Deceased
Sargun Ragi
Demographics
22y, female
Coroner
State Coroner Judge Ian L Gray
Date of death
2012-10-04
Finding date
2015-10-30
Cause of death
Effects of burns
AI-generated summary
Sargun Ragi, a 22-year-old woman recently arrived from India on a spousal visa, was killed by her husband Avjit Singh in October 2012 after obtaining an intervention order and leaving their relationship. The coroner found Victoria Police inadequately responded to multiple breaches of the intervention order, specifically telephone contact breaches that indicated escalating risk. Police failed to submit updated L17 risk assessment forms and did not arrest Singh despite repeated violations. The response was passive rather than active, contrary to the Code of Practice. Systemic deficiencies included failure to track cumulative breaches, lack of information sharing between police officers, and insufficient escalation. Cultural and patriarchal attitudes contributed to Singh's behaviour. Key lessons: repeated contact breaches can indicate serious escalating risk; dynamic risk assessment is essential; proper documentation and review of previous risk assessments enables better protection.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
Court Reference; 2012 / 4184
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of: SARGUN RAGI
Delivered On: 30 October 2015
Delivered At: Coroners Court of Victoria 65 Kavanagh Street, Southbank
Hearing Dates: 24, 25 and 26 November 2014 Findings of: JUDGE IAN L. GRAY, STATE CORONER Representation: MS C. HOLT and MS K. THOMAS appeared on
behalf of the Department of Immigration and Border Protection.
MRS. REID appeared on behalf of the Chief Commissioner of Police and Police Members
MR M PAGE appeared on behalf of Mr Jasraj SinghSidhu
Police Coronial Support Unit SERGEANT D. DIMSEY
I, JUDGE IAN L GRAY State Coroner, having investigated the death of SARGUN RAGI
AND having held an inquest in relation to this death on 24, 25 and 26 November 2014 at MELBOURNE
find that the identity of the deceased was Sargun Ragi
born 17 August 1989
and the death occurred 4 October 2012
at 80 Belford Road, Kew East
from:
1 (a) EFFECTS OF BURNS
in the following circumstances:
This is a shocking case of family violence perpetrated by a man seemingly determined to exact vengeance on a woman who had obtained the protection of an intervention order. Ms Sargun Ragi (Ms Ragi) had done all she could to ensure her own protection from her husband, Mr Avjit Singh (Mr Singh) through the legal system. It was to no avail. Ms Ragi
was highly vulnerable and it appears that cultural factors were also against her.
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 explore whether any lessons can be learnt, which might prevent similar deaths in the future. This role is one of two parallel functions of the modern coronial system.
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 I am permitted to conduct surrounding the circumstances of a death
that gives rise to my ability to consider broader issues of public health and safety. These
considerations form the second parallel purpose of a coronial investigation into a death. This purpose has been enshrined in the Preamble of the Coroners Act 2008 (Vic), which sets out
that the role of the 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.
Sargun Ragi was born was born in India on 17 August 1989 to parents Anureet Kaur (mother) and Mandip Singh (father). Ms Ragi had one sibling, Prabhjeet Singh. Ms Ragi had
a graduate degree in Arts and had completed a travel and tourism course.
In July 2011, while visiting India, Mr Avjit Singh and his father, Gurmit, met with Ms Ragi’s uncle, Ravi. Gurmit was friends with Ravi and had known him for about 20 years.
Ravi arranged for Mr Singh to meet Ms Ragi. Within one or two days, Ms Ragi and her grandmother, Kawal Ragi, travelled from New Delhi to Amritsar to meet Mr Singh and his family.
Usual Indian custom dictates that the families who are undertaking an atranged marriage will do their due diligence into the respective families. This usually takes more than seven days, sometimes several weeks. On this occasion, as Gurmit had known Ravi for so many
years, Mr Singh and Ms Ragi immediately got engaged to be married.
On 24 July 2011, Ms Ragi and Mr Singh were married in Amritsar in a traditional Sikh wedding. On 25 July 2011, they registered their marriage at the local court.
Ms Ragi then stayed with Mr Singh and his parents. In September 2011, Mr Singh, who had been living in Australia since 2005, travelled back to Australia alone. Ms Ragi, who had not
yet been granted a spousal visa, remained with Mr Singh’s parents.
At the start of 2012, Mr Singh travelled back to India. Ms Ragi’s visa had been granted by that time, so they prepared to travel back to Australia together. On 24 May 2012, Ms Ragi
and Mr Singh arrived in Melbourne.
They first stayed in Coburg for approximately one month, with a couple, Shivoy and Parul, and their daughter. With help from one of Mr Singh’s friends, Jaspreet Mahwaha, they then moved to another property in Coburg. Living in this house were three of Mr Singh’s friends.
13,
On 9 August 2012, Mr Singh and Ms Ragi moved into a rental property in Fawkner where they lived by themselves. Mr Singh drove taxis at night, but Ms Ragi was not employed and stayed at home most days. The house was only fitted with basic necessities, including a mattress on the floor where they slept. There was no television, computer, refrigerator or landline telephone. Mr Singh was said to lock the doors when he left for work, taking the keys and Ms Ragi’s mobile telephone. The windows were left unlocked and Ms Ragi climbed out of these if she needed to. On several occasions, Mr Singh allegedly threatened Ms Ragi with deportation if she did not have sex with him. Ms Ragi alleged that, on more than one occasion, Mr Singh slapped her in the face and made her have sex with him. She said that he never physically forced her to perform sex but would use threats of divorce and
deportation. She stated that she also had consensual sex with him on other occasions.
On Wednesday, 15 August 2012, Ms Ragi spoke with her neighbour, Mr Alfred Villetri. She explained to him how unhappy she was in her relationship to Mr Singh. She climbed out a window and stayed in his house where they discussed the relationship. Mr Villetri called an Indian friend of his, who he believed to be a lawyer, Ms Hayat Dean-Thompson (Ms DeanThompson is a legal cost consultant). Ms Dean-Thompson agreed to help Ms Ragi and try to
find her different accommodation, away from Mr Singh.
Mr Singh returned home in the early hours of 16 August 2012, and discovered that Ms Ragi was not in the house. He asked Mr Vellitri if he had seen Ms Ragi, and he told him that he helped her out the window and she walked off down the street. Mr Singh later attended the Fawkner Police Station and reported her missing. Police door-knocked the area and located Ms Ragi in Mr Velletri’s house, where she had stayed that night. Ms Ragi then attended the Fawkner Police Station and made a statement in relation to assault, rape and false
imprisonment.
As a result of Ms Ragi’s allegations, Fawkner Criminal Investigations Unit commenced Operation Stallmen. Police searched Ms Ragi and Mr Singh’s house and seized several exhibits. Ms Ragi was not examined by the Family Medical Officer (FMO) as she stated she
had consensual sex with Mr Singh over several days.
Police obtained a complaint and warrant against Mr Singh and he was bailed to appear at Broadmeadows Magistrates’ Court on 20 August 2012. His bail conditions excluded him from the Fawkner address and prohibited him from contacting Ms Ragi in any way. Mr
~ Page 4 of 42 _
Singh was interviewed by Fawkner SOCIT’ in relation to rape and false imprisonment. He maintained that the sexual intercourse was consensual and he made ‘no comment’ in relation
to the locking of the only door. He was released pending summons.
Ms Dean-Thompson allowed Ms Ragi to stay at her mother’s home in Balwyn for several weeks. Ms Dean-Thompson assisted Ms Ragi with court appearances, money, food and a new mobile telephone. During this time, both Ms Ragi and Ms Dean-Thompson were
present when Mr Singh phoned Ms Ragi and asked her to take him back.
An interim intervention order was made at Broadmeadows Magistrates’ Court on 20 August
Commencing on 20 August 2012, Ms Dean-Thompson and Ms Ragi contacted four different
family violence welfare organisations. These were:
e inTouch (Multi Cultural Centre against Family Violence);
e Berry Street;
e Women’s Domestic Violence Crisis Service (WDVCS); and e Eastern Domestic Violence Service (EDVOS).
During these contacts, both Ms Ragi and Ms Dean-Thompson explained Ms Ragi’s situation regarding the violence that had occurred in her relationship with Mr Singh. Berry Street offered Ms Ragi refuge, but she refused initially as she was living with Ms DeanThompson’s. Ms Ragi later requested refuge at Berry Street but was refused as her request was then too late and no longer met the criteria (as it was more than one month after the violence occurred). Accommodation was also offered to Ms Ragi in Ballarat, but she
declined this as it was too far away.
Between June and September 2012, Ms Ragi saw several doctors. None of the post-assault
examinations revealed any physical evidence of assault.
While looking for work at a local supermarket, Ms Ragi met Mr Sanjeev Devgan and commenced a relationship with him. Ms Ragi did not tell Mr Devgan that she was married
and did not mention previous marital problems.
' Sexual Offences and Child Abuse Investigation Team
24,
Mr Singh obtained Mr Devgan’s telephone number and spoke with him. Mr Singh told Mr Devgan that he was Ms Ragi’s husband and to stay away from her as she was trouble. Mr Devgan was not deterred by Mr Singh, as he understood that they had separated. Mr Devgan ignored Mr Singh’s advice by continuing to see Ms Ragi. Mr Devgan later asked Ms Ragi about her relationship with Mr Singh and she said that they were divorced.
On 28 September 2012, Ms Ragi moved to 80 Belford Road, Kew East. This house was owned Ms Dean-Thompson’s friend, Hamid Jafari. Ms Ragi commenced living alone at the
address, but planned to have other people move in.
