Finding into death of Divesh Sharma

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2012 001544

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: DIVESH SHARMA

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Police Coronial Support Unit:

8 May 2015

Coroners Court of Victoria 65 Kavanagh Street, Southbank

8 July 2014

JUDGE IAN L GRAY, STATE CORONER

Sergeant D Dimsey, assisting the Coroner.

Page | of 26

I, JUDGE IAN L GRAY, State Coroner, having investigated the death of DIVESH SHARMA

AND having held an inquest in relation to this death on 8 July 2014 at Melbourne

find that the identity of the deceased was DIVESH SHARMA

born on 26 May 2006

and the death occurred between 28 and 29 April 2012

at 9 Marcia Court, Glen Waverley Victoria 3150

from:

T(a) UNASCERTAINED

in the following circumstances: Relevant Historical Facts

1. Divesh Sharma was a 5-year-old boy, who was born on 26 May 2006 in Box Hill to parents Mr Nilesh and Ms Preetika Sharma. He had a younger sister, Divya Sharma.

2. Mr Nilesh Sharma was born in Ba, Fiji, in 1975, In November 2000, he migrated from Fiji to Australia. In around October 2002, Mr Sharma returned to Fiji with his parents, where he was introduced to Ms Prectika Sharma. This introduction was made via family connections for the purpose of an arranged marriage. Mr and Ms Sharma married in Fiji in 2003 and moved to

Melbourne together shortly after.

3. At the time of his death, Mr Sharma was employed as a finance manager at a crash repair business called Capital Smart Repairs. Following various contract positions, Ms Sharma commenced ongoing employment with Southern Health in 2005, and from 2007 to her death, she worked in the accounts payable department. Mr and Ms Sharma had two children; a son, Divesh, aged 5 years and 11 months, and a daughtcr, Divya, aged 3 years and 1 month. The family were renting their home at 9 Marcia Court, Glen Waverley. Although not present at the time of the fatal event, Mr Sharma’s mother, Ms Jai Kumari Sharma, was primarily residing

with them at the time.

4. Approximately six months before the fatal event, the family was involved in a serious motor vehicle collision, On 29 December 2011, Mr Sharma, Ms Sharma and the children were travelling along Mountain Highway, Sassafras. Mr Sharma was driving and Ms Sharma was seated in the front passenger scat. While travelling cast the car drifted onto the opposite side of the road, toward oncoming traffic, before vecring off the left side of the road and over an embankment. The vehicle came to a stop when it collided with a tree. It was estimated that they were travelling between 45 and 55 km/hr at the time, and all occupants were wearing seatbelts. The family were helped from the car by several persons who observed the crash. Mr Sharma was taken to the Alfred Hospital and"Ms Sharma taken to the Royal Melbourne

Hospital. The children were taken to Royal Children’s Hospital and treated for minor injuries.

5. Asa result of crash, Ms Sharma sustained multiple injuries including cervical, lumbar and rib fractures, a small bowel perforation, a sprained ankle and perinephric haematoma,’ Mr Sharma’s injurics consisted of a closcd head injury, cardiac contusions, right shoulder and knee contusions and superficial burns.” After being discharged from hospital, both Ms Sharma and Mr Sharma received further treatment from the Victorian Rehabilitation Centre (VRC).

Ms Sharma was treated as an inpatient and outpaticnt, and Mr Sharma as an outpatient only.

6. As part of the coronial investigation, police considered whether the collision had been an attempted homicide-suicide by Mr Sharma. This involved re-interviewing available witnesses to the collision, examining the scene and obtaining an expert opinion from Detective Leading Senior Constable (DLSC) Jenelle Mehegan of the Major Collision Investigation Unit. It was established that the most likely reason that the vchicle left the road was due to unintentional driver error, whereby Mr Sharma became distracted and lost control of the vehicle? Both Mr and Ms Sharma had given various descriptions of what occurred prior to the collision. The only reference to Ms Sharma having indicated possible concerns that Mr Sharma’s actions may have been intentional is in the statement of a relative, Ms Reshmi Singh. She stated that while Ms Sharma was at the VRC, she sent Ms Singh a text message to the effect that Mr Sharma had tried to kill her (this appeared to be a reference to the motor vehicle collision), Ms Singh did not take this message seriously and thought Ms Sharma was affected by pain

medication, and when she returned Ms Sharma’s call, she told Ms Sharma that she was being

' Statement of Dr Sarah Abrahamson, Exhibit 15, inquest brief page 93.

? Neuropsychology Report, VRC medical records page 470.

. 3? Statement of DLSC Janelle Mehegan, Exhibit 15, inquest brief pages 67-74.

silly because Mr Sharma had been so concerned for her after the collision. Ms Singh visited

Ms Sharma in hospital a few days later, and Ms Sharma did not raise the issuc again.*

Just prior to his death, Mr Sharma was in the process of retumming to work on a part-time basis.

He was still complaining of headaches and had expressed some concern to family members that he was slower at completing work tasks. As part of his rehabilitation program, Mr Sharma had taken part in a neuropsychology assessment. This revealed that he had reduced information processing speed, borderline impaired auditory attention span and some deficits to his working memory capacity. Feedback from this assessment was given to Mr Sharma on 19 March 2012, and he subsequently met with the neuropsychologist to learn relaxation

techniques to help address his headaches and manage stress in general.°

On around 21 April 2012, Mr Sharma spoke to his sister, Ms Pushpa Chanel, about his perceived work pressures, feelings that he might not cope at work and continued headaches.” According to Ms Chanel, Mr Sharma had resigned from previous positions he held due to work and personal pressures.® On 28 April 2012, Ms Chanel visited Mr Sharma at home. She stated that he was happy when talking about football to the children, but when he spoke about work and his illness, he was very negative.’ Mr Sharma informed her of difficultics he was having completing tasks that hc had previously found easy. Ms Chanel’s observation was that Mr Sharma appeared sad and emotional, and she called him upon returning home, to suggest

he request a magnetic resonance imaging (MRI) scan and have a prayer session,”

Historically, there was evidence of family violence involving Mr and Ms Sharma, primarily in the form of controlling and isolating behaviour. Several witness statements provided by Ms Sharma’s friends and family suggest that Mr Sharma monitored and controlled with whom she communicated. There is limited evidence of prior physical violence, although Ms Sharma

reported that this had occurred early in their marriage in the form of Mr Sharma slapping her.

The couple separated shortly after the birth of Divya in 2009 for about 12 months, when Mr

Sharma found out about a previous relationship Ms Sharma had been in before they had met.

4g a¥ &s 7s

atement of Ms Reshmi Singh, Exhibit 15, inquest brief pages 305-6.

RC Medical Records, page 458.

atement of Dr Simone Field, Exhibit 15, inquest brief page 87.

atement of Ms Pushpa Chanel, Exhibit 5, inquest brief page 226,

® Thid page 224.

? Thid page 227.

bid page 228.

Police had received no prior reports of family violence, and it appears that nor did any other service providers. Similarly, the observations of the many healthcare professionals involved with both Mr and Ms Sharma in the months following the motor vehicle collision were either neutral or positive, in that they appeared to be supportive and concerned about cach other’s

rehabilitation.

Summary of Fatal Incident

ll.

