Finding into death of Kelly Ann Thompson

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 0824

FINDINGS INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Inquest into the Death of: KELLY ANN THOMPSON

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Representation:

Counsel Assisting the Coroner

21 April 2016

Coroners Court of Victoria 65 Kavanagh Street Southbank, VIC 3006

17, 18 and 19 June, 27, 28 and 31 August and 1, 2,3 & 4 September 2015

JUDGE IAN GRAY

Ms Sharon Keeling with Amanda Burnnard on behalf of the Thompson family

Mr Ron Gipp instructed by the Victorian Government Solicitors Officer for the Chief Commissioner of Police

Ms Elizabeth Brimer instructed by Russell Kennedy on behalf of Constable Attard, Senior Constable Whichello and Constable Pringle

Ms Rachel Ellyard instructed by the Coroners Court InHouse Solicitors Service

I, JUDGE IAN GRAY, having investigated the death of KELLY ANN THOMPSON

AND having held an inquest in relation to the death on 18 and 19 June, 27, 28 and 31 August and 1, 2,3 & 4 September 2015

at the Coroners Court at MELBOURNE

find that the identity of the deceased was KELLY ANN THOMPSON born on 29 April 1970

and the death occurred on 9 February 2014

at 5 Hamilton Street, Point Cook, Victoria 3030

from:

1(a) STAB WOUNDS TO THE CHEST

in the following circumstances:

Ms Kelly Ann Thompson, aged 43 years, resided at 5 Hamilton Street, Point Cook (‘the Hamilton Street address’) at the time of her death. She was the daughter of Wendy and John Thompson. Ms Thompson had no children.

Ms Thompson had been fully employed throughout her life in various import and export businesses. She was, at the time of her death, seeking to establish an import business with three others. Her mother said that she had a desire to ‘take a risk and do something out of the box.’ Her mother also said this about her: ‘Kelly was one of those people that only saw the best in people. She was never negative about people. She would always focus on the positives of what you had done. Kelly sought to be happy and smiling — she took a lot of joy in living. She was exuberant. She lived life fully participating in it. There was never a mundane day passing day to day.

She got something out of every day. She was always vibrant and feisty. That’s how I remember her. She was a loving and giving person. She would give more than she

would take at any time. If there was something good she was doing she would try and involve other people to share the good experiences.”!

At approximately 9.10am, 11 February 2014, police forced entry into the Hamilton Street address to conduct a welfare check on Ms Thompson who hadn’t been heard from for several days. A deceased female and male were located in the front bedroom, in what presented as the scene of a murder/suicide. The female appeared to be the victim. The bodies were later identified as that of Kelly Ann Thompson and her estranged partner,

Wayne Phillip Wood.”

' Inquest brief p 1983, Statement of Ms Wendy Thompson, 3 June 2015.

? Lalso investigated the death of Wayne Phillip Wood (COR 2014 825). This investigation comprises a separate finding.

At the time of her death, Ms Thompson had a full intervention order (IO) against Mr Wood following physical violence towards her. Ms Thompson had reported two breaches of the

earlier interim intervention order (IIO) to police.

The events leading to her death from first contact with police occurred over a relatively short time frame, I note that the first contact with police regarding issues of family violence as between Ms Thompson and Mr Wood occurred on 1 January 2014 — making it less than

39 days between that event and Ms Thompson’s death.

Medical Examinations

A post mortem examination was conducted by Dr Jacqueline Lee, forensic pathologist of the Victorian Institute of Forensic Medicine (VIFM). Ms Thompson’s remains showed signs of ‘putrefactive decomposition’. She noted that there were six stab wounds to the body including five to the chest, one to the abdomen as well as two incised wounds to the left

arm. She determined the cause of death to be ‘Stab Wounds to the Chest’.

A toxicological examination revealed the presence of ethanol in the amounts of 0.24 g/100mL in blood and 0.28 g/100mL (Vitreous Humour), Delta-9-tetrahydrocannabinol (the active form of cannabis) in the amount of ~23ng/ml in blood as well as ~0.4 mg/L of

Desmethylvenlafaxine (for the treatment of depression).