Approximately one to two days before the deaths of Ms Ragi and Mr Singh, Mr Singh spoke to his father on the telephone and told him that he had found Ms Ragi’s address and that he found out that Ms Ragi was seeing Mr Devgan. The evidence revealed that Mr Singh had
sought and used, the assistance of private investigator in his attempts to locate Ms Ragi.
At 7.00 pm on 3 October 2012, Mr Singh collected his taxi from the owner, Mukhdeep
Singh, and commenced his shift, taking several fares that night.
27,
29:
At approximately 2.07 am on 4 October 2012, Mr Singh went to Kmart in Cambellfield.
There he purchased a snap knife (box cutter), a pair of gloves, a wrecking bar, a flexible gas lighter, a wood chisel, a riveter, bolt cutters, a four-piece knife set and a five litre fuel can.
At approximately 2.43 am, he went to the BP service station in Fairfield where he filled the can with petrol, purchased a quantity of rope and a roll of masking tape. At approximately 4.21 am, Mr Singh got out of his taxi in Beresford Road, Kew East, one block from Ms Ragi’s house.
At approximately 7.30 am, the owner of the taxi, Mukhdeep Singh attended the Boroondara Police Station to report that Mr Singh had parked the taxi in Beresford Street, Kew East (as
was showing on the taxi’s GPS tracker).
At some time prior to 8.00 am, Mr Singh used the wrecking bar to force one of the front doors of Ms Ragi’s house. After he gained entry, Mr Singh attacked Ms Ragi and inflicted several injuries to her using one of the knives he had purchased. The attack was prolonged
and occurred in several rooms of the house. Ms Ragi’s throat was cut, causing a significant
34,
35,
injury. Mr Singh then poured petrol on Ms Ragi and lit her, most likely using the lighter he
purchased. Ms Ragi was alive when she was on fire, but soon died from her burns.”
Mr Singh also set fire to the bed in the front bedroom. Subsequently, Mr Singh also caught fire himself. It is unclear if Mr Singh intended to take his own life or caught fire unintentionally. Testing of what remained of Mr Singh’s clothing revealed no traces of
accelerant.
At approximately 8.00 am on 4 October 2012, police from Boroondara Uniform, who were responding to Mr Mukhdeep Singh’s report, noticed smoke billowing from the residential premises at 80 Belford Road, Kew East. Upon arrival, they were confronted with a house full of thick black smoke down to approximately 60cm from the floor. Over several minutes, police entered the house on numerous occasions but were forced out by thick black smoke
each time.
Police could hear Mr Singh’s voice in the front bedroom. They smashed the windows to the room where Mr Singh was trapped, but he was unable to move due to injuries. Police entered the house where they were confronted by thick black smoke and flames in the entrance to the hallway. Police made several unsuccessful attempts to retrieve Mr Singh,
needing to leave the house each time due to smoke inhalation.
Police eventually pulled Mr Singh through a broken window of the bedroom as members of the Metropolitan Fire Brigade (MFB) and Ambulance Victoria arrived. Mr Singh had received extensive burns to his entire body and the only clothes remaining were those around his waist. He also received lacerations to the front of his body from being pulled over broken glass.
At this point, the MFB informed police that they had located Ms Ragi, deceased, inside the hallway of the house. Police later observed injuries to Ms Ragi, apparently inflicted before the fire, as well as signs of an assault throughout the house.
The fire was thoroughly investigated and it was determined that it was caused by the actions
of Mr Singh. It is clear that Ms Ragi’s death was caused by Mr Singh, as was his own death,
? Autopsy report dated 4 December 2012, Dr Michael Burke, Forensic Pathologist, Victorian Institute of Forensic Medicine.
On 5 October 2012, Dr Michael Burke from the Victorian Institute of Forensic Medicine (VIFM) performed an autopsy on Ms Ragi. He determined the cause of death as ‘effects of burns’. He further stated that she had incised injuries across her neck, one of which had extended into the airway. These wounds did not involve any major blood vessels. The presence of soot in Ms Ragi’s airway suggested that she was alive at the time of the fire, The toxicology report indicated the presence of volatile compounds such as Toluene. This was
most likely due to Ms Ragi having petrol poured on her.
Ms Ragi’s death was included in the Court’s Victorian Systemic Review of Family Violence
Deaths (VSRFVD)*. The criteria for inclusion in the Review are:
a. the death was caused, directly or indirectly, by an offender through the
application of assaultive force or by criminal negligence;
b. the relevant parties (deceased and offender) were or had been (at any point in time) in an intimate or familial relationship as defined by the Family Violence
Protection Act 2008 (Vic); and
c. the death occurred in the context of family violence (including evidence of: a history of family violence between the deceased and offender as defined by the Family Violence Protection Act 2008 (Vic); pending or actual separation; or child custody dispute).
The parties involved in this incident were Ms Ragi and Mr Singh. Mr Singh’s actions caused Ms Ragi’s death. Ms Ragi and Mr Singh were married, but had recently separated. There was an identified history of violence perpetrated by Mr Singh against Ms Ragi. Prior to her death, Ms Ragi had contact with Victoria Police, the Courts and specialist family violence services. Based on this information Ms Ragi’s death met the criteria for inclusion in the
The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition, the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focussed recommendations aimed at reducing the incidence of family violence in the Victorian community.
The Issues
There were four issues identified as the focus of the coronial investigation: (A) police engagement and contact with Ms Ragi and the adequacy, or otherwise, of police responses to her; (B) attempts by Mr Singh to locate Ms Ragi and the role of Mr Jasraj Singh-Sidhu; (C) the role of Department of Immigration and Border Protection (DIBP) in advising persons coming to Australia about family violence and the Australian legal system, and the role of DIBP in assisting or advising Ms Ragi; (D) and finally, the role, if any, of issues of custom and religion in the relationship between Ms Ragi and Mr Singh and any bearing
those factors had on her death.
A. Engagement of Ms Ragi with Victoria Police
What follows is a summary of the investigation of Ms Ragi’s complaints taken from the inquest brief combined with a chronology prepared Detective Senior Sergeant (DSS) Fiona Richardson of Fawkner Sexual Offences and Child Abuse Investigations Team (SOCIT):
15/8/12 Mr Singh reported Ms Ragi as missing to Fawkner Police Station.
16/8/12 Police located Ms Ragi, who stated that Mr Singh had raped her, locked her in the house and not fed her. Constable Jessica Egan (Fawkner) obtained a complaint and warrant and bailed Mr Singh to Broadmeadows Magistrates’ Court on 20 August 2012. Constable Egan submitted an incident field report (L1) and a Family Violence risk assessment and management report (L17). The L17 referred to the type of family violence behaviour as “false imprisonment and rape”. It referred to “risk of future violence” as “likely”. The L1 gave a detailed case progress narrative. The narrative related to the allegation of false imprisonment, rape and assault. The L17 referred “in the case progress narrative” to the recent history of the relationship, to Mr Singh keeping Ms Ragi locked inside their unit, Mr Singh not leaving food for Ms Ragi and coming home “to feed her once a day”. It referred to her claim that she was beaten on a daily basis because she had had an affair. It referred to bruising on her legs from injuries inflicted by Mr Singh. It stated that “the AFM is in fear for her life and believes
her husband will kill her. The respondent has showed controlling behaviours and
~ Page 9 of 42
is believed to have committed serious sexual assault. Police have grave concerns
for the welfare of the AFM and believe she is vulnerable and in danger”.* Events proved this to be an accurate assessment — one made at the outset of police contact.
17/8/12 Ms Ragi told Detective Senior Constable (DSC) Zoe Butler that she had received calls from family friends encouraging her to reconcile with Mr Singh. Ms Ragi believed these calls breached the intervention order, (however the order was not made until 20 August 2012, and she was presumably referring to the bail conditions), and said that she changed her phone number as a result. DSC Butler took details of these calls and passed this information on to DSC Samantha Spencer.° She asked if Ms Ragi had safe accommodation and was told that she did.
18/8/12 DSC Emma Tobin received calls at Fawkner Police Station from person(s) who claimed to be related to Ms Ragi and wanting to contact her. DSC Tobin terminated the calls, contacted Ms Ragi to confirm that Ms Ragi’s details should not be disclosed to anybody and warned Mr Singh not to use anybody (including Ms Ragi’s family) to make contact with Ms Ragi. Mr Singh denied this.
20/8/12 An interim intervention order was made on the application of Constable Egan at Broadmeadows Magistrates’ Court. The order was made in favour of Ms Ragi and contained standard terms. It prohibited all contact and specifically, any attempt to “locate, follow the protected person or keep her under surveillance”, and “get another person to do anything the respondent must not do under this order”. In the notations to the order it was noted that Mr Singh (the respondent)
did not agree to the order being made, but was present at the time.
8/9/12 Ms Ragi phoned DSC Shelley Carton to report that Mr Singh had called her regarding her statement to police. Ms Ragi asked DSC Carton to call Mr Singh and tell him to stop phoning her. Ms Ragi was advised that a formal complaint could only be made by attending a police station in person to make a statement.
DSC Carton called Mr Singh and left a voice message telling him to stop calling
Ms Ragi and to contact the police.° A new L17 was not submitted.
22/9/12 Ms Ragi again called DSC Carton to report two anonymous phone calls and text messages from a friend of Mr Singh. Again a new L17 was not submitted. DSC Carton advised Ms Ragi that she would need to make a statement in person before the calls could be investigated. Ms Ragi agreed to consider making a
statement following a court hearing on 24 September 2012.’