On Friday 27 April 2012, Mr Sharma went to work at about 10.00am. He appeared to be in good spirits. He told a colleague that whilst it appeared that there was nothing wrong with him physically, he pointed to his own head and stated that things were coming along slowly.’ Mr Sharma placed a lunch order for the following Tuesday, 1 May 2012, before leaving for the day at around 2.00pm.

At around 3.00pm on 28 April 2012, Ms Chanel attended the Sharma home to pick up their mother, as stated above. All members of the family were at home. When Ms Chanel left the house, she stated that Mr Sharma’s behaviour was strange and that she suspected that something was not right. Ms Chanel and Ms Jai Sharma spoke about Mr Sharma’s unusual behaviour and agreed that he appeared to be emotional. Ms Chanel called Mr Sharma when

she returned home, and again at around 7.00pm. 2

Ms Chanel tried to contact Mr Sharma by telephone on 29 and 30 April 2012, but there was

no answer.

At around 1.00pm on 29 April 2012, a gardener attended the home to mow the lawns, This was a fortnightly arrangement by the Transport Accident Commission (TAC) and had been organised two weeks prior. The gardener noted that the curtains were closed and believed this to be unusual. He knocked on the door but there was no answer. The family car was parked in the driveway and a newspaper that had been delivered was on the front lawn. The gardener propped the newspaper against the window, mowed the front lawn and did not go to the rear of the house. He attempted to telephone Mr Sharma but reccived no answer, so he left. He

tried to call Mr Sharma again in the following days but reccived no answer."

"! Statement of Mr Daniel Vakadinovic, Exhibit 15, inquest brief page 362.

” Statement of Ms Pushpa Chanel, Exhibit 5, inquest brief page 227.

5 Police summary of evidence, Exhibit 1, inquest brief page 7.

At around 4.00pm on 29 April 2012, a neighbour across the road saw Mr Sharma whilst standing at her gate. She stated that he walked from the family car towards the front door. She waved at him and he waved back. The neighbour did not see Mr Sharma enter the house but

stated that she was sure that it was him.'*

On Monday 30 April 2012, Divesh was absent from school. The school did not attempt to contact Mr or Ms Sharma. Divya was also absent from childcare on this date and the centre

also did not attempt to contact the family,’°

On Tuesday 1 May 2012, Mr Shane Chanel, a nephew of Mr Sharma, contacted emergency services to report concerns for the family. He had been contacted by Divya’s childcare provider that morning, following her sccond day of unplanned absence. Mr Chanel subsequently attended the family home and observed their car in the driveway and the curtains closed. Efforts made to raise the family were unsuccessful. Police attended at around 11.12am and gained access to the property, where they discovered all four members of the family

so 1 inside the home, deceased.’®

Police looked through a window and saw a child (later identified as Divesh Sharma) who appeared to by lying motionless in bed. Police forced entry to the house and Divesh was found deceased, lying face up in bed in the rear bedroom with a pillow placed over his face. He was

wearing pyjamas and there were no obvious injuries to his body.

Divya Sharma and Ms Sharma were found deceased in bed in the front bedroom. Divya was lying face down in bed with a pillow over the back of her head. She was wearing pyjamas and

there were no obvious injuries to her body.

Ms Sharma was lying next to Divya on the same bed, face down with a pillow over the back of her head. She was wearing a tracksuit top and pants and there were no obvious injuries to

her body.

Mr Sharma was found deccascd, hanging from a rope tied to a rafter in the roof that was fed through a manhole in the hallway. An aluminium ladder was found in the hallway at the entry to the laundry. A smaller stepladder was found at Mr Sharma’s feet. A red plastic bag was

covering his head and a torch was found switched on, on top of the washing machine. Mr

14 Statement of Ms Joan Brand, Exhibit 15, inquest brief page 215.

'S Police summary of evidence, Exhibit 1, inquest brief page 7.

1S Thid page 8.

23,

24,

Sharma was wearing a tracksuit top and pants. There were no obvious injuries to his body. A suicide note was not located, nor were there any signs of a struggle, violence or forced entry.

The home appeared secure, tidy and well kept.””

Police seized and examined a desktop computer located in the home. This indicated that a website titled ‘Buy Chloroform’ had been accessed 27 times, with the last visit on 11 April

2012. At this time, the computer was logged in under the username ‘Neil’, a nickname for Mr Sharma. No suspicious liquids were found at the scene, nor were police able to track any purchase of chloroform (enquiries were made with Australia Post and customs). Post mortem toxicological analysis of Mr Sharma’s blood detected the presence of chloroform. The presence of chloroform was not detected in post mortem toxicology testing for the other

family members. '*

Investigating police formed the view that Ms Sharma, Divesh and Divya died at their home some time between the evening of Saturday. 28 April and the morning of Sunday 29 April 2012, and that their deaths were caused by smothering or suffocating by Mr Sharma. Police concluded that following this, at some time between the evening of 28 April and discovery by police on 1 May 2012, Mr Sharma suicided by hanging. Police formed the view that Ms Sharma could not have caused Mr Sharma’s death by hanging him from the roof due to her relative small sizé compared to his, and because it was thought to be impossible for her to have taken her own life, given the position in which her body was found. Police formed the

view that there was no evidence of involvement of another person. I accept this conclusion."

Acute (short-term) inhalation exposure to chloroform causes central nervous system depression. Despite there being no positive post mortem toxicology results for the presence of chloroform for Ms Sharma and the children, | am satisficd on the balance of probabilities that Mr Sharma exposed Ms Sharma, Divesh and Divya to chloroform, disabling them so that he could then cause their deaths by smothering or suffocating. Chloroform is rapidly eliminated from the body; therefore a negative post mortem toxicology result is not reliable, as it docs not necessarily indicate non-exposure to the substance.”° This is especially so having regard to the

passage of time between the deaths and the toxicology testing taking place, the evidence

T Police summary of evidence, Exhibit 1, inquest brief pages 8-9.

18 Ibid pages 14-5. Chloroform is a volatile organic liquid, used as a chemical solvent in laboratories. Due to its volatility, a negative result does not necessarily indicate non-exposure to chloroform.

" Police summary of evidence, Exhibit 1, inquest brief pages 15-6.

Amended VIFM Toxicology Report 2 for Mr Nilesh Sharma, page 2.

25,

indicates that the three family members died some time between the evening of Saturday 28 April and the morning of Sunday 29 April 2012. Their bodies were discovered by police on 1 May and the post mortem specimens were received in the laboratory between 2 and 3 May

At very high levels, chloroform exposure itself may cause anaesthesia and then death; with lower concentrations resulting in dizziness, headaches and tiredness.” It is therefore also possible that Mr Sharma caused the deaths of Ms Sharma, Divesh and Divya by exposure to

chloroform alone, and without smothering or suffocating.

Purpose of a Coronial Investigation

27,

This finding is based on the totality of the material the product of the coronial investigation of the deaths of the Sharma family. That is, the brief of evidence compiled by the Coroncr’s Investigator Detective Leading Senior Constable Chris Pricc, the statements, reports and testimony of those witnesses who testified at inquest and any documents tendered through them, and the final submissions. All of this material, together with the inquest transcript, will remain on the coronial file. In writing this finding, I do not purport to summarise all the material and evidence, but will refer to it only in such detail as is warranted by its forensic

significance and in the interests of narrative clarity.

