employment status they are living in community housing with undesirable neighbours. It was also recorded that the deceased believed she had nothing in common with her husband, besides their children, and that he was distrustful and obsessive and followed her around, Mr Ahmadi, reported that over the previous three months he had noticed a change in their relationship. The deceased had refused his offers to drive her places, notwithstanding her driver’s license was expired, and when he had attempted to verify her

stories about her whereabouts from time to time he had discovered she had lied.

It was also recorded that the deceased had recently left the home for a number. of days and had resided at accommodation arranged through a friend. It was noted that this had occurred several times before, the first time being four years earlier when Mr Ahmadi’s mother had just

died and they were under extreme financial pressure. It was noted that the deceased obtained

57 City Life Community Care, Procedure for Intake and Referral, Update 5 September 2011.

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Sl.

an intervention order at this time because of Nathan’s “(verbal) abuse”. It is also noted that the deceased “claims she has been physically attacked recently by her 15 year old son, and

that she stated: ‘I’m sick of living like this!’”.

Under the heading “Counsellor Observations”, the following was recorded:

Nathan and Mandy were extremely antagonistic toward each other for most of the session and continually tried to talk (or shout) one another down. (Other staff members commented on hearing the shouting at the start of the session!!) They had to be helped to allow each other to speak and for them to listen to each other. Toward the end of the session they seemed to be willing to look at their personal issues and to have some hope that they could work through

their relationship difficulties. ” Under the heading “Issues explored and discussed”, two point were noted as follows: a. lack of respect

b. their desire to reach the marginalised and the fact that their current rental location may

be an opportunity in that regard, provided they work on their own relationship first.

Finally, under the heading “Action to be taken by counsellor or client’, the following was

recorded:

a. Each to consider what they themselves have been contributing to their conflictual relationship; , b. Each to examine the hand out relating to respectful communication and acknowledge

where they are having difficulty.

It is apparent from the record of the session, that the counsellors did not have access to, or did not access, the records of the deceased’s previous contact with CLCC and were not made aware of a prior history of family violence by the pastor who assisted in arranging the

counselling.

During the session, the deccased disclosed that she had been recently “physically attacked” by her 15 year old son. The deceased did not discuss an immediate fear of physical violence from Mr Ahmadi. However, she described him as obsessive and following her around. It was also apparent that she had made tentative steps towards leaving the relationship, thus potentially placing her at increased risk. It is not apparent from the records provided that this information gathered in the course of the session prompted any formal assessment of the risk of family

violence.

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The deceased failed to attend the next counselling session which was scheduled for 8 December 2011. The pastor who had arranged the sessions said in her statement that “the first session is an information session and Mandy was not keen and did not want the

counselling.’5* She noted that the deceased did not attend the next session and that prior to

• going on leave she suggested to the deceased’s friend to remind Mr Ahmadi and the deceased

that counselling was important and they needed to continue with it.?

The fatal event

57,

The deceased was killed by her husband, Mr Ahmadi, in the family home on the afternoon of 16 December 2011. The couple were home alone at the time. In admissions made to police, Mr Ahmadi claimed that he confronted his wife with evidence of a suspected affair and that, in response, she made a number of disclosures including regarding a plan to move to Adclaide with another man. In the course of the ensuing argument, Mr Ahmadi claims that his wife pushed him, there was a physical altercation, he pushed his wife onto the couch, placed a curtain chord around her neck and applied pressure until the deceased stopped moving. He then conccaled her body in their bedroom before burying her later that evening in the backyard. Over the following days, with the unwitting assistance of his two sons and their

friends, he built a deck over the gravesite. 60

Mr Abmadi initially reported the deccased missing to police on 18 December 2011. However, when a search warrant was cxccuted on his home on 13 January 2011 and the body was located, Mr Ahmadi confessed to police that he had killed his wife. Police were unable to locate the curtain chord: that Mr Ahmadi had said he uscd to strangle the deceased, but they did locate a charger chord on top of a filing cabinet which it was accepted was likely used by Mr Ahmadi.