Ms Ragi reported that one (unnamed) Constable would not take her statement because ‘he is only texting you to say he still loves you’. Eastern Domestic Violence Outreach Service intervened on Ms Ragi’s behalf and asked that Ms
Ragi’s statement be taken .°
24/9/12 The intervention order matter was listed at Broadmeadows Magistrates’ Court for a Directions Hearing. The intervention order was continued. A new order was produced bearing that date. The order was in exactly the same terms but involved clarified order number 6 prohibiting Mr Singh approaching or remaining within 5 metres of Ms Ragi. The other terms were identical. The notations on that order stated that Mr Singh was present at the hearing and agreed to the order. However a review of the transcript of the proceedings suggest that he did not agree to the
order, and that it was not made “by consent”.
At the hearing, Ms Ragi gave evidence of a number of breaches of the orders made on 20 August 2012. She gave evidence that “he started ringing me from 24 August”, that he “rang me 24" two times”, and “after that he rang me on 29 August”, and “31 August’, and “2 September and 8 September”. She was asked by the Magistrate whether she spoke to him on those occasions. She said she did on 8 September, but on other occasions she listened and he spoke. She gave evidence that Mr Singh also “messaged me in Facebook as well”. She gave the date of that message as 20 August. She also gave evidence that “he has given my number to his friend...his friend was also calling me”. The matter was adjourned
for a contested hearing on 4 December 2012. The order was continued.
25/9/12 Ms Ragi attended Fawkner Police Station with handwritten notes to make a statement in relation to phone conversations initiated by Mr Singh, phone calls
and text messages from Mr Singh’s friend ‘Monty’, silent calls and Mr Singh’s
’ Brief of Evidence, Statement of Shelley Carton, p 129 8 Brief of Evidence, Exhibit #8: Case notes from EDVOS, p 319
calls to Ms Dean-Thompson (with whom Ms Ragi was living). Constable Michael Campbell informed Ms Ragi that the silent calls and calls to Ms DeanThompson were not breaches of the intervention order, but took her statement.
Constable Campbell handed the file over to Constable Egan on 26 September
trying to contact her via phone and text message”.
It is not clear why Constable Campbell’s risk assessment on 25 September 2012 was different from Constable Egan’s on 16 August 2012. On the face of it, given the events that had occurred between the two dates, it should have been at the same level or even higher. I do not criticise Constable Campbell, however the system issue on this point is whether his training and the expectation of an officer in his position was that he should inform himself of the previous risk assessment (Constable Egan’s), and consider the circumstances he was dealing with in the light of that earlier assessment and subsequent developments. In addition, if DSC Carton had submitted L17s on 8 and 22 September, Constable Campbell (or any officer in his position) would have seen on LEAP a succession of L17s and associated risk assessments. This would have at least provide the potential to identify escalating breaching activity on Mr Singh’s part. The corollary would have been the
potential to respond actively to the evolving risk to Ms Ragi.
The Code of Practice
DSS Richardson’s evidence involved an exploration of police responses to Ms Ragi’s complaints, contacts and allegations. This evidence needs to seen in the context of the applicable obligations of police officers at the time to investigate alleged breaches of family
violence intervention orders.
7 ~~ Page 12 of 42 =
44,
The obligations of police officers dealing with breaches of intervention orders were then,
and are now set out in the Code of Practice for the Investigation of Family Violence. The
Code of Practice applicable at the time was published in 2004. It provided as follows:-
|
Victoria Police acknowledges that a strong and effective criminal justice response
can have a deterrent effect. Police will respond to and take action on any family
violence incident reported to them, regardless of who made the report and how it
was made. The action taken will be based on an assessment of the risks and threats,
regardless of whether the aggrieved family member make a verbal complaint or
written statement. (My emphasis).
In meeting this policy of mandated action, police will:
— Take immediate action to protect and support aggrieved family members
— Be sensitive to the individual circumstances of each incident
—> Investigate all family violence incidents coming to their notice by gathering background information and physical evidence, including pictures, clothing and statements from witnesses
Arrest any offenders where it is appropriate
bd
Pursue criminal and/or civil options where there is sufficient evidence to do so and regardless of whether an arrest has been made
uf
Refer all parties involved to appropriate services
— Record all family violence incidents reported to them with a view to identifying recidivist offenders, monitoring trends, and identifying persons at risk.”
I note the terms of the second edition of the Code of Practice which commenced in
November 2012. Paragraph 4.8 provides:
FVIOs and FVSNs must be strictly interpreted and enforced. There is no such lawful term as a ‘technical’ contravention and police should consider laying charges for any contravention. Ignoring the contravention conveys to the respondent and the AFM that the order is not taken seriously. An outcome of this could be continued abuse, further police involvement in subsequent contraventions, and possible harm to the AFM and/or their children.
4.8.2 — What police do if a contravention is reported to them
4.8.2.1...Regardless of the perceived seriousness of the alleged contravention and whether the respondent is at the scene, police will conduct a thorough investigation.
4.8.2.2 — Investigation
A contravention of a FVIO or FVSN is a family violence incident and a criminal offence.
Even if there are no other additional criminal charges, police must still conduct a risk assessment and compile and submit an L17 identifying an appropriate risk management strategy to address any safety concerns. In all cases, the safety and welfare of the AFM and children is paramount...
4.8.2.3 — Continuing protection of AFMs
° Victoria Police — 2004 Code of Practice for the Investigation of Family Violence
During the process of investigating a contravention of a FVIO the police informant responsible for the investigation must consider the ongoing safety needs of the AFM or any children.”°
The case for the CCP was put on the basis that the L17s should have been submitted in reference to family violence incidents in this case. I note however that the terms of the 2004 Code of Practice set out above, do not explicitly refer to the L17. Clearly by October 2012 the L17 was, in practice, a routine Victoria Police procedure. I infer that by the time of this incident, there was a clear obligation to use the L17. I note in any event that it is clearly
expressed in the 2012 edition of the Code of Practice (see above).
In essence, the requirements and obligations of police officers investigating family violence were the same under each edition of the Code. The emphasis was on the requirement for police to “act on any report”. I note that in the November 2012 Code of Practice there is also an explicit rejection of the proposition that some contraventions of family violence orders can be characterised as “technical”. The emphasis in both editions of the Code is that complaints are to be taken seriously and acted on, and the respondent to be made aware that
the order is taken seriously.
In relation to the first telephone breach of the intervention order, DSS Richardson stated that the risk rating it would be given now, as opposed to then, would be:
“Hypothetically ... it should sit in the very high or extreme ... Because I'm armed with a lot of information that I didn't have at the time ... So I think the difficulty in terms is whether the — the initial incident that caused the report, how that factors in, in terms of the risk assessment with the next one... [The sheer fact of the number and the repetition creates the risk category?] -Yes. Yes.”"'
This is a clear recognition of the need to interrogate the implications of repeat breaches.
Even if they appear to be minor in themselves, the very fact of repetition can mean that the threat to the safety of the person in Ms Ragi’s position becoming greater. That was the case
here.
In her evidence, DSS Richardson spoke of what could have been done better. She referred to the response on 8 September 2012 by DSC Carton to Ms Ragi in relation to Mr Singh continuing to ring her, and DSC Carton saying that Ms Ragi would need to go to a police station to make a statement. As to that, DSS Richardson said, “it is not an entirely
appropriate response”. She then went onto say:-
© Victoria Police — Code of Practice for the Investigation of Family Violence '' Transcript pages 186, 187 ” Transcript page 188
Page 140f42
“The additional thing that should have been done is a LEAP report and the family violence report because that then records the crime. It then places the supervision place in process, so that then that the proper assessment can be done, the proper resources allocated to it.”"*
Submissions
Community Legal Centres (joint CLCs’)
The Joint Community Legal Centres
By letter dated 22 December 2014 the Eastern Community Legal Centre, the Broadmeadows Community Legal Service and the Federation of Community Legal Centres (Vic) Inc, sought permission to play a part in this proceeding and to make submissions. Although the joint CLCs’ had not been parties at the inquest, I permitted them to make submissions on the facts and on system issues, on the basis that they may assist me to make appropriate comments and possibly recommendations. The Joint CLC submission was dated the 10
April 2015.
The joint CLCs” sought a re-opening of the inquest to enable them to take a more active role. The CCP opposed the application for the inquest to be re-opened. Having considered this request, I determined not to re-open the inquest because the relevant evidence had all been received, and the joint CLCs’ have in fact been able to make a constructive
contribution to the inquest by way of detailed submissions.
Chief Commissioner of Police
The CCP submitted that there was no relevant step that Victoria Police could have taken (either differently or better) that would have resulted in a different outcome (one that did not involve the death Ms Ragi). However, the question is whether any steps that should have been taken were not taken, and if had been, whether they could have reduced risks to Ms Ragi. Whether such steps would have ensured that she was not killed by Mr Singh, is not the
point.
8 Transcript page 188
_ Page 150f42
Breaches of the Intervention Order
The original intervention order was made on 20 August 2012. Mr Singh was present and
aware of the terms of the order. As noted earlier, it prohibited any contact.
Mr Singh made contact with Ms Ragi in breach of that order on 24 August 2012 (twice), 29 August 2012, 31 August 2012, 2 September 2012 and 8 September 2012 — by reference to Ms Ragi’s evidence in the Magistrates’ Court.
On 8 September 2012, Ms Ragi reported to DSC Carton that Mr Singh had rung her. She
was told to come to the police station and make a complaint in writing.
On 22 September 2012, Ms Ragi reported two anonymous calls and spoke again to DSC Carton who told her she would need to make a statement in person before the calls could be
investigated.
As the chronology notes, she attended the police station on 25 September 2012 to make a
statement about the various contact by, and apparently on behalf, Mr Singh.