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.

In this finding I will cxplore whether any lessons can be learned, which might prevent similar

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

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.

It is the investigation 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

*! Source: United States Environmental Protection Agency http://www.epa.gov/ttnatw01 /hithef/chlorofo.html.

31,

parallel purpose of a coronial investigation into a death. This purpose has becn enshrined in the Preamble of the Coroners Act 2008, which sets out that the role of the Coroner should be

to: ~ contribute to the reduction of the number of preventable deaths and

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

It is important to stress that coroners are not empowered to determine the civil or criminal liability arising from the investigation of a reportable death, and are specifically prohibited from including in a finding or comment any statement that a person is, or may be guilty of an offence. However, a coroner may include a statement relating to a notification to the Director of Public Prosccutions if the coroner believes an indictable may have been committed in

connection with the death.

Findings as to uncontentious matters

32,

In relation to Divesh Sharma’s death, most of the matters I am required to ascertain, if possible, were uncontentious from the outset. His identity and the date and place of death were not at issue. I find, as a matter of formality, that Divesh Sharma, born on 26 May 2006, aged

5, died at 9 Marcia Court, Glen Waverley Victoria 3150, between 28 and 29 April 2012.

Forensic Medical and Scientific Investigation

33,

On 2 May 2012, an autopsy of Divesh’s body and post mortem CT scanning (PMC) were performed by Senior Pathologist Dr Michacl Burke at the Victorian Institute of Forensic Medicine, who formed the opinion that the medical cause of his death was unascertained” Post mortem toxicological analysis of blood did not reveal the presence of ethanol (alcohol) or

any common drugs or poisons.

Dr Burke stated that the post mortem examination showed no evidence of any natural discase or injury that would have contributed to or led to death. He stated that whilst the cause of Divesh’s death was unable to be ascertained, ‘it ts clear from the overall scene findings that the death is one of homicide’ and that ‘fi]n the setting of no discernable head or neck injury, and no significant changes on the toxicology examination, the most likely cause of death would be smothering’. Dr Burke also stated that from the police examination of the scene, it

appeared that Ms Sharma, Divesh and Divya ‘may have all died from suffocation potentially

® Report of Dr Burke dated 27 June 2012, Exhibit 15, inquest brief pages 167-73.

3 Thid page 172.

by bed pillows being placed over their head’, and that Mr Sharma then suicided by hanging

himself from a rope in the laundry area,”

Specialist Family Violence Investigation

35..

Following a review of this evidence, I requested the Coroners Prevention Unit (CPUY* to examine the four deaths as part of the Victorian Systemic Review of Family Violence Deaths

(VSRFVD).°

The CPU identified the presence of risk factors known to increase the risk of fatal family

violence between intimate partners: history of family violence, prior separation and

_ reconciliation and. cultural beliefs that reinforced gender inequality.?” This evidence was

drawn from statements of family members and work colleagues who recalled disclosures

made by Mr and Ms Sharma on these issues.

Evidence of History of Family Violence

37,

Witness statements indicate there was a history of family violence perpetrated by Mr Sharma toward Ms Sharma. Primarily, Ms Sharma’s friends and family described what appears to have been controlling and isolating behaviour by Mr Sharma, although Ms Sharma had also

disclosed past physical violence.

Outwardly, Mr Sharma appears to have presented as a calm and cooperative person. Mr Sharma’s manager, Mr Evan Camilleri, described him as a ‘diligent and responsible worker’ who had high attention to detail, was very autonomous, could work independently to produce results and ‘was a very calm employee’.”* He stated that prior to the motor vehicle crash, Mr Sharma had worked with a difficult colleague, and that he had not lost his temper or acted

unreasonably towards her, Rather, he had requested that his manager deal with these matters.”?

4 Report of Dr Burke dated 27 June 2012, Exhibit 15, inquest brief page 172.

25 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.

26 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition, the VSRI'VD 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.

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

8 Statement of Mr Evan Camilleri, Exhibit 15, inquest brief page 352.

9 thid page 356.

42,

A friend of the family, Ms Amrita Ram, described Mr Sharma as presenting as a decent, humble and intelligent person.*° Neighbours stated that Mr and Ms Sharma appeared to be happy and they were not aware of any marital or mental health issues.’ "Ms Sharma’s younger sister, Ms Nitika Krishna, reported that she thought Ms Sharma was happy with her marriage

and that if there were issues, Ms Sharma would have told the family.*”

Tn December 2006, after Divesh was born, Mr and Ms Sharma took him to New Zealand to visit Ms Sharma’s sister, Ms Ashika Prasad. It was Ms Prasad’s recollection that Ms Sharma seemed quieter and withdrawn, and appeared ‘almost too scared to say much around Nilesh and had become quite timid’. In 2009 after Divya was bom, the landline was disconnected at their home.** Ms Sharma had told her sister this was because Mr Sharma wanted to control with whom she communicated. Ms Prasad stated:

[s]he was so afraid of him that she would secretly call from work at lunch times

just to talk to my dad and sisters...fi]f we accidently called or texted her when

Nilesh was around she would not answer and would later tell us that if he rang the number back to confirm who it was then I should deny it was me. 5

Ms Ram made similar observations. She was not in regular contact with Ms Sharma, but had visited her in hospital after the crash. She also recalled a conversation that occurred on 13 March 2012. Ms Sharma had called Ms Ram at work from her mobile phone. She sounded ‘very happy and very normal’ °° Ms Ram stated that she asked how the ‘cartoon’ was, which was a name she used for Mr Sharma as ‘sometimes he was in a good mood and sometimes he got into a really bad mood’ 2" Ms Sharma teplied that he was occasionally moody but that he

was overall okay.

Ms Ram recalled that they were laughing and having fun, before Ms Sharma went quiet and hung up the phone suddenly without saying goodbye. Ms Ram stated she knew Mr Sharma had returned. Shortly afterwards Ms Ram received a call from Ms Sharma’s mobile number.

When she answered, she heard Mr Sharma say something that she could not make out, but Ms

® Statement of Ms Amrita Ram, Exhibit 15, inquest brief page 301.

3! Siutement of Ms Joan Brand, Exhibit 15, inquest brief page 216.

• Statement of Ms Nitika Krishna, Exhibit 15, inquest brief pages 285-6.

33 Tirst statement of Ms Ashika Prasad, Exhibit 3, inquest brief page 272.

4 Sccond statement of Ms Ashika Prasad, Exhibit 4, inquest brief page 278.

• Thid.

*6 Statement of Ms Amrita Ram, Exhibit 15, inquest brief page 300.

• Thid.

4A,

Ram became nervous and hung up.** Shortly afterwards, Ms Ram received further calls on her work number that she did not answer. The following day, 14 March 2012, Ms Ram received a text message from Ms Sharma asking her to pretend her name was Jasmine and that she was from Southern Health if Mr Sharma called. Ms Ram stated that when she read this message she felt scared and had asked herself why Ms Sharma was so scared of Mr Sharma knowing

that they had been communicating.”