Mr Ahmadi later repeated his admission to his sons when they visited him in custody. He told

his sons that he had choked their mother because she had been secing another man.°!

Medical Evidence — post mortem examination

38 Coronial Brief, p310.

59 Coronial Brief, p310.

90 The Queen v Ahmadi [2013] VSC 293; Coronial Bricf, p696 — 714.

6l The Queen v Ahmadi [2013] VSC 293 at [3]; Coronial Brief, p85 — 86; Coronial Brief, p696 -714.

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A full autopsy was performed on the body of deceased by Dr Heinrich Bouwer, forensic pathologist, of the Victorian Institute of Forensic’ Medicine. Due to advanced post mortem

decompositional changes, an unequivocal cause of death could not be determined.

The entire larynx was sectioned and examined under the microscope. There were no fractures or microfractures of thyroid cartilage. Due to the degree of autolysis however, the presence of microfractures was not definitely excluded. Other findings which are seen in deaths due to neck compression (strangulation) include bruising of the skin and soft tissues of the neck, haemorrhage around the sites of laryngeal fractures, conjuctival and facial petechial haemorrhages and congestion of the facial skin. Many of these signs disappear with decomposition and these signs were not identified in this casc. The absence of larynx fractures

or bruising to the neck does not exclude neck compression or strangulation.

Criminal Trial and Sentencing

60. Mr Ahmadi pleaded guilty to manslaughter and was scntenced to 11 years imprisonment with

a non-parole period of seven years. In her sentencing remarks, Justice Curtain noted the

following:

The crime committed by Mr Ahmadi was a significant example of the crime of manslaughter. To kill the deceased in the manner claimed, that is strangulation by cord,

required a sustained act with the application of significant pressure.

It was a spontancous and unplanned act, but it was followed by a number of wecks of

significant deception designed to conceal the death and Mr Ahmadi’s role in it.

The sentence must both punish Mr Ahmadi and also send a message to the broader community that killing one’s spouse in circumstances such as these will be met with

salutary punishment.

At the same time, Mr Ahmadi has no prior convictions and pleaded guilty, which was an

indication of his remorse.

He had suffered significant trauma in his youth in Tehrani, where he had been

incarcerated and severely tortured as a result of his political allegiance.

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£ Tle had suffered considerable setbacks in establishing a life for himself and his family in

Australia.

. He suffered from anxiety and depression and, while there was no causal connection

between these and the offence, together with his history, they affected his ability to cope

when confronted with a situation of conflict.

_ He had made a considerable contribution to the community, particularly in his work with

asylum seekers and recent migrants to Australia,

Findings pursuant to section 67 of the Coroners Act 2008

61. Section 67 of the Coroners Act 2008 sets out the matters that a Coroner investigating a death

must, if possible, find. Accordingly, I find:

a. The identity of the deceased was Zahra Rahimzadegan, also known as Mandy Ahmadi

born 6 January 1965;

. Due to decomposition, the precise medical cause of the deceased’s death was

unascertained, despite extensive post mortem examinations. Whatever the precise cause of death, it is clear from admissions made to police that it occurred in the course of an assault by her husband Mr Ahmadi on 16 December 2011 at her home at 95 High St Road Ashwood.

The fatal incident occurred in circumstances where there had been a history of family violence, including physical assault and threats, perpetrated by Mr Ahmadi against the

deceased.

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

with the death:

The deceased was a capable, oulgoing person who was highly active in various communities, on many occasions assuming a leadership position. She was ostensibly better educated than Mr Ahmadi, spoke superior English and was perceived to be the socially dominant partner.

She was at times openly dismissive of Mr Ahmadi and his abilities and prepared to engage in public confrontation with him. Statements provided by friends and colleagues suggest that the public dynamics of their relationship meant that, even in the face of disclosures of abuse and

fear by the deceased, people failed to comprehend the impact of Mr Ahmadi’s violence on the -

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65,

deceased and the risk that he posed to her safety. The deceased confounded expectations of “a victim of family violence” and this appears to have impacted on how friends and colleagues

understood and intervened in her relationship with Mr Ahmadi.