At this point, Ms Ragi appears to have done all that she could in terms of reporting contacts by and on behalf of Mr Singh including those that constituted breaches of the intervention
order.
The CCP submitted that DSC Carton’s failure to create LEAP records and a family violence (L17) report regarding telephone breaches would not have changed the outcome. The submission was:-
“there is no evidence to support a finding that the failure to record these details played any part in the circumstances of the death and similarly it is not connected to the deaths."
This is strictly, and narrowly, accurate: the failure to submit L17s cannot be said to have contributed to the death. However, the CCP submission failures to acknowledge the broader
system issue which DSS Richardson herself acknowledged and which I refer to above in
paragraph 46.
Submission by the Joint CLCs
The joint CLCs’ submissions argued that the increased and persistent telephone contact breaches, and the additional contact attempts through third parties (even if some may not
have strictly constituted breaches of the intervention orders), showed a heightened risk and
'* Submissions on behalf of the Chief Commissioner of Police, paragraphs 16 & 17
Page 16 of 42 |
increasing determination by Mr Singh to contact and locate Ms Ragi. The evidence supports that submission. Cases such as this demonstrate that frequent, persistent or increasing telephone contact can be an indicator of escalation and increasing risk to a person protected
under an intervention order and should be treated in that light. (See again paragraph 46).
The joint CLCs’ submission argued:
i, the police did not investigate or proceed criminal action on the evidence of these telephone breaches; ii. “the sum total of their enforcement activities around the ... alleged breaches was to make 2 telephone calls to Avjit Singh’s mobile phone”; and iii. the breaches were “contact breaches and attempts to locate her ... these breaches
alone should have alerted the police to Avjit Singh’s heightened risk and increasingly obsessive attempts to contact and locate Ms Ragi.”
The joint CLC submission referred to the evidence Ms Ragi gave in the Magistrates’ Court.’° It is apparent that Ms Ragi was afraid to go into the courtroom when Mr Singh was in there. However the Magistrate needed her to do so to hear her evidence, and in appropriate terms he sought to reassure her.
The joint CLCs submitted that: “(he Court and the Victorian Community can hear (the fear in) Ms Ragi’s voice at the interim intervention order hearing of 23 September 2012, reading multiple alleged
breaches of the intervention order into the Court record despite being extremely fearful of even entering the Court while Mr Singh was present.’”®
I agree. The transcript of these proceedings in the Magistrates’ Court reveals that Ms Ragi was concerned for her own welfare about the ongoing breaches by telephone calls. She gave evidence of blocked calls, believed to be coming from Mr Singh, of Mr Singh telephoning her from 24 August (the original intervention order having been made on 20 August), of her saying on 24 August that Mr Singh rang her twice and that he rang her on 29 and 31 August and further on 2 and 8 September. She stated that he had messaged her through Facebook.
l accept the joint CLCs’ submission that in the face of Ms Ragi’s evidence, the police should have strengthened their response to the emerging threats to Ms Ragi’s safety and welfare. As was conceded, the sum total of the enforcement response in respect of the intervention order breaches was to make two telephone calls to Mr Singh’s mobile telephone. There is a question what the police should have done in that regard. The Code of Practice mandated “take immediate action to protect and support aggrieved family members”. It also mandated
“arrest any offenders where it is appropriate”. Arrest was an option, even assuming Mr
'S Submission by Joint CLC’s paragraph 10 '® Submissions of joint CLCs, paragraph 24
71,
Singh would have been released on bail. Bail conditions would likely have been in the same terms as the intervention order conditions. If granted, bail would have exercised an additional constraint on Mr Singh and subjected him to arrest again for breach of bail conditions if that occurred. This approach would have constituted an appropriate and proportionate escalation of the overall police response to the emerging threat posed by Mr
Singh to Ms Ragi
Although I found DSS Richardson to be a credible witness and a conscientious police officer (clearly deeply affected by this death), in my view, earlier steps should have been taken to
assess and reduce the risks to Ms Ragi and strengthen the police response.
Here there was a trajectory of increased risk to Ms Ragi, with Mr Singh’s repeated attempts to contact and locate her, his involvement of third parties and, ultimately, the involvement of a private investigator. The early signs in this trajectory were the seemingly more minor breaches, but more should have been done at that point. The police responses on 8 September 2012 and 22 September 2012 did not in my view accord with the letter or the spirit of paragraph 2.1 of the Code of Practice. In particular, a requirement that a person in Ms Ragi’s position make a written statement before a matter would be investigated was
clearly at odds with the terms of paragraph 2.1 of that Code of Practice.
Although it is difficult, if not impossible, to determine the extent of the impact of one breach on a subsequent death, the point of the policy, and that the Code of Practice was and remains to ensure that risk is recorded, managed, reduced and above all, not permitted to escalate.
An active, not a passive response was required. The Code of Practice made that clear.
In her evidence, DSS Richardson said that she had not come across any report of personal contact between Ms Ragi and Mr Singh at Crown Casino. Also, she had not been made aware of any contact or sighting by Ms Ragi of Mr Singh in Brunswick Street. When asked what would have happened if she had been made aware of those things, she said:
“... [find that difficult to make a comment in relation to (the Crown Casino incident).
However, the fact would be that there were two breaches here ... I'd need to read what that evidence is in order to make a comment ... Assuming it is, yes, that would be a clear breach. And that is setting a pattern ... that Singh was going to continue his behaviour in terms of breaching the intervention order, regardless of any direction or comment by a court or by police, in terms of the conditions of the intervention order. So, and continual breaches of that nature do take on a heightened risk, yes.”""
'T Transcript pages 175 - 176
~ Page 18 of 42
DSS Richardson is absolutely correct: in this passage of evidence she recognises that
“continual breaches” can indicate “a heightened risk”.
Improved system responses by Victoria Police
The CCP submissions refer to DSS Richardson’s evidence that a localised risk assessment tool, developed since the death, would have categorised the allegations as ‘high to extreme’ (including the alleged breaching phone calls). However, oral submissions on behalf of the CCP later corrected this, stating that the risk assessment tool is:
“a matter that arises and is in the context of duties that (DSS Richardson) doesn’t perform ... a high to extreme risk assessment is now, we understand to be, incorrect ...
in relation to the phone calls it would be an assessment of ‘low to medium’.’”
DSS Richardson’s evidence was that had there been contact breaches, it would have changed, “the investigation process and ... the timing and the prioritisation of the
investigation a:
I do not accept the CCP submission on this point and prefer the evidence of DSS
Richardson. She had, after all, done a thorough review of the case.
DSS Richardson stated that the risk assessment now, in response to the report of the rape and false imprisonment, would be ‘high to extreme’, stating:
“when I talked about the risk assessment earlier, I was referring to the risk assessment that was done in terms of that particular breach, but the breach ... was treated independently of the initial report... The risk assessment was done in relation to the Phone call ... the phone call on its own was risk assessed, and that was risk assessed as low.”
DSS Richardson expressed the view that the new risk assessment tool is:
“useful because it takes away the subjective assessment because it is a clear objectiye statement with a risk rating, and then they add it up. Then if you go to the bottom, the very high and the extreme are the triggers which warrant some additional support or action by the family violence teams.’”
DSS Richardson also identified that Ms Ragi did not have a single point of contact within a domestic violence service that could assist in contact between Victoria Police and the relevant agency. This was said to be a specific factor that can impact the assistance that police give to family violence victims and I make comments later in this finding regarding a
single advocate. DSS Richardson stated:
'8 Submissions of behalf of CCP paragraphs 19 & 20 Transcript page 167
° Transcript pages 182, 183
zl Transcript page 182
“(w)hen we've had single point of contact with domestic violence service or with support workers or —as is the case, we deal with child protection and we have single point of contact. The single point of contact I think allows two things. It allows the police to have a contact there in terms of how the victim is and whether there are any issues... And the converse is that that person who is ... case managing in terms of the victim, they then understand the system and they then have a point of contact back within Victoria Police.
And since this particular matter we have had a number of matters that that has worked very effectively in terms of the communication between the two organisations in support of the victim, because there are two quite specific roles in terms of a criminal investigation and welfare and support of the victim. ””?
The CCP submissions refer to the role of the family violence teams having been enhanced since the death, in terms of resourcing and responsibilities. One of the key areas they have reformed is a triage function, which the family violence team now performs on all family violence reports submitted within the division. The family violence team then performs a risk assessment with the new tool. DSS Richardson’s evidence was that, even under this new system, it would not have altered the outcome because telephone contact breaches of
intervention orders on their own are not considered evidence of high or escalating risk.
DSS Richardson identified a document called ‘The First 48 Risk Assessment Process’? and advised that it was developed by a Sergeant at the family violence team and was
implemented earlier this year.” The CCP submission states:
“...0n the evidence of DSS Richardson, the natural progression of policy and protocol within Victoria Police has led to improved approaches both as to communicating to alleged victims the non-authorisation of brief and better channels of communication between family violence services and Victoria Police arising in the context of intervention orders. ””°
l accept the evidence of DSS Richardson, and the CCP submission on the measures taken to
improve Victoria Police’s response to family violence.
Summary of conclusions regarding police contact
I consider that the overall police response to the position Ms Ragi was in, to her complaints
about breaches and to the escalating seriousness of her predicament, was inadequate.
» Transcript page 178, 179
pal Transcript page 181
a Transcript page 181
86,
89,
T agree with the joint CLCs’ submission that the two phone breaches in early September and the text messages from a friend of Mr Singh’s revealed an attempt to locate Ms Ragi. It
could have been inferred that Mr Singh was increasingly determined to locate Ms Ragi.