Witness statements refer to Ms Sharma having described past physical violence perpetrated by Mr Sharma. Ms Prasad stated that Ms Sharma had told her in the early stages of their marriage Mr Sharma slapped her ‘whenever she questioned him’."° She also stated that Ms Sharma told her that Mr Sharma locked her out of the house one night when she was pregnant,’ Ms Sharma told her that Mr Sharma would ‘ge mental’ when there was a full moon.” Ms Sharma had. told Ms Singh that Mr Sharma would become nasty to her if he had been drinking alcohol,? A former colleague of Ms Sharma, Ms Victoria Lines, stated that Ms Sharma had informed her that she had been physically abused by her husband. Ms Lines stated that she had offered to help Ms Sharma, but she responded that there were cultural issues involved.

However, during the time that they worked together, Ms Lines did not observe any physical

injuries on Ms Sharma.“*

With respect to Mr Sharma’s treatment of the children, Ms Sharma had told her sister Ms Ashika Ram that if Divesh were naughty Mr Sharma would ‘shut him in the toilet in a rage’.

However, there are no other references to physical harm against the children by Mr Sharma.

Ms Shalini Johari had provided childcare to Divesh and Divya at her home since 2006. She stated that both children presented as happy and healthy, and were always happy to see their parents when they were picked up. Ms Johari stated that at no time did either child ever

indicate that they were unhappy or scared about going home, nor did they present with any

38 Statement of Ms Amrita Ram, Exhibit 15, inquest brief page 300.

• Ibid.

® Second statement of Ms Ashika Prasad, Exhibit 4, inquest brief page 277.

“ Thid.

© Ibid page 279.

© Statement of Ms Reshmi Singh, Exhibit 15, inquest brief page 304.

** Statement of Ms Victoria Lines, Exhibit 9, inquest bricf page 337-8.

% Second statement of Ms Ashika Prasad, Exhibit 4, inquest brief page 278.

unexplained or suspicious injuries.“* Mr Sharma’s mother, Ms Jai Sharma, stated that some time after 22 April 2012, Ms Sharma was unnecessarily angry with the children and shook Divesh by the back of the neck, stating that she was going to ‘kill both of them some day’ and kill herself,’ There is no other evidence that Ms Sharma had threatened harm against the

children.

Separation and Reconciliation between Mr and Ms Sharma

The separation between Mr and Ms Sharma occurred some years prior to the fatal event, however it is worthy of noting in terms of the factors that led to it. In 2009, shortly after Divya’s birth, Mr Sharma found an email addressed to Ms Sharma from a male she had been in a relationship with before they werc married. Ms Sharma had reportedly become pregnant, and had terminated the pregnancy. Mr Sharma accused Ms Sharma of being unfaithful (despite the relationship having occurred before he met Ms Sharma), and initiated a

separation. They remained living in the same home but slept in separate bedrooms.

Witnesses stated that the separation was known widely among friends, family members and work colleagues. Of note are the many people who were made aware of Ms Sharma’s pregnancy termination, which was conveyed by Mr Sharma. This included Ms Sharma’s

father and family, who had not previously been aware of this information.

Ms Sharma remained living with Mr Sharma, seemingly for the children.** She disclosed to Ms Prasad that she could not complain to police about Mr Sharma because she was afraid that they would force them to separate and that the children would be removed from her care. Ms Sharma told her that that Mr Sharma said that he had ‘gone to child welfare and arranged

custody of the kids as soon as they separated » 9

Ms Sharma had advised her manager at work, Ms Chloe Hall, of the separation and atrangements were made for her early return from maternity leave. Ms [all’s statement indicates she was quite direct in asking Ms Sharma about the reason for the separation, and

she stated that Ms Sharma denied any physical violence.*® Ms Hall states that she would

46 Statement of Ms Shalini Johari, Exhibit 15, inquest brief page 319.

4” Statement of Ms Jai Sharma, Exhibit 15, inquest brief page 221.

48 First statement of Ms Ashika Prasad, Exhibit 3, inquest brief page 272.

” Second statement of Ms Ashika Prasad, Exhibit 4, inquest brief page 280.

• Statement of Ms Chloc Hall, Exhibit 10, inquest brief page 342.

intermittently ask how Ms Sharma was going, as she was aware that they were still living in the same house,”

In January 2010, Mr and Ms Sharma informed their family members that they had decided to

remain married and to reconcile. Ms Sharma also told Ms Hall in January 2011 that they had

resumed their relationship and that things were going well.”

Evidence of Help Seeking — Victoria Police

Aside from the motor vehicle crash, the family had no historical contact with police recorded on the Law Enforcement Assistance Program (LEAP) database. In particular, there were no recorded family violence incidents involving the family prior to their deaths.°? Enquires made by the CPU with the Women’s Domestic Violence Crisis Service revealed that there was no

record of Ms Sharma having had sought assistance from them.

Evidence of Help Seeking — Health Services

Since moving to Australia, the family had attended the Brandon Park Medical Centre. Neither Mr Sharma nor Ms Sharma had been treated for depression or any other mental iliness during

this time.

Dr Jabeen Syeda was the Sharma family’s general practitioner from 2005. Both Mr Sharma and Ms Sharma consulted with Dr Syeda aftcr the motor vehicle collision and were always together. This was likely to have inhibited Ms Sharma’s ability to raise concerns or freely - discuss her situation if she were inclined to do so. However, Dr Syeda described the couple as friendly and remarked that the children were well looked after by their parents. He stated ‘both Nilesh and Preetika always showed very caring behaviour towards each other?" Dr Syeda described Mr Sharma as a pleasant and positive person, who never expressed concerns

regarding his relationship or psychological issues.

As part of this investigation, DLSC Price sought information from Medicare to ascertain details of other medical professionals seen by Mr and Ms Sharma. Dr Sylvia Lim-Tio,

Endocrinologist, provided assistance to Mr Sharma for possible low testosterone from January

5! Statement of Ms Chloe Hall, Exhibit 10, inquest brief page 342.

Ibid.

% Police summary of evidence, Exhibit 1, inquest brief page 11.

• Statement of Dr Jabeen Syeda, Exhibit 15, inquest brief page 81.

55 yn: Ibid.

54,

55,

57,

2009 to May 2011. Dr Lim-Tio stated that Mr Sharma’s symptoms included ‘fatigue, moodiness, lack of libido but in the context of having changed jobs twice in 12 months, two small children and long hours at work’°* Medical investigation revealed that his levels were in the normal range and treatment was not commenced, The statement of Dr Lim-Tio indicates that she had raised with Mr Sharma that he might be depressed and should consider secing a general practitioner, however he denied being depressed or requiring help. Dr Lim-Tio had not

seen Mr Sharma for a year prior to his death.*”

After being discharged from hospital following immediate treatment for their injuries, Ms Sharma was transferred to the VRC. Mr Sharma was later referred for multidisciplinary

outpatient assistance by his gencral practitioner.

Dr Sarah Abrahamson was the rehabilitation physician for Ms Sharma while she was an inpatient (6-15 January 2012) and as an outpatient up until her death. While treating Ms Sharma, Dr Abrahamson stated that she did not ask about the cause of the crash and that this was not discussed. Dr Abrahamson stated that Ms Sharma revealed very little personal information, which she acknowledges might have been due to cultural differences (stating that Ms Sharma’s English skills were excellent and that language was therefore not an issue), however, Ms Sharma did not show signs of psychological distress. She did express concern on 13 January 2012 that Mr Sharma had not returned to work and had no rehabilitation follow up.