Identification of Ms Thompson’s remains was confirmed by Dr Richard Bassed, Senior Forensic Odontologist, VIFM following an examination of dental records and Dr Dadna

Hartman, also of VIFM, who conducted DNA testing.

Mr Wood’s cause of death following an autopsy was found to be as a result of ‘hanging’.

Toxicological analysis of Mr Wood’s blood showed 0.01g/100mL of ethanol and ~0.9mg/L Fluoextine (for the treatment of major depressive disorder and obsessive compulsive

disorder).

Purposes of the Coronial Investigation

Vi.

The primary purpose of the coronial investigation of a reportable death? is to ascertain, if possible, the identity of the deceased person, the cause of death (interpreted as the medical cause of death) and the circumstances in which the death occurred.* An investigation is conducted pursuant to the Coroners Act 2008 (the Act). The practice is to refer to the

medical cause of death incorporating, where appropriate, the mode or mechanism of death,

? Section 4 of the Act requires certain deaths to be reported to the coroner for investigation.

4 Section 67 of the Act.

7"

12,

13:

and to limit investigation to circumstances sufficiently proximate and causally relevant to

the death.

Coroners are also empowered to report to the Attorney-General on a death they have investigated; the power to comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice; and the power to make recommendations to any Minister, public statutory or entity on any matter connected with the death, including recommendations relating to public health and safety or the

administration of justice.° This is generally referred to as the prevention role of the Coroner,

I was initially assisted in my investigation by Detective Senior Constable (DSC) Adam Sharp, Wyndham Criminal Investigation Unit (CIU) and later by Detective Sergeant (DS) Graham Ross, Homicide Squad. Their investigation was oversighted by DS Glenn Grandy, Professional Standards Command (PSC) in accordance with the Victoria Police Oversight principles. The manner in which this death was investigated by police as well as the manner

in which it was oversighted by PSC was an issue in this investigation.

Standard of proof

Coronial findings must be made on the basis of proof of relevant facts on the balance of probabilities and that in determining whether a matter is proven to that standard, consistent

with the principles enunciated in Briginshaw v Briginshaw*.

THE EVIDENCE

15;

This finding is based on the entirety of the investigation material comprising of the coronial brief of evidence’ compiled by DSC Sharp and DS Ross including material obtained after the provision of the brief, the statements and testimony of those witnesses who gave evidence at the inquest (listed below) and any documents tendered through them, documents tendered through counsel (including counsel assisting) and written (and oral) submissions

(including replies) of Counsel following the conclusion of the inquest.

All this material, together with the inquest transcript, will remain on the coronial file and

comprise my investigation into Ms Thompson’s death. I do not purport to summarise all the

Sections 72(1), 72(2) and 67(3) of the Act regarding reports, recommendations and comments respectively.

§ (1938) 60 CLR 336

7 Which included witness statements, photographs, maps, audio material, telephone and computer records as well as other records and documents such as the Werribee Magistrates’ Court file and the legal file of Ms Thompson.

a

material/evidence in this finding, but will refer to it only in such detail as is warranted by its

forensic significance and where otherwise appropriate. ®

17. I was assisted by the Submissions (and Replies) provided by all counsel (including Counsel Assisting) appearing in this matter.

SECTION 67 FINDINGS

18. Prior to the commencement of the inquest, it was apparent that most of the facts about Ms Thompson’s death are known and were not in dispute. This includes Ms Thompson’s identity, the medical cause of her death and most of the circumstances surrounding her death, including mode of death as well as the relative time and place of her death.

19, As Ms Thompson’s death was suspected to be as a result of homicide, an inquest was mandatory under section 52 (2)(b) of the Act.

ISSUES FOR THE INQUEST

20. A number of discrete matters were sought to be resolved at inquest including clarification of

the facts surrounding all the events and incidents leading to