In my view, the police failed to accord sufficient urgency and seriousness to Ms Ragi’s reports of Mr Singh’s telephone contact breaches of the intervention order. The lesson from this case is that telephone breaches can, in fact, be clear evidence of escalating risk to a
person protected under an intervention order.
There was no dynamic risk assessment. There was no overall view of risk and no consideration of whether the increasing contact represented an increasing danger to Ms Ragi. There was a narrow, incident by incident assessment of risk. There was a failure to see and comprehend the bigger picture and to act accordingly. There was a failure to strengthen
the police responses in the face of repeated breaches of the intervention order.
However, I note that in this case, (the victim Ms Ragi), was assisted by services and, at the outset, decisively assisted by police who obtained firstly a warrant (complaint and warrant) for the purposes of arresting Mr Singh, and then initiated intervention order proceedings in
the Magistrates’ Court. An order was sought in appropriate protective terms.
None of the inadequacies or flaws in the police responses to Ms Ragi’s situation, singularly or in combination, caused or directly contributed to her death. Mr Singh was solely responsible for Ms Ragi’s tragic death. However the system flaws I have referred to in this finding lead to a weak response to her predicament and an inadequate response to the
breaches of the intervention orders.
B. Attempts by Mr Singh to locate Ms Ragi and role of Mr Jasraj Singh-Sidhu
Mr Jasraj Singh-Sidhu was a friend of Mr Singh. He gave evidence about his role in
assisting Mr Singh to locate Ms Ragi.
Mr Singh-Sidhu had originally declined to cooperate with the coronial investigation.
However, he appeared at court at the inquest. He objected through counsel, to giving evidence on the grounds of self incrimination (because of the potential to be charged as an accessory to the breach of an intervention order), Ultimately, I determined that he should be
compelled to give evidence under the protection of s.57 Certificate.
Page21of42
I gave detailed reasons for that ruling, but central amongst them was the fact that Mr SinghSidhu appeared to be in a position to provide useful information as to how Mr Singh was
able to locate Ms Ragi.
Mr Singh-Sidhu gave evidence that he had known Mr Singh for seven or eight years at the time of Mr Singh’s death. He regarded Mr Singh as a friend. He never met Ms Ragi.
He gave evidence of when Mr Singh first came to his house. Mr Singh was upset and said that his wife had been unfaithful to him. Mr Singh-Sidhu said to him “7 guess he was just upset, I mean I guess as anyone would be that you know, his partner's been unfaithful, but
nothing out of the ordinary.””®
Mr Singh-Sidhu described the next visit that Mr Singh made to him. A few days later, Mr Singh came to tell Mr Singh-Sidhu that Ms Ragi had left him and that he was trying to find her in order to reconcile with her. He stated that Mr Singh, “wanted to hire a private investigator basically because he didn't know where to find her in order to try and talk to
”
her.
In this context, he gave evidence about the existence of the intervention order, stating that he did not see the intervention order, or go through the terms of the intervention order, nor did Mr Singh explain to him what an intervention order meant.?’ However, it was apparent that Mr Singh-Sidhu understood that the intervention order prevented Mr Singh from seeing or
contacting Ms Ragi.
Mr Singh-Sidhu evidence was that Mr Singh told him that: a. he (Mr Singh) had been in touch with a private investigator;
b. the private investigator had told Mr Singh that he could not act for him because of
the existence of the intervention order;
c. the private investigator told him that somebody else could hire that investigator on
his behalf; d. Mr Singh asked him to be his intermediary;
e. he and the private investigator were then in contact, but he could not recall if the
investigator contacted him or vice versa; and
ai Transcript page 208 Bf Transcript page 209
f.. that the investigator’s name was George but he could not remember George’s
surname.”® Mr Singh-Sidhu gave evidence of speaking to the private investigator, ‘George’. He said:
“I was a bit hesitant because I thought - I asked the private investigator if you know, if Avyjit wants to hire a private investigator why can't he just hire it and I was told by the Private investigator that he wasn't allowed to but someone on his behalf could and that you weren't doing anything wrong because he was going to reconcile. All he wanted to do was - the purpose of the private investigator was to try and reconcile with his wife.”
As to Mr Singh-Sidhu’s understanding of Mr Singh’s intent, his evidence was that Mr Singh
never mentioned wishing to hurt Ms Ragi, that he only wanted to reconcile with her.*°
Mr Singh-Sidhu said that he spoke to the private investigator “at the most 5 times.’?! He said that he provided Ms Ragi’s name and date of birth, and was told that they would do searches and try to locate her. He was told in one of the conversations that the only thing
the private investigator established was a PO Box address.
He agreed that he was essentially acting as an intermediary between Mr Singh and the private investigator.” He stated that the last time he spoke to the private investigator was, at a guess, the day of the last court hearing.? Mr Singh-Sidhu gave evidence about the intervention order proceeding at the Broadmeadows Magistrates’ Court on 24 September
“... So basically, the private investigator had said to me - he'd suggested, "Should we try
and do surveillance at the courthouse?" And I later on - I asked Avjit that, he said, "Yes." So they went ahead and did that but that was to no avail...”**
Mr Singh-Sidhu stated that he never paid the private investigator himself and did not know how he was being paid. He went on to say :- “On the 24th, Your Honour, I felt uneasy at the fact that surveillance was being done. I basically told Avjit that day that you know, I wanted nothing more to do with it and that
he needed to move on ... I didn't want to speak to him ... You know, I felt uneasy on the . 9335 issue.
a Transcript page 210 # Transcript page 211 a Transcript page 211 ad Transcript page 211 5 Transcript page 210 ° Transcript page 212 *" Transcript page 212 >> Transcript page 213
Mr Singh-Sidhu stated that, apart from speaking to the private investigator four or five times over the period of about two weeks, he did not assist Mr Singh in any way in finding the
address. °°
Mr Singh-Sidhu denied that he was frequently in Mr Singh’s company in the days prior to the deaths of Ms Ragi and Mr Singh. Asked towards the end of his evidence, whether he knew how Mr Singh located Ms Ragi, Mr Singh-Sidhu responded:
“... I don't know. I didn't have any contact with him - like I said, I didn't see him in
person, we didn't discuss the topic, I didn't want to. Like I said, I think he rang me once and that's from memory going back two years.’*"
In relation to the suggested use of contacts in the telecommunications industry to help locate
Ms Ragi, Mr Singh-Sidhu stated that:
a. he did not have any contacts in the telecommunications industry to help Mr Singh
find a phone number;
b. other than acting as intermediary with the private investigator, he did not give him
any assistance at all locating Ms Ragi’s address;
c. they did not discuss the use of Ms Ragi’s iPhone to locate her with GPS tracking;**
and
d. the private investigator did not inform him that he had been able to locate Ms Ragi’s address in East Kew.
Under cross-examination, Mr Singh-Sidhu stated that he did not remember being told that Ms Ragi had made allegations about rape and false imprisonment against Mr Singh (he had
heard that evidence in court).
In relation to the intervention order, and the use of the private investigator and whether this should have caused him some concern, Mr Singh-Sidhu stated that he was:- “reassured that (he) wasn’t doing anything wrong and that otherwise they (the investigator and Mr Singh) wouldn’t be doing it.” *” Asked further about the proposal of physical surveillance after the proceedings on 24 September 2012, Mr Singh-Sidhu’s evidence was that he:-
*© Transcript page 214 *” Transcript page 217-218 °8 Transcript page 218 *® Transcript page 221
112,
“became uneasy about what Avjit was proposing to do in regard to effectively wanting to tail her to figure out where it was that she was living ... you shouldn't have to go to extreme lengths to try and reconcile with someone...’
He gave evidence that he did not report his role or any concern about the apparent escalation
in the attempts to locate Ms Ragi to the police.
He went on to give further evidence as to his feelings about his involvement. He gave this evidence in the context of describing the events at the Broadmeadows Magistrates’ Court on 24 September 2012. His evidence was that he was not at the court himself, but agreed with
Counsel Assisting’s summary, as follows:-
“SERGEANT DIMSEY: We'll run through that sequence; you get a telephone call from George, the private investigator says, "We're at the court. We saw Avjit talking to Sargun and her lawyer, they drove away very quickly, we attempted to follow, we lost contact with them"?---Yes.
Your evidence is that you've indicated to them you want nothing more to do with this ?---Yes.
Have you then rang Avjit or did Avjit ring you to say, "This is the situation," they couldn't find her or they didn't follow her?---I believe he rang me, Your Honour, and - and yeah, I told him basically that they you know, they lost - they weren't able to do anything and that was the end of it.
Did you have any more contact with the private investigator after that date?---No.
Mr Singh-Sidhu’s evidence was that he made contact with the private investigator by phone and email, but that he had not saved any of the calls or any of the emails. He did not have the investigator’s phone number. He went on to say that, on reflection, he did not phone the investigator but the investigator only ever phoned him. He admitted that he had had the phone number but did not have it recorded anywhere. He stated he did not save any of the
emails on his computer. In fact, he said that he deleted them all.
In relation to the issue of Mr Singh using information and/or contacts in the
telecommunication industry, Mr Singh-Sidhu’s evidence was:-
“SERGEANT DIMSEY. ... in relation to telephone traces, there's evidence on the brief that Avjit has spoken to a person two days before the incident and indicated, "I located your address through a telecommunications company in India." Are you aware whether Ayjit had those capabilities or had contacts within a telecommunications company in India to be able to trace and locate telephones?”