Dr Abrahamson suggested that Mr Sharma obtain a referral for the vec

Ms Sharma undertook a psychological screen with Ms Mary Sandiland on 12 January 2012 while she was an inpatient at the VRC. She reported that her mood was good when not in pain, and stated she had no prior mental health issues. While her answers were described as succinct, this was not interpreted as reason for concern by the psychologist. It was concluded

that there were no significant psychological issues requiring intervention.”

Dr Ircna Churilov was the rehabilitation physician for Mr Sharma. She states that Mr Sharma had reported ongoing cognitive and physical symptoms, including problems with his memory

ability to concentrate and fatigue. She further stated that ‘his mood fluctuated, his sleep was

56 Statement of Dr Sylvia Lim-Tio, Exhibit 8, inquest brief page 92.

5" Ibid,

Statement of Dr Sarah Abrahamson, Exhibit 15, inquest brief page 94. While Dr Abrahamson was on holidays, Ms Sharma was sccn by Dr Regina Hoeppner on two occasions. She also states that Ms Sharma did not raise any concerns about her mental state or rclationship.

• Statement of Ms Mary Sandilands, Exhibit 15, inquest brief pages 95-6.

disrupted, and he felt his overall cognition was worse than premorbidly’° Dr Churilov referred Mr Sharma to multidisciplinary rehabilitation that included physiotherapy, occupational therapy, social work and psychology, as well as a neuropsychological assessment,*! There is no reference to indicate that Dr Churilov had inquired with Mr Sharma specifically about suicide or family violence, however, she notes that he did not disclose any

concems about his wife or children.”

Mr Sharma was seen by Dr Simone Field, Clinical Ncuropsychologist, as an outpatient on 7 February 2012. He undertook neuropsychological assessment on four occasions during February and March 2012. During these sessions he complained about the onset of headaches when cognitively challenged. After the assessment, he was offered, and accepted, additional neuropsychological sessions to learn relaxation techniques to address his headaches and stress. Mr Sharma completed a self-report of mood looking at areas such as anxiety, stress and depression, with his responses reportedly normal. He attended two 50-minute sessions on 22 March and 2 April 2012, where he learnt relaxation techniques.“ Dr Field’s statement does not suggest that his presentation during her contact with him alerted her to any possibility of

homicide-suicide.

Medical records for Mr and Ms Sharma from the VRC also do not reveal concerns about Mr

Sharma’s behaviour or comments made by Ms Sharma about possible emerging violence.

Evidence of Help Seeking — Faith Leaders

Statements provided by Mr Sharma’s family indicate that he had been a religious person, and that prayer sessions were oftcn held to mark major life events and to help address problems.

Mr Hemant Sharma met Mr Sharma in Melbourne in 2002. He described himself as a Hindu minister, and stated that he was a distant relative. He stated that Mr Sharma used to attend the Hindu temple at 88 Princess Highway, Dandenong, and described him as a keen supporter of

the organisation.” After Mr and Ms Sharma marricd in Fiji and moved to Australia, Hemant

© Statement of Dr Irina Churilov, Exhibit 15, inquest brief pages 83-4.

5! Ibid page 84.

® Thid page 83.

§ Statement of Dr Simone Field, Exhibit 6, inquest brief pages 86-7.

5 Thid page 87.

§5 Statement of Mr Hemant Sharma, Exhibit 15, inquest brief page 312.

63,

Sharma conducted various prayer rituals, including when Ms Sharma came to Australia, when

the children were bor and following the death of Mr Sharma’s father.

Hemant Sharma stated he had never spoken to Mr Sharma about any problems and never expressed signs of depression. Mr Sharma had never discussed suicide, and had in fact been critical of people who suicided. After the motor vehicle crash, Mr Sharma asked Hemant Sharma to check the family’s horoscopes to sce if there was any ‘bad luck’ on them. Hemant Sharma states that he did this and advised Mr Sharma that ‘for his wife and his children they had a little bit more [bad luck] that was not good and to remedy this then they would be required to take part in some prayers’ Mr Sharma was reportedly keen to do so and Hemant Sharma attended their home on 19 February 2012. However, Mr Sharma requested a few more weeks as Ms Sharma was still unable to sit on the floor due to her back injuries. Hemant Sharma stated the news of the family’s death was very surprising, and he was not aware of

anything that would cause Mr Sharma to do this,”

Witness statements do not identify a major conflict between Mr and Ms Sharma, nor escalating family violence, and there was no reference to another separation taking place.

Witnesses were not aware of Mr Sharma having had thoughts of suicide and there is no documented history of prior suicide attempts. In addition, the family were not in immediate financial difficulty, with Ms Sharma described as being positive about her anticipated return

to work.

The main change in Mr Sharma’s circumstances proximate to the fatal event was his recent return to employment. While he had been assisted by VRC to undertake a gradual return, and appears to have been well supported by his employer, he had expressed to family members that he was slower in completing tasks and was experiencing difficulties with his memory. Mr Sharma reported that he was still experiencing headaches and was described by his sister as negative about work and his health in the days leading up to the fatal event. However, both Mr

and Ms Sharma had been seen by multiple health professionals in the weeks following the

• Statement of Mr Hemant Sharma, Exhibit 15, inquest brief page 313.

“"Thid.

% Ihid page 314.

• Ibid.

® Thid page 316.

crash, While not directly assessing for family violence or the potential for homicide-suicide, it

appcars there were no outward signs to indicate concer for the welfare of the family.

Inquest

Pursuant to section 52(2) of the Coroners Act 2008, inquests into the deaths of Preetika, Divesh and Divya Sharma were mandated as it is suspected that the deaths were the result of homicide. I exercised my discretion to hold an inquest into Mr Sharma’s death pursuant to section 52(1) of the Act, and held a joint inquest into all four deaths pursuant to section 54 of the Act. Expert opinions were sought from the family violence sector to gain an increased understanding of the risk factors identified, particularly those of cultural significance, and

prevention interventions.

Expert Evidence

Dr Ruchita Ruchita

67,

Dr Ruchita Ruchita, Case Worker at the inTouch Multicultural Centre Against Family

Violence (inTouch) provided an expert report to the Court’' addressing the following matters:

• the socio-cultural and religious beliefs practiced in India that relate to gender roles,

discrimination and violence against women

• social practices

• barriers for Indian women living in Australia experiencing family violence.

Dr Ruchita was asked by the Court to provide her report in general terms, and in relation to several open coronial investigations involving family violence deaths of people from Indian background,” including the deaths of the members of the Sharma family. Dr Ruchita also examined the circumstances of each of these deaths, and provided an opinion on the sociocultural and religious factors that might have contributed to the deaths. Dr Ruchita also testified at inquest and clarified that her report detailed factors that ‘could have been’ relevant to the deaths, against the background of the general issues that Dr Ruchita outlined regarding

social, cultural, religious, legal and other factors.”

Dr Ruchita’s report aimed to provide,

1 Exhibit 11, report of Dr Ruchita Ruchita dated 4 July 2014.

® COR 2009 2344 Mohinder Kaur; COR 2012 2038 Anitha Mathew; COR 2012 2039 Mathew George; COR 2012 2040 Philip George; COR 2012 2201 Nidhi Parashar and COR 2012 2202 Asim Kumar.