This was perhaps most pronounced in the months preceding the deceased’s death when friends, with whom she collaborated in her Christian ministry, urged the deceased to undertake marriage counselling and suggested that she should put her ministry work on hold in order to prioritise resolving the conflict within her marriage and family. There was no obvious consideration of the appropriatencss of this course given Mr Ahmadi’s history of violence towards the deceased and her stated fear of him, and no apparent concern for the

deceased’s safety prior to her disappearance.

The deceased’s relationship with Mr Ahmadi appears to have been marked by physical violence, from as carly as their time in Pakistan, and this continued, at least intermittently, throughout the following fifteen years. Over the course of their relationship, the deccased disclosed to friends and others incidents of beatings, threats to her life and children, and a history of jealous, angry and erratic outbursts. The deccased reported that she had nothing in common with Mr Ahmadi, that he had failed to adequately provide for the family, and that she had married him not out of love but as a means of escape. The deceased left the family home (with her children in some instances) on at least four occasions prior to her death and, on two of these occasions, intervention orders were obtained by her or on her behalf preventing Mr Ahmadi from contacting or approaching her, their children or the family home. On each of these occasions the deceased returned to the relationship. It is not possible to determine, from the evidence now available, the factors which led the deceased to remain in a relationship in which she was both unhappy and in fear of her safety. The circumstances outlined above point to a number of possibilities. However, unfortunately, the deceased’s motivations are not

readily revealed in her statements to friends and counsellors.

Mr Ahmadi alone bears the responsibility for the deceased’s death and he has been sentenced accordingly. Nonetheless, it is valuable to reflect on the service contacts the deceased had in relation to her experiences of family violence and to consider whether any relevant

shortcomings or opportunities for improvement arc indicated.

Intervention order applications

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In 2007 and again in 2010 intervention orders were sought and made against Mr Ahmadi. In both applications (the first made on the deceased’s behalf by a member of Victoria Police) the deccased was very frank in describing the level and nature of ongoing abuse she had suffered from Mr Ahmadi and the fears she harboured for herself and her children. However, in both

cases, within a month, the order had been revoked or the application withdrawn.

The evidence does not indicate that the deceased abandoned the process on either occasion because she considered the orders ineffective. There is no evidence that she reported any breaches of the 2007 order or 2010 interim order. That is not to say that no breaches occurred, but rather that she did not have any experience of seeking to cnforce the order and finding it futile. Moreover, she told a colleague in the months before her death that she would not hesitate io seek another order or to involve the police if Mr Ahmadi did not respect the boundaries she set for his involvement in her ministry activities.© In this regard, she implied

that she considered intervention orders a somewhat useful tool, readily available to her.

In 2007, the evidence indicates that the deceased was reasonably well supported following the making of an intervention order against Mr Ahmadi, with at least interim financial, housing and counselling assistance offered to her. Child Protection was also involved with the family at this time. However, Mr Ahmadi’s conversion to Christianity during this period appears to have complicated the deceased’s decision to separate from him. An online newsletter article about the couple suggests that their reconciliation was celebrated as an act of god. This is not a matter that I have investigated further and it is not clear from the available cvidence whether this narrative was driven by the deceased, accepted by her or imposed upon her. The persistence of this theme, however, is evident in the police interview conducted with the deccased’s youngest son after her death when he states that his father used to hit them “whcn

he was a Muslim”, but that “he doesn’t really hit [them] anymore”.&

Very little is known about the circumstances of the deceased’s 2010 application for an intervention order, For example, it is not mentioned in any statements from family or friends, police involvement was limited to serving the interim order on Mr Ahmadi upon his

attendance at a police station, the Dandenong Magistrate’s Court file reveals nothing about

® Coronial Brief, p249.