(Counsel Assisting then took Mr Singh-Sidhu to the statement of Sanjay Devgan):- “SERGEANT DIMSEY: At p.157, the second paragraph, "Avjit came to my place three or four days before the fire. Avjit told me that he was Sargun's ex-husband and they
me Transcript pages 222-223 “! Transcript pages 231-232 ® Transcript pages 232-233
—+ Page 25 of 42
were separated... He also told me he knew my last address in Rosanna, he actually said the address. He said he knows everybody's addresses and phone numbers. He told me that he knew Sargun was living in Nott Street Balwyn and she was now living in Hale Street Kew. He says he knows all this because he has contacts in a phone company, he didn't say which one"?---No - I - no. No, Your Honour.
You had no knowledge at all that Avjit was also using telephones or Phone companies to try and track people down?---No. No, Your Honour.”
“...Was that ever passed on to you by George?---No, Your Honour. No. No, no, never heard that till today...
HIS HONOUR. Thank you. Did George give any addresses to you? Did he tell you he had any address details?---Like I mentioned earlier, the only thing that they actually Sound was a PO Box but they weren't even sure if it belonged to her.
That's all he told you?---Yes"™
identify the name and details of that particular private investigator.
remains unexplained.
2015, Victoria Police made further attempts to locate the private investigator.
unsuccessful. Until Victoria Police can identify the private investigator and question him
8 Transcript page 233 Ht Transcript pages 233-234
about his role in locating Ms Ragi, this remains the missing piece in the puzzle. If further information was to come to light which could assist to determine the private investigator’s identity, I would expect Victoria Police to vigorously investigate it to solve this unexplained aspect of Ms Ragi’s death and pursue any relevant criminal charges. I note that Mr SinghSidhu gave evidence** that he received phone calls and emails from the private investigator and I consider that there may be opportunities to obtain telephone company and internet
service provider records in relation to those calls and emails.
The solicitors acting on behalf of Mr Jasraj Singh-Sidhu made written submissions. Under the heading “Avjit Attempts to Find Sargun” it states as follows:-
“It is apparent that from very soon after the intervention order was granted, Avjit was attempting to locate the whereabouts of Sargun.
Harpreet Marwaha states that Avjit had been tracking Sargun’s phone and had a GPS history during the period they were living with Rajvinder Singh.” He also gave evidence that he met Avjit once after “that incident” and that Avjit had hired private detectives.”
He further states that Avjit had told him that “Jas” (Jasraj Singh-Sidhu) was helping him track Sargun.® He had never met Singh-Sidhu until after the fire.” Dolly Dhingra reports that Ayjit told her he was going to hire a detective to find Sargun.> Sanjeev Devgan reports that Avjit told him he “knows everyone’s addresses and phone numbers.” Jasraj Singh-Sidhu stated that Avjit told him he was trying to find her’’. As outlined ...
he was aware that Avjit was attempting to locate Sargun.”* I accept that the references above are accurate references to the material in the coronial brief. The gravamen of the submission is that I should not make a finding that Mr Singh-
Sidhu, or anyone else, knew Mr Singh’s true intention once he located Ms Ragi.
I agree that it is clear from the evidence that Mr Singh told numerous people that he was
looking for her in the hope of “reconciling with her”, as the submission states:- “[Avjit] told Harpreet Marwaha that: “he’s trying to locate her, trying to get her back,
if she can come back and he’s going to forget everything, and if they can come back and they can live together.”**
*® Transcript page 232
ng Transcript page 51
a Transcript page 51
si Transcript page 54
® Transcript page 68
°° Inquest Brief — Statement of Dolly Dhingra
) Inquest Brief — Statement of Sanjeev Devgan
» Transcript page 209
® Submissions on behalf of Jasraj Singh-Sidhu paragraphs 12-17 34 Transcript page 59
Page 27 of 42.
He told Rajvinder Singh that “‘he might still try and work things out.”
He told Jasraj Singh-Sidhu that he was trying to find her to reconcile with her.”
The only evidence that Avjit ever told anyone of an intention to harm Sargun is in the statement of Harpreet Marwaha, when he stated that Kulwant Kaur had let slip that Avyit had told her that he would kill Sargun and flee.”
This conversation was denied under oath by Kulwant Kaur.° In response to a query from Det. LSC Lunny, Nita Singh, Avjit’s mother, does not mention any such conversation.””
It is respectfully submitted that the Coroner should make a finding that no such conversation took place.”
conservation took place.
“It is submitted that Jasraj Singh-Sidhu gave a truthful and credible account of his involvement in assisting Avjit.
He admitted that he was aware of the existence of the intervention order, but never sighted it” and was not aware of the conditions.”
He admitted that Avjit had spoken to a private investigator, but that the investigator has told him he could not act on his behalf’ because of the intervention order, but that someone else could hire the investigator.
That he made contact with the private investigator, named George, and acted as an intermediary between Avjit and George. Bf
That he provided the investigator with Sargun’s name and date of birth, and the investigator tried to locate her, to no avail. 4
He spoke with the private investigator five or six times and never paid him any money.
He last spoke to the private investigator on the 24" September 2012. He felt uneasy at physical surveillance being done, and told Avjit that he wanted nothing more to do with it.” He had no more to do with the investigator.”
He only spoke to Avjit once in the period between 24 September 2012 and 4 October 2012, and the reception made the call unintelligible.
At no point did Avjit indicate that he wished to harm Sargun.”
Inquest Brief Statement of Rajvinder Singh
Transcript
Transcript
§! Transcript © Transcript a Transcript s Transcript ® Transcript fF Transcript 5’ Transcript 8 Transcript a Transcript
nquest Brief — Statement of Harpreet Marwaha
pages 107-108
nquest Brief page 79 Submissions on behalf of Jasraj Singh-Sidhu
At all times he expressed a desire to reconcile with Sargun.”°
That he no longer had any contact details of the private investigator."1"”
Having seen and heard Mr Singh-Sidhu in the witness box, and considering his evidence in the context of the whole of the evidence at inquest and in the coronial brief, I accept this submission. I am satisfied that Mr Singh-Sidhu played a role of an intermediary on behalf of Mr Singh for the purposes of hiring and liaising with a private investigator, The purpose of that was to locate Ms Ragi. On the whole of the evidence, I am not satisfied that Mr Singh-Sidhu knew of, or suspected, Mr Singh’s true intention.
In my opinion, Mr Singh-Sidhu made an extremely serious mistake in acting as the middleman for his then friend, Mr Singh. He did so, at best, naively. He should have made himself familiar with the terms of the intervention order and played no role whatsoever in assisting Mr Singh to locate Ms Ragi. I accept that he did not know, at any relevant point in time, that Mr Singh intended harm to Ms Ragi. I accept that he became uneasy about the matter, but even then appeared to still believe that the intent was for some form of reconciliation. In any event, Mr Singh-Sidhu’s actions as an intermediary constituted, at least prima facie, the
offence of aiding and abetting a breach of the intervention order.
“in the weeks leading to the fire, she established a relationship with Sanjeev Devgan. Mr Devgan estimated the time he met her as 6 weeks before the fire, which places their first meeting either when SARGUN was still in Fawkner, where she was allegedly not allowed out, or immediately after leaving the premises. She did not mention being married or her personal situation,”
I note that Mr Devgan also stated that Ms Ragi was living at Nott Street, Balwyn when they met and that Ms Ragi approached him when he was working at the Coles Supermarket in Warringal Mall, Heidelberg. I accept the evidence that Ms Ragi was living in Balwyn when she met Mr Devgan, though this may not accord exactly with his suggested/recalled timeline
of six-to-eight weeks before the fire.
investigation.” I do not accept that there has been a distortion of the investigation or E ‘D g
gi Transcript page 218; 211
i Transcript page 232
” Submissions on behalf of Jasraj Singh-Sidhu
Page 290f42.
“permeation” in the way the submission puts it. However, it is important to state, emphatically, that any relationships Ms Ragi was involved in, could in no sense justify, amount to a legal defence or lend a veneer of legitimacy to Mr Singh’s violence. In addition it could not justify or legitimise the involvement of any of Mr Singh’s friends in assisting him locate Ms Ragi, given the existence of the intervention order and the prohibition on
contact, either directly by the respondent (Mr Singh) or anyone else on his behalf.
C. Department of Immigration and Border Protection (DIBP)
128,
I sought the assistance of the DIBP to outline the information they provide to migrants
regarding Family Violence and the Australian legal system.
The DIBP was represented by Ms Holt at the inquest. The role played by the DIBP and the materials provided in submissions after the inquest were helpful and constructive and I
thank the DIBP for its assistance.
The DIBP provided material by way of letter dated 19 November 2014. Two emails provided by the solicitors for the DIBP were exhibited.”* Ms Holt spoke to the various
documents tendered.
The documents were instructive and informative. The DIBP undertook considerable investigations in examining its interactions with Ms Ragi. I accept the accuracy of the
statement describing those interactions in the letter of 19 November 2014.
In its final submission, the DIBP stated:-
“Tn relation to the circumstance of their deaths, and without seeking to pre-empt the Coroner's assessment of this matter, the Department’s understanding is that the evidence before the Coroner indicates:
(a4) On 25 May 2012 Ms Ragi arrived in Australia on a partner (provisional_ visa sponsored by Mr Singh.
(b) On 15 August 2012 Ms Ragi left her relationship with Mr Singh.
(c) On 29 August 2012 received two statutory declarations alleging family violence, and on 25 September 2012 were provided an interim violence order which Ms Ragi had obtained against Mr Singh, which was the preliminary step to obtaining a visa on family violence grounds.
(d) At some point on or prior to 4 October 2012, the evidence suggests that Mr Singh located where Ms Ragi was living, and on 4 October 2012 went to that address and caused serious injuries to Ms Ragi and to himself, leading to her death and his own.
™ Exhibits 16 and 17
. Page 30 of 42.