® Inquest transcript pages 84-5.

anecdotal evidence and an in-depth analysis of the practical aspects of how culture, norms and values manifest themselves into the ‘everyday’ life of Indians, and how they influence people's choices, decisions and actions in relation to self harm or harm to others within the family context.”

68. In Dr Ruchita’s specific analysis of the circumstances of the deaths of the Sharma family, she explained that being of Fiji Indian background, they had similar cultural, social and religious beliefs to people from an Indian background. Dr Ruchita identified the following as possible

contributing factors:

• arranged marriage

• — infidelity

~ gender roles and expectations

• family violence as a personal matter

• joint family system

• birth of female child in the family

• separation/divorce and reconciliation

• family violence not disclosed to police or other services

• professional help versus horoscope reading and religious prayers.”

69. Dr Ruchita concluded, specifically regarding the deaths of the Sharma family, that ‘cetural and religious beliefs could have been a major contributing factor’.” She cited examples of cultural norms such as Mr and Ms Sharma’s arranged marriage, living with Mr Sharma’s mother and looking after the needs of his family, and verbal and emotional abuse by in-laws.

Dr Ruchita explained that /ajlthough physical and financial abuse was not ongoing, Preetika was controlled by Nilesh as reported by witnesses. Indian women take that as part of being married and do not complain about it.”

70. Dr Ruchita also explained that infidelity and pre-marriage sex and pregnancy is taboo for

Indian women, that divorce is not accepted in the community and that culturally, family

% xhibit 11, report of Dr Ruchita Ruchita dated 4 July 2014 page 2.

• Thid pages 8-11. An extract of Dr Ruchita’s report that touches on the deaths of the members of the Sharma family is attached at Appendix A.

• Thid page 11.

" Tid.

violence is a personal matter, and is the reason Ms Singh did not intervene when Ms Sharma reported threats to her life. Dr Ruchita also noted that, whilst there was no direct link between the deaths and the religious practice of horoscope reading to address personal problems, Mr Sharma sought assistance by these means rather than sccking professional help from qualified

practitioners.”

Dr Ruchita provided evidence about culturally and linguistically diverse (CALD) specific programs that have been implemented across the health, justice, education and human/community services sectors to identify family violence, assess risk and provide assistance. She explained that inTouch provides direct crisis intervention and family violence support services to CALD women experiencing family violence in Victoria. The service includes 12 bicultural and multilingual workers who speak 26 languages, and includes the provision of culturally appropriate family violence support.” Dr Ruchita made several general (not case-specific) recommendations for interventions to reduce the incidence of family

violence within CALD communities, including:

• funding for increased CALD-specific services at magistrates’ courts

• education programs for faith leaders, given their position as role models in the

community

• programs targeting international students

• education for newly arrived migrants by consulate offices and settlement providers

• culturally appropriate training for staff of organisations that work with victims of family

violence at the point of crisis

• engagement of CALD communities in changing behaviour and attitudes to reinforce

gender equality

• engagement of CALD media outlets to convey prevention messages on an ongoing basis

• language-spccific men’s behaviour change groups for non-English speaking men of

CALD backgrounds.®"

*8 Exhibit 11, report of Dr Ruchita Ruchita dated 4 July 2014 page 11.

” Thid page 16.

® Ibid pages 20-1.

Ms Fiona McCormack

74,

Ms McCormack provided an expert opinion to the Court. She also provided her report in general terms in relation to scveral open coronial investigations involving family violence deaths of people from Indian background®! in addition to the deaths of the Sharma family. Ms McCormack is the Chief Executive Officer of Domestic Violence Victoria, the peak body in

Victoria for specialist family women and children’s family violence services.

Ms McCormack stated that violence against women, rather than being the result of any single factor, is the outcome of multiple determinants including gender roles and relations, social norms and practices relating to violence against women and exposure to violence, and access to resources and support systems.” Ms McCormack further stated that ‘fe]vidence tells us that violence against women and their children is globally pervasive and not confined to culture, relation or particular groups of women within society’, but that ‘research demonstrates that

ethnicity and culture are significant determinants of women's vulnerability to violence’ .*

With respect to barriers to accessing family violence support for CALD women, Ms McCormack identified possible barriers as including cultural appropriateness of scrvices, language barricrs and lack of awareness of community services and support available through the Australian legal system. She noted that a common theme throughout the cases reviewed was the relatively high levels of dependence the women had upon their partners, and that ‘this

can act as a powerful deterrent for women seeking support’

Ms McCormack also addressed programs in place in Victoria and referred to the 2013 Victorian Multicultural Commission document, ‘Domestic Violence Service and Support Available though Victorian Government and Community Sector Agencies’ ,®° which identifies most of the family violence services in Victoria, Ms McCormack stated that there are a wide range or services and programs available to women in Victoria, and specifically noted services

for CALD clients.*

5! COR 2009 2344 Mohinder Kaur; COR 2010 0463 Sirin Bayram; COR 2012 2038 Anitha Mathew; COR 2012 2039 Mathew George; COR 2012 2040 Philip George; COR 2012 2201 Nidhi Parashar and COR 2012 2202 Asim Kumar.

® Rxhibit 12, report of Ms Fiona McCormack dated 4 July 2014, page 3.

83 Ibid.

"4 Ibid page 5.

• Fxhibit 13,

86 Lixhibit 12, report of Ms Fiona McCormack dated 4 July 2014, pages 5-6.

76. Ms McCormack also made general recommendations for interventions, including:

• Department of Immigration and Border Protection (DIBP) providing newly arrived migrants with information about the Australian legal system, including family violence-

specific information

• The DIBP being required to bring to the attention of prospective spouses any information

about a sponsor’s family violence history and conviction®”

• outreach and awareness-raising on the impacts of family violence and help-seeking

• astatewide early intervention plan

• Department of Human Services (as it then was) determining family violence service

providers’ capability to respond appropriately to CALD clients

• additional resourcing for CALD-specific court workers

~ increasing state and commonwealth funding for culturally appropriate family violence service delivery

• state and commonwealth government action for primary prevention of family violence, to

prevent violence before it occurs.

77. In reference to evidence that no services or agencies that had contact with Mr Sharma were aware of the presence of family violence, Ms McCormack stated that there are a range of agencies that encounter men who are a risk to others. She explained that Domestic Violence Victoria is currently advocating for better systems to share information across sectors where men are identified who are at tisk to others.” Although Mr Sharma was not specifically identified as a risk in the sense Ms McCormack is talking about, I agree with the emphasis she

places on information sharing.

78. Ms McCormack also recommended working within CALD communitics to educate about the

increased risks of CALD women of family violence, and to challenge beliefs that generate

57 Whilst not relevant to the circumstances of the deaths of the Sharma family, the role of the DIBP in providing newly arrived migrants with information about the Australian legal system generally and Australian law regarding family violence was examined in my investigation and inquest into the deaths of Sargun Ragi (COR 2012 4184) and Avjit Singh (COR 2012 4188), I intend to address this in detail in my findings in these matters.

8° Exhibit 12, report of Ms Fiona McCormack dated 4 July 2014, pages 6-8.

• Inquest transcript page 95.