& Coronial Brief p297,

$4 “Bx.Muslim baptised into Jesus Christ at Catch the Fire Ministries” published 4 June 2007 on the Catch the Fire Website — accessed 15 April 2015 at hitp://catchthefire.com.aw/2007/06/ex-muslim-baptised-into-jesus-christ/

6 Coronial Brief, p138.

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whether the deceased was assisted or accompanied by anyone when she filed the application or withdrew the application two weeks later, and there is no record of the deceased having had any contact with Safe Steps at this time. In the circumstances, it is difficult to speculate about whether the deceascd’s decision not to follow through on this occasion was in some respect a product of deficiencies in the level and nature of the advice or support offered to her in the

process.

It is of note that the allegations that Mr ‘Abmadi had assaulted and threatened to kill the deceased’s children, which were contained in the 2010 intervention order application, did not generate a notification to the Child Protection, even when the application was withdrawn two

weeks later and any putative protection offered by the terms of the interim order was lost.

In this case, there is insufficient connection between this issue and the death to warrant further investigation of the potential advantages and disadvantages of greater automatic/mandatory Child Protection involvement in the intervention order process where an application made by an affected family member discloses potential protection concerns. However, I consider it useful to record that serious allegations of child abuse were made in an intervention order application in this case. An interim order was subsequently made which listed the children, along with their mother, the deceased, as affected family members. The intervention order application was withdrawn by the deceased for unknown reasons before a final order was made. The children do not appear to have been separately represented or heard in this process.

Neither Victoria Police nor Child Protection werc made aware of the allegations in the deceased’s application regarding Mr Ahmadi’s assaults and threats against the children. In the circumstances, no investigation followed from the deceased’s allegations and no, assistance and support for the deccased and her children was provided or coordinated by the Child

Protection.

Couple’s counselling and family violence

72,

The deceased was persuaded, by persistent friends and associates, to attend marriage counselling at CLCC. The pastor who was involved in organising this was aware of the history of family violence between Mr Ahmadi and the deccased but did not consider that couple’s counselling may be inappropriate in the circumstances. ‘The counselling intake form makes no mention of a history of family violence and no rigorous family violence screening

appears to have been conducted prior to organising counselling sessions. There was no review

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74,

of earlier counselling session notes from 2007 and 2010, in which a history of violence was

disclosed.

During the counselling session, when the deceased discussed matters such as Mr Ahmadi’s obsessive behaviour, a past intervention order, and a recent alleged physical attack by her son, this did not prompt any specific family violence risk assessment, even given the. obvious hostility between the couple and the fact that the deceased had made tentative moves to leave

the relationship, thus potentially placing her at increased risk. No referrals were made.

The advice given by the Commonwealth Government funded National Sex Assault Domestic Family Violence Counselling Service is that couple counselling is usually inappropriate where there is domestic family violence. Amongst other reasons, this is because it is not possible to be safety focussed in couple’s counselling and because work with perpetrators is a specialised.

area of therapy and cannot be safely undertaken in a couple counselling context.®°

In its 2010 Report, “Family Violence - A National Legal Response”, the Australian Law Reform Commission (“ALRC”) considered, at some length, the appropriateness of pursuing family dispute resolution where there is family violence.6’ The ALRC commented that negotiation or mediation about family violence itself is never appropriate, however, where there is family violence, alternative dispute resolution to resolve issues other than violence may be appropriate, depending on effective and reliable family violence screening, risk assessment and risk management being in place. The ALRC further discussed the challenges of ensuring that practitioners engaged in family dispute resolution understood their screening role and were appropriately trained and equipped with the right tools to competently and consistently discharge their family violence screening and risk assessment obligations. Family dispute resolution occurs in a different context and has a different purpose to couple’s counselling but the ALRC’s discussion of the potentially harmful ramification of pursuing dispute resolution in a context of family violence, particularly where the violence is not

disclosed or detected and its impact not properly understood, remains relevant.

CCLC’s Procedure for Counselling Intake and Referral lists the need to establish a risk or history of family violence, but the procedure does not prescribe the tools that should be

employed to ensure that this occurs. There is nothing on the Intake Form which might prompt

6 Advice for Counsellors, Psychologists and Therapists published by [S0ORESPECT National Sexual Assault, Domestic Family Violence Counselling Service online at: https://www.1800respect.org.au/workers/workplacesectors/family-community-services/counsellors-psychologists-therapists/ (accessed 16 April 2015).