The Department respectfully submits that there is no evidence before the Coroner which could lead to any finding that the Department, its people or processes were in any way a causal factor in the deaths of either Ms Ragi or Mr Singh. Specifically:
(a) Although it is of course true that both deceased persons were in Australia as a consequence of successive grants of visa, including, in respect of Ms Ragi, a visa granted as a result of her marriage to Mr Singh, it is submitted that this grant of visa is too remote a factor to be causally linked with the death or the circumstances in which the death occurred.
(b) There is no evidence before the inquest which indicates that Ms Ragi was unaware of her visa options at the time of her death, or that her visa situation either at the time or prior to her death was a causal factor in relation to her death. Ms Ragi’s death occurred after she had left the relationship with Mr Singh, and taken preliminary steps to access the visa options open to a person in her circumstances.
If Mr Singh was seeking to use Ms Ragi’s visa status as a means to coerce her into remaining in a relationship with him, he was unsuccessful.
(c) There is no evidence that Mr Singh or any person acting on his behalf successfully obtained any information from the Department concerning Ms Ragi’s phone number or home address or that any Department officer was deficient in their dealing with the deceased in the months prior to their death. The Department relies on evidence read by Ms Carter during the inquest in respect of the action taken by the Department’s officers.””
and submissions. The joint CLCs have proposed two recommendations:
“a. (Recommendation 8): That the DIBP should seek the consent of women who report domestic and family violence to the Police so that the intersecting migration and family violence issues can be dealt with in an integrated way. (Officers of any State Police force in Australia are defined pursuant to section 5 of the Migration Act 1958 to be officers under the Migration Act); and
b. (Recommendation 10): That any person who is a victim of family and domestic violence should be case managed by the DIBP family violence team who should be trained in the common risk assessment framework and operate in an integrated way with the police, courts and specialist family violence services who are engaged with the person.”
“The issue of whether to require the provision of family violence histories from visa sponsors, and to disclose those histories to visa applicants, or factor them into visa decisions, is being actively considered by the Department.
If the Coroner does consider it is in the public interest to make comment or recommendation in connection with these issues, the Department will welcome, actively consider and respond to any position the Coroners expresses. The Department respectfully submits it would be preferable that any comments or recommendations the
” Further submissions on behalf of the Department of Immigration and Border Protection paragraphs 11 & 12 76 Submissions of Joint CLCs paragraph 4 (a) & (b)
‘Page 31 of 42
Coroner make seek to avoid pre-empting detailed policy development in this area by the Department or Executive government.””!
response to that proposal.
“We refer to paragraph 36 of the DIBP submission and note that in fact the Coroner is legislatively required under the Act to contribute to the detailed policy development in this area by the DIBP and/or executive government because of the prevention function of the Court.”
coronial prescription of the “detailed policy development”.
e the DIBP’s telephone contact with Ms Ragi and Mr Singh in August and September
2012, especially where the officer was unable to identify the caller;
e the contention that the DIBP should have drawn the calls to both the police and Ms Ragi’s attention; and e the proposed recommendation for additional training by DIBP specialist family violence unit and client service staff, and greater integration between DIBP and police and courts.
case;
e Ms Ragi was, throughout September 2012, aware of Mr Singh’s attempts to locate her and that he had contacted her, and the police were aware of Mr Singh’s direct contacts to
Ms Ragi;
” Purther submissions on behalf of the Department of Immigration and Border Protection — paragraphs 35 & 36 ’8 Submissions of Joint CLCs paragraph 7
additional advice from the DIBP to police or Ms Ragi would not have added to the weight of evidence against Mr Singh, nor would it have altered Ms Ragi’s attempts to
secure her personal safety and hold Mr Singh accountable for his criminal behaviour;
the context of DIBP officers’ situation and knowledge of Ms Ragi’s situation is as
follows:
o The 22 and 31 August phone calls were taken at a call centre that deals with considerable numbers of contacts from the public (for example, they took 99,865 public enquiries in February 2015 alone) and that staff members typically take 50-60
phone calls per shift;
© prior to 25 September 2012, the DIBP relied upon statutory declarations supporting Family Violence Visa applications. The DIBP received Ms Ragi’s paperwork on 29 August 2012;
o the DIBP procedures do not require call centre officers to familiarise themselves with all documentary material, but require identity verification and record-keeping
practices, which appear to have been followed in this case;
o the 22 and 31 August callers’ identities remain unknown and, although it cannot be excluded, it is possible that the calls were not from persons acting on Mr Singh’s
behalf to locate Ms Ragi, including possibly Ms Ragi’s brother in India; and
o the Privacy Act 1988 (Cwth) restricts DIBP’s use of visa application and sponsor information, and must be considered in assessing exceptions for potential disclosures
to police or third parties without the person’s consent.
The DIBP officers acted appropriately and professionally, and did not compromise Ms Ragi’s safety. The officers’ contemporaneous and accurate note-taking assisted the
Court.
It noted the joint CLCs’ submission proposing a recommendation that the DIBP ensures that Family Violence Unit (FVU) officers receive appropriate education and awareness training. It stated that the FVU’s role is to advise persons regarding family violence provisions and to process relevant visa applications. FVU officers are trained to refer visa applicants for family violence counselling services, not to provide such counselling
themselves, and they undertake a range of appropriate internal and external training,
Page 330f42
including ‘Walk in her Shoes’ training sessions run by the Melbourne Magistrates’
Court Specialist Family Violence Service. ”
Departments submissions set out above.
has advised it will adopt the following approach:-
“Since it was contacted by the Coroner’s Court about this matter, the Department has proactively sought to draw relevant information to the Coroner’s attention and provide comprehensive responses to all issues raised.
The Department is in respectful agreement with the CLC submissions that family violence requires a whole of government approach. It is committed to doing whatever it meaningfully and workably can to help to reduce the risk of family violence in the community and is receptive to any suggestions which will enhance its processes in this respect.
For the reasons outlined in previous submissions, the Department is of the view that there is nothing about its involvement in this case which makes it necessary for the Coroner to make a recommendation affecting the Department.
However, given its commitment to ongoing process improvement, the Department has examined the CLC submissions and requested the relevant police areas consider if there are process improvements which can be made in light of their comments. Specifically, the Department now proposes to:
e Liaise with the CLC submission authors to provide a briefing on the role the Family Violence Unit (“FVU”), and offer them an opportunity to provide input on the training procedures the Department currently provided for the FVU and the manner in which the Department interacts with police in respect of family violence matters. If, in view of the function the FVU fulfils, it appears that further training would be of value the Department will be receptive of any such suggestion.
Client Service Environment systems would have a practical value.
” Submissions in reply on behalf of the Department of Immigration and Border Protection paragraphs 8 -16
% Submissions in reply on behalf of the Department of Immigration and Border Protection paragraphs 3-6
I thank the joint CLCs for their constructive and detailed contribution to proposed
recommendations in this case.
Evidence of Ms Dean-Thompson
147,
Ms Dean-Thompson gave evidence at the inquest.
I found her evidence to be reasonable, credible and well-informed. She was a good
samaritan in the context of this case. She assisted Ms Ragi to the best of her ability.
There is no need to deal with her evidence in detail other than to note that I accept it. She acted in good faith and her actions were motivated toward protecting Ms Ragi, and I
commend her for them. I thank her for giving evidence at the inquest.
D. Cultural issues
I was assisted in this inquest by the evidence of Dr Ruchita Ruchita®’, She has given evidence in relation to relevant cultural and religious factors in a number of inquests, including this one. That evidence has been very helpful in providing a better contextual
understanding of factors relevant to each case.
In this case, Dr Ruchita did not give oral evidence, but provided a report, dated 20 November 2014.* In her report, she sets out both Ms Ragi’s and Mr Singh’s backgrounds.
She deals with the cultural context of arranged marriages in India. She notes that, in this case, when Mr Singh visited his parents in March 2011, his family started to tell relatives that he was looking for a bride. As a result, Ravi, Ms Ragi’s uncle, arranged a meeting
between Mr Singh and Ms Ragi. They got engaged very shortly after they met.
Dr Ruchita goes on to make the following point in her report:-
“Arranged marriage is the most common form of marriage in India where even though in the majority of cases women and men are given an opportunity to meet their potential spouse, they have limited choice to refuse. Women must abide by the wishes of her family. The case summary does not suggest that there was any unwillingness by any party at the time of marriage.
Marriage is not only the union of two individuals, but it is between two families. The wife is expect to live with the husband’s family. In this case, when Avjit visited Sargun’s family along with his family in New Delhi, there was an argument where Sargun’s grandmother said that Sargun wasn’t to travel back to Amritsar with Avjit.*?
‘! Dr Ruchita’s qualifications are - Bachelor degree in Law and a Master in Law from the Guru Nanak Dev University in India and these qualifications have been assessed by the Australian Education International-National Office of Overseas Skills Recognition as the equivalent to a Bachelor and Master degree in Australia
® Exhibit 15
& Inquest Brief page 541b - Report of Dr Ruchita Ruchita
"Page 35 of 42.
with Sargun’s extra marital affairs.** She then goes on to say:-
“Adultery (infidelity) is grounds for divorce in India and a contributing factor for abuse in the case study. Any pre-marital relation or sex outside of marriage is not acceptable and disclosure of such could result in various forms of abuse. The majority of Indian men have a sense of ownership and possession of their wife and feel justified to use disciplinary. actions towards their wives even if the allegations of affairs are not validated.”
“The case summary mentions various factors that may have contributed to homicide.
However cultural and religious beliefs could also have been a major contributing factor.