79,

violence.” Based on their experience and expertise, Dr Ruchita and Ms McCormack have good reason to identify this issue in the terms they did. I agree with their opinion, although this case docs not provide the basis for a formal rccommendation on this point. Ms McCormack also stated that improvement to scrvices requires coordination across the health and justice systems, including police, corrections, cducation and community services.” Again,

I agree with this general proposition.

Ms McCormack agreed with Dr Ruchita that family violence other than physical violence is often not understood by members of CALD communities to constitute family violence, | agree with them that good, clear, rcliable information should be provided to CALD communities in a culturally appropriate way.”” They have highlighted a significant problem, and I infer from the facts of this case that it is probable that neither Mr or Ms Sharma understood, (or perhaps had not been informed), that violence other than physical violence can constitute family violence and that this is the Australian legal position. The answer in part will always lie in better information provision to those coming into our community, and a targeted approach to informing members of CALD communities about the varying forms that family violence can

take, and which are recognised by our legal system.

Conclusion

The standard of proof for coronial findings of fact is the civil standard of proof, on the balance of probabilities, (with the Briginshaw™ gloss or explication), The effect of the authorities is that coroners should not make adverse findings against or comments about individuals, unless the evidence provides a comfortable level of satisfaction that they caused or contributed to the

death.

The evidence gathered assisted to better understand the relationship between Mr and Ms Sharma, and the context and potential factors that led to the deaths of the Sharma family. Iam unable to conclude that any one particular factor referred to by either Dr Ruchita, Ms

McCormack or by other witnesses, has necessarily been the significant stressor in this case.

° Tnquest transcript pages 97-8.

°! Thid page 98.

• Thid pages 99-100.

° Briginshaw v Briginshaw (1938) 60 CLLR. 336 esp at 362-363. ‘The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the

reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences...’

83,

Mr Sharma’s reasons for taking his own life and that of his wife and children remain unknown. In the week prior to his death, he described experiencing headaches and some difficulty completing work tasks he had previously found easy. Witness statements indicate that he did not disclose thoughts of suicide to family members or health care professionals.

While there was evidence of a history of family violence, with the exception of Ms Sharma’s comment to Ms Singh that Mr Sharma had threatened her life, there were no other reported threats to or attempts on her life. The evidence suggests that Mr Sharma might have been feeling frustrated, depressed or negative about his circumstances and work prospects following his injuries. This appears, on the evidence, to be the only proximate stressor or

motivation for his actions.

This investigation had dealt with the tragic, largely unexplained (and probably inexplicable} deaths of an entire family. For the purposes of section 67(1)(b) of the Coroners Act 2008, Iam satisfied that the deaths of Ms Sharma, and Divesh and Divya Sharma were the result of homicide, and that they were caused by Mr Sharma between 28 and 29 April 2012. I find that

Mr Sharma then intentionally took his own life.

Under scction 48 of the Coroners Act, the Principal Registrar must notify the Director of Public Prosecutions if a coroner determines that an indictable offence may have been committed in connection with a death. If Mr Sharma were alive and had not yet been charged with any offence in rclation to the deaths of Ms Sharma, Divesh and Divya, [ would have asked the Principal Registrar to make such a referral. However, referral to the Director is futile

in the circumstances as Mr Sharma is deceased,

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, [ make the following comment(s) connected.

with the death:

The Court has examined the intersection between CALD status and family violence previously. Family violence exists within, and is influenced by, religious, ethnic and cultural contexts. While it is important to avoid generalisations and stereotypes, cultural valucs and

belicfs can have implications for the way in which violence is experienced.” Further, CALD

• Bartels, L. 2010, Emerging issues in domestic/family violence research, Research in Practice Report, No. 10, Australian Institute of Criminology, Canberra, ACT.; Fawcett, J., Starr, K. & Patel, A. 2008, Now that we know: Findings from the Washington State Domestic Violence Fatality Review, Washington State Coalition Against Domestic Violence, Washington.; Bonar, M. & Roberts, D. 2006, A review of the literature relating to family and domestic

victims may also encounter greater difficulty eliciting assistance and support from mainstream

service providers.”> There are many reasons for this.

86. A broad range of cultural groups have been represented among the fatal incidents investigated by the Court to date, and cultural and linguistic diversity has been a salient feature. Cultural and. language barriers, traditional views of marriage, social isolation and a reluctance to speak out about abuse due to the negative perceptions of others have previously been identified as

relevant factors that shaped the victims’ experiences of violence.

87. Ms Sharma’s reported reluctance to seek assistance from the police, because she was afraid that her children would be taken from her, is consistent with the themes discussed and recommendations made by Dr Ruchita and Ms McCormack. Ms Sharma may well have not understood the Australian legal system and policing system. Migrants to Australia from a CALD background need to be given every opportunity to understand the system and have confidence in it and its institutions. This case presents as a reminder of the need for police and/or family violence services to increase awareness of the role of and trust in police in

addressing family violence among members of the CALD community.

I direct that a copy of this finding be provided to the following: Mr Shailesh Sharma, Senior Next of Kin Ms Margaret Leech, Marshalls & Dent Lawyers Ms Anna Chapman, Victims of Crime Assistance Tribunal Dr Irena Churilov, c/o Ms Naty Guererro-Diaz, Avant Law Acting Chief Commissioner Tim Cartwright, Victoria Police The Hon Wade Noonan MP, Minister for Police Dr Ruchita Ruchita, inTouch Multicultural Centre Against Family Violence Ms Fiona McCormack, Chief Executive Officer, Domestic Violence Victoria Detective Leading Senior Constable Chris Price, Victoria Police, Coroner’s Investigator

Sergeant David Dimsey, Police Coronial Support Unit.

violence in culturally and linguistically diverse communities in Australia, Department of Community Development, Family and Domestic Violence Unit, Western Australian Government, WA.

5 Garcia, L., Soria, C., & Hurwitz, E.L, 2007, ‘Homicides and intimate partner violence: A literature review,’ Trauma, Violence and Abuse, vol. 8., no. 4., pp. 370 — 383.

Signature:

an Can,

JUDGE IAN L STATE CORONER

Date: % L>0)$—

Appendix A

Extract of report of Dr Ruchita Ruchita

Gourt Reference Number 20121542

20121543 20121544 20121545

sharma Family

As: mentioned in the case summary, this couple came from a Fifi Indian background, Generally, people from a Fiji lidian background have similar cultural, social, and religious beliefs to people from an Indian background. In this case, the te following socid-cultural/religious factors could have been a contributing factor:

Arranged marriages: In this case, Preetkka was Introduced to Nilesh Sharma via family connestlons for the purpose of an arranged marriage.

It is the most common form of marriage in the: india where even though in majority of cases women and men are given an opportunity to meet their potential spouse, they have limited choice to refuse, Women have to abide by the wishes of her family. The report does not suggest that there was any unwillingness by any party.

Marriage is not only the union of two individuals, but it is between two families. The wife is expected to live with husband’s family and cater the nedéds of not only her husband but also the whole farnily, If she is unable to do so, she is abused verbally and emotionally by whole family, especially mother-in-law. In this case, Nilesh’s mother was living wlth the deceased

couple and did not seem very happy with Preetika, according to her statement given to police.