§7 Australian I.aw Reform Commission (2010) Family Violence — A National Legal Response, Final Report, ALRC Report 114, October 2010.

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77,

information gathering relevant to this type of screening and asscssment. Further, the Procedure for Intake and Referral docs not appear to be accompanied by a more coniprehensive policy statement about the circumstances in which couple’s counselling may be regarded as inappropriate in view of a history or risk of family violence, nor about the approach that should be adopted to screening, risk assessment and safety planning if

counselling has begun.

T cannot conclude, on the available evidence, that participating in couple’s counselling with her husband and the manner in which that counselling was conducted, increased the level or severity of the risk of family violence faced by the deceased. I cannot conclude, on the available evidence, that a fatal outcome would have been avoided if the intervention of CLCC had identified the risk Mr Ahmadi posed to the deceased and focussed on addressing Mr Ahmadi’s use of violence and/or on upholding the deceased’s right to live free from violence,

irrespective of her contribution to the conflict within the relationship.

However, I do consider that, given the potential harm of embarking upon couple’s counselling in a context where there is ongoing family violence, it is regrettable that CLCC’s processes for detecting, assessing and responding to the risk of family violence, both at intake and during

the actual counselling sessions, were not more rigorous.

In submissions made to this Court, CLCC has stated that they have a zcro tolerance for

_ domestic violence and treat such matters very scriously. The organisation strongly contests

any suggestion that in this case, or any other, CLCC prioritised maintaining the marriage over a person’s safety and wellbeing. Since the death of the deceased, CLCC have carried out various training sessions for their intake staff, counsellors and pastoral staff to increase

awareness about family violence. These sessions have focussed on matters such as: a. How to carry out effective intake processes and background checks; b. How to effectively assess risks such as suicide, family violence and drug abuse; and

c. How to comprehensively and accurately record information in the client intake form and.

brief the welfare worker and/or counsellor.

I am further informed that the Procedure for intake and referral has becn updated and that a working party has also been established to formulate a Church policy/position paper on family violence. This later step arose from a Workshop entitled: Family Violence: what can we do to help? How do we improve our response as a church, agency, and individual

practitioners?

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I recognise these endeavours and accept that they reflect a genuine commitment to reducing family violence. However, [also recognisc that there are ongoing challenges for non-specialist organisations in identifying and appropriately responding to family violence encountered in the course of their general welfare and community work. For that reason I have made a

number of recommendations directed at CLCC.

RECOMMENDATIONS |

Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendations

connected with the death:

CityLife Community Care

I recommend that cLCc:

Ensure that the organisation’s couple’s counselling intake form prompts screening questions to be asked which give effect to the requirement of the organisation’s Intake Procedure to “establish a risk or history of family violence”, and further ensure that potential participants

have the opportunity to provide that information in a safe and confidential environment.

Ensure that the organisation has clear and established referral policies and pathways to allow

referral to culturally appropriate men’s behaviour change, or similar programs.

Ensure that the organisation has clear and established referral pathways which allow for disclosures or identified risks of family violence to be referred to appropriately qualified agencies.

Develop and publish a clear policy on whether or not couple’s counselling can be provided where there is a history or risk of family violence, and to the extent that the organisation determines that couple’s counselling may proceed in those circumstances, the additional

safcguards and safety planning that are required.

Fnsure that CLCC’s counsellors understand that, irrespective of the screening processes employed at intake and the characterisation of the presenting issue, family violence screening and risk assessment is their ongoing responsibility, and further ensure that their counsellors have the professional training and tools to be able to competently and consistently undertake this task

and respond appropriatcly to any disclosures.

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I extend my condolences to the family and friends of Ms Zahra Rahimzadegan I direct that a copy of this finding be provided to the following:

Mr Ali Rahimzadegan, Senior Next of Kin Mr Peter A Leigh, City Life Community Care

Signature:

—_—_o

Le

JUDGE IAN L GRAY STATE CORONER

Date: . 2yups

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