Cultural norms like the arranged marriage of Avjit and Sargun and non-acceptance of adultery have been mentioned in the case summary.
The summary does not mention much about physical, verbal or psychological abuse but sexual abuse has been mentioned. Indian women accept sexual abuse as part of being married and do not complain about it.
Infidelity and pre-marriage sex is a taboo for Indian women. Avjit was unhappy about Sargun’s extra marital affairs.
The homicide by Avjit Singh could have been motivated by his sense of male privilege.
Family Violence research indicates that a person's safety is at most risk during times of recent separation. As reported in the police summary Sargun moving out of the family home could also have ignited further anger and could have brought shame to him.
There does not seem to be a direct link with the religion as a motivation for this homicide as his religion and faith system does not support violence. His cultural beliefs and values such as gender inequality, male superiority, and a patriarchal society belief system appear to have overridden his religious beliefs. °°
values and beliefs can have implications for the way that family violence is experienced. 8”
“4 Thquest Brief page 541c — Report of Dr Ruchita Ruchita
® Inquest Brief page 541c — Report of Dr Ruchita Ruchita.
86 86 Taquest Brief page 541d — Report of Dr Ruchita Ruchita.
§7 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 violence in culturally and linguistically diverse communities in Australia, Department of Community Development, Family and Domestic Violence Unit, Western Australian Government, WA.
Page 36 of 42 =
Cultural factor — Male entitlement
On Dr Ruchita’s evidence, Mr Singh appeared to have been motivated by a culturallyentrenched patriarchal/male entitlement attitude. In my opinion, Mr Singh’s killing of Ms Ragi appears to have been primarily an act of vengeance. The extent to which it was influenced by a sense of entitlement cannot be determined but, I infer from the evidence (including evidence about the controlling way he treated her after moving into their home in Fawkner), that an attitude of entitlement was a factor, perhaps a significant one. On Dr
Ruchita’s evidence, such an attitude had a cultural basis.
Dr Ruchita has previously provided evidence about 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 has 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 has made several general (not case-specific) recommendations for interventions
to reduce the incidence of family violence within CALD communities, including: e funding for increased CALD-specific services at Magistrates’ Courts;
e education programs for faith leaders, given their position as role models in the
community; ® programs targeting international students; e 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;
e engagement of CALD communities in changing behaviour and attitudes to reinforce
gender equality;
e engagement of CALD media outlets to convey prevention messages on an ongoing
basis; and
e language-specific men’s behaviour change groups for non-English speaking men of
CALD backgrounds.
Page 37 0f 42 _
In this case, Ms Ragi had sought and received support to leave Mr Singh. She had sought and found refuge, and then support to live independently, and had accessed family violence and sexual assault support services. She had obtained an intervention order and reported breaches by Mr Singh and she had applied for a Family Violence Protection Visa.
Tragically, Mr Singh was still able to locate and kill her.
It is important to note that there was no formal intervention directed at attempting to educate Mr Singh in relation to what constitutes family violence in Victoria (and Australia) and/or, direct him or refer him to a behaviour change type program. It is impossible to gauge what effects such a program may have had on Mr Singh, given his apparent state of anger.
Nonetheless, there is a critical need to ensure that in responding to family violence all possible attempts are made to not only bring perpetrators to account, but also to educate and inform them. In my view it is highly likely that on the ultimate hearing of the contested intervention order application (in December 2012) a magistrate would have made it a condition of any order that there be a referral to a behaviour change program. If it could not be made a mandatory condition, it is highly likely it would have been a referral on a
voluntary basis.
In my findings in the Luke Batty case, I emphasised the need to balance the response to family violence by actions taken to protect victims, and at the same time, both actions taken
to intervene and change the direction and behaviour of perpetrators.
[ will make recommendations which I consider appropriately fit the facts and circumstances of these deaths. However, I note that Ms Ragi had personal support (from Ms DeanThomspon), and had accessed support agencies and legal avenues for protection. Some of Dr Ruchita’s suggested recommendations (at paragraph 156) are not relevant to the particular circumstances of this case. However, I will make a recommendation directed at the issue of behaviour change programs and education programs for men, specifically men from a CALD background. In that context, I note that Dr Ruchita made the following comment in her report:
“Early Intervention Recommendation
CALD men who are perpetrators of family violence currently have limited access to Men’s Behaviour Change Programs as proficiency in English is one of the eligibility criteria for current programs. inTouch has advocated for language specific behaviour change groups to non English speaking men from CALD backgrounds. It established the first CALD Men's Behaviour Group program in Vietnamese and is currently in the process of establishing another language specific group (Arabic speaking), These
groups, even though they occur after incidents of family violence, have the potential to be educational in preventing further episodes of abuse.’”**
Telecommunications
Ms Ragi’s friend, Mr Sanjay Devgan, stated that Mr Singh told him that he had used a telecommunications company to locate Ms Ragi and identifies that he may have found her without the use of a private investigator. This may be correct, however, I am satisfied that the private investigator, through Mr Singh-Sidhu, assisted Mr Singh’s attempts to locate Ms Ragi despite the intervention order being in place.
If Mr Singh did indeed use a telecommunications company to locate Ms Ragi, this raises
issues regarding possible aiding and abetting offences by telecommunications company staff overseas and the larger issue of possible use of IT for cyber-stalking of protected persons.
This issue is not within the scope of this investigation and cannot be taken any further. In any event as Mr Singh is deceased and there is no further evidence beyond Mr Devgan’s statement that Mr Singh may have used such means to locate Ms Ragi. In light of technological advances that allow persons to be tracked through their mobile telephone use, I consider it worth noting that such means of surveillance are unlawful. Further, if overseasbased telephone company employees are potentially breaching local legislative provisions, this is a matter for which the relevant Australian-based/run telecommunications company could potentially be held responsible. Local telecommunications companies may wish to note this as an opportunity to remind overseas providers and staff of their obligations regarding local criminal offences, which may arise from such conduct as Mr Devgan
identified.
A family violence advocate
I refer to my comments in the finding into the death of Luke Batty regarding a family violence advocate. In that finding, I endorsed the evidence of the Expert Panel, which supported a formalised advocacy role for women navigating the family violence system.
Expert Panel members Ms Fiona McCormack and Ms Catherine Plunkett noted that the capacity of family violence services to undertake advocacy roles for women is limited due to
the increase in referrals.®° In addition, Professor Cathy Humphreys explained that in the
‘8 Report of Dr Ruchita Ruchita, 4 July 2014 a Transcript, pages 1783 and 1778
‘Page 39 of 42
United Kingdom the role of the Domestic Violence Advocate is a formalised position.
Evaluations indicate that for 57% of women who have been supported by such an advocate, there is a near cessation of abuse following three or four months of contact.
“There was a clear link between the number of services offered and the abuse ceasing...
the [advocacy system] because it’s got a greater authorisation within the UK system did
have the potential to deliver some greater safety and some greater accountability”.”°
Dr Lesley Laing stated:
“Good domestic violence advocacy, to me, would be a joint discussion between the woman and the advocate and often the way that comes about is through a process of risk assessment”! T, hrough the process of sharing all the available information, an advocate might assist a woman to best appreciate the level of risk.”
Although Ms Ragi had the assistance of Ms Dean-Thompson, her level of vulnerability, relative isolation, and cultural factors, may well have meant that having such an advocate available to her would have enabled her to more clearly identify the increasing risk to her
safety and to obtain safe (or safer) accommodation and/or additional supports.
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)
connected with the death:
Victoria Police
Ls
In line with my recommendations in the Luke Batty finding relating to the use of the L17, I recommend that the Chief Commissioner of Police amend the Victoria Police Manual and other relevant operating instructions and, if appropriate, the Code of Practice for the Investigation of Family Violence, to require police officers completing an L17 to review previous L17s relating to the same offender and, where possible, to contact the authors of
previous L17s to ensure information regarding risk is shared and considered.
State of Victoria
The following recommendations are directed to the State of Victoria through the agency of the
Secretary of the Department of Premier and Cabinet.
In line with my recommendation in the Luke Batty finding, I recommend that the State of
Victoria give consideration to the creation and resourcing of a Family Violence Advocate
9 Transcript, page 1780-1781 be Transcript, page 1807 ” Transcript, page 1808 - 1809
service to provide advocacy services for women and families modelled on the UK Domestic
Advocate position.
have limited or no access to such programs.
Department of Immigration and Border Protection
of Victoria and made public.
Pursuant to section 73(1) of the Coroners Act 2008, this finding and these comments and
recommendations will be published on the Court’s website.
Pursuant to section 72 of the Coroners Act 2008, a public statutory authority or entity which receives recommendations made by the coroner under s.72(2) of the Coroners Act 2008 must provide a written response, not later than three months after the date of receiving the
recommendations.
The written response referred to above is required to specify a statement of action (if any) that has, or will be taken in relation to the recommendations made by the coroner. These responses
will be published on the Court’s website.
I convey my sincere condolences to Ms Ragi’s family at her tragic death in 2012.
T direct that a copy of this finding be provided to the following parties for their information only:
Mr Mandeep Singh Ragi, Senior next of kin DLSC Cameron Lunny, Coroner’s investigator Belinda Lo, Eastern Community Legal Centre
Justice Marcia Neave, Commissioner, Royal Commission into Family Violence
= Page 4lof42.
I direct that a copy of this finding be provided to the following parties for their action:
Chief Commissioner of Police Graham Ashton Mr Chris Eccles, Secretary, Victorian Department of Premier and Cabinet
Mr Micahel Pezzullo, Secretary, Department of Immigration and Border Protection
Signature:
ay ae
Bow
Date: 3, 2 [1s
Page 42 0f42 _
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