Infidelity:

Infidelity (Adultery) is a ground for divorce in India. Pre marital relation, sex and pregnancy ts not acceptable at all and disclosure of such could result in- abuse. In this case the couple separated shortly after the birth of Divya in 2009, when Nilésh found out about a previous relationship Preetika had been involved In before they were married. In some cases, abuse starts subtle with these kinds of disclosures which could progress fo silent treatment, separation, lack of communication, verbal and psychological abuse.

in this case, Nilesh disclosed about Preetika’s pregnancy termination to many people to lower-

her. image in the wider community as well as her family.

Gender roles and expectations:

In India, the wife’s role has traditionally been understood as submissive, docile and that of a home maker, and women are sometimes kept in slavery like conditions,

Indian women go through marital discord, family violence; frauds, marital rape, harassrnent,

dowry torture, threatening and blackmail by spouse. Women also bear pressure from families

from bath sides alang with social and cultural pressures.

Every argument between a couple may lead to a threat to the woman to pack her bag and leave the house, knowing quite well that it would:shut her up and she would never do that._

‘Birth of female child in family:

Sense of ownership for femates is there especially for wives and daughters. Physical violence used if woman speaks back or questions.

n this case, there was evidence of family violence involving Preetika and Nilesh, primarily In the form of controfling and fsolating behaviour.

The statement of Jal Sharma, notes that “at times Preetika would talk back to Nilesh a ot”

Talking back or questioning a husband is not acceptable and woman Is expected to be submissive. She has to abide by all the directions of her husband and his family.

Family violence as a personal matter:

Friends do not want to intervene even If they know there is tension in the relationship.

At inTouch Indian clients have reported that if she has shared her story relating to abuse with common friends, they do not want to get involved as they think {t is personal matter. Male frlends do not want to get Involved thinking that it might influence their wives and give them ideas to retaliate.

In this case, Reshmi acknowledged that she did not take the message sent by Preetika as serious, She assumed that everything was good as Preetika and Nilesh have always portrayed themselves as a normal couple.

Reshml stated that while Preetika was at the VRC, she sent Reshmi a text message to the effect that Nilesh had tried to kill her. Reshmi did not take this message seriously, and when she rang Preetika back, she told Preetika that she was being silly.

Friends don’t want to be blamed for breaking up a marrlage by wider Indian community.

Preetika discussed her situation with work colleagues, but not with community members out

of fear of shame and stigma. When Preetika was offered help by colleagues, she did not accept it as it would be shameful to seek help from soméone outside the family for matrimonial matters. . '

• Women cannot go out to seek help. If she tries to raise an issue with his family or her own

family, she is not heard or the Issue is not addressed.

Joint family system:

Women are expected to live with their husband's family after marriage. She has to serve the needs of not only her husband but also for his family.

In this case, Nilesh’s mother was also living with the Sharma couple although she was not

‘present at the time of fatal accident. After marrying and. moving to Melboume, Preetika had

once told her sister that Nilesh’s family had treated her like a servant and expected her to cook and clean for them while they socialised.

‘These family and cultural expectations put women in‘an inferior position and amounts to

emotional, psychological abuse,

A girl is taken as being burden on the family whereas a male child fs. taken as being old age insurance. Son Js called as KULDEEPAK (Torch bearer for clan, one who Is going to take lineage further).

Girls are deprived of good food and education to save money for their dowry. Giving, birth to males improves the position of woman amongst in-laws and the whole society. Giving birth to females lowers the status of women and she has to face her in-laws adversely, especially her.

mother-in-law.

Having female child displeases the husband and his family. ! worked with a woman recently, who was doserted by her husband because she gave birth to a female. This woman was pressurised to terminate the pregnancy. .

In this case, Preetika was also worrled while she was expecting Divya.

"Preetika having held concerns when she was pregnant with Divya that she might have a daughter and this would displease her mother-in-law.”

Separatlon/ Divorce and re-conciliation:

Marriage is perceived for seven births to come not only this life time. Divorced girls face a lot of humillation from the society. People refrain from socialising with divorcees (women only, men can get re married easily even after divorce) as. they think that the negative vibe will rub off on them or their families. Such sensitive and vital consequences often stop women to move out of relationships.

If a woman separates from her husband, she is: pressurised by her famlly, frlends and the community to reconcile. The majority of my clients at InTouch report that they have to go back to their husbands otherwise they will be outcast by everyone, Currently, | am working with a client from Fiji Indian background, who is under tremendous pressure to revoke her IVO and go back to her husband. She does not want to do that, but families from both sides are threatening her for breaking all the ties with her, if she is not abiding their order.

In this case, Preetlka separated once but then went back to him as she did not want her children to be without thelr father, as reported In summary.

Family Violence not disclosed to Police or other services:

Indian wornen are reluctant to disclose family violence for various reasons. These could be fear of consequences back home; the perpetrator may retaliate in some other way or mistrust of mainstream culture and authorities, Sometimes, by reporting tha matter to police, a woman does not find an immediate solution to thelr crises. They feel their husband deserves a second chance to save their marrlage, even if they never felt happy, safe, respected or cared by their spouse.

In this case, Ashika Prasad stated that Preetika did not seek assistance from the police because she was afrald they would force separation and that they would take her kids away from her. : ,

The couple-never showed any sign of tension in their relationship, when they accessed services from Brandon Park Medical Centre and the Victorian Rehabilitation’ Centre. This could be due to keeping family dignity and integrity in front of world outside.

Professional help v/s Horoscope reading and religious prayers:

Hindus believe in astrological charts. An astrologer/ horoscope reader makes that chart as per date, tlme, and place of birth. He normally advises peaple to do certain religious prayers or charity to avoid bad luck, bad health. Even before fixing the marriage, horoscope charts are mapped to see if the couple are going to be compatible,

n this case, Nilesh approached a horoscope reader to look af their hordscopes as he wanted ‘0 know If they needed to do some prayers and if there was some bad luck on them, the reader advised: Nilesh to have religious prayers to fix his headache.

Horoscope readers:also advise about religious prayers and donations as part of a remedy to ix any problem such as performance in studies, health ailment or fixing marital problems etc,

Rather than seeking professional help from services, the majority of hindus tend to fix all their problems with religious prayers. However, very little is known if Nilesh has approached a horoscope reader for matrimonial discord.

Gonclusion

The case summary of the Sharma family murder suicide mentions vartous, factors that contributed homicide such as mental health and work pressure. However’ cultural and religious beliefs could have been a major contributing factor, Cultural norms like the arranged marrage of Nilesh and Preetika, living with the husband's family and looking after the needs ~ of all of them have been mentioned in,the case summary. Ongoing verbal and emotional abuse by In laws family has been reported, which is very common in Indian women.

Although physical and financial abuse was not origoing, Preetika was controlled by Nilesh as reported by witnesses. indian women take that as part of being married and do not complain

about it,

Infidelity and pre marrlage sex and pregnancy Is a taboo for Indian women and this was the major reason for separation between the couple. Agaln, divorce is not accepted amongst wider Indian community, Preetika chose to reconcile with Nilesh due to cultural pressures.

Culturally, family violence is taken as personal matter, so Reshmi did not intervene when this

was disclosed to her.

Although there does not seem to be a direct link with religious practice of horoscope reading to flx personal problems, it seems Nilesh tried it rather than seeking professional help from

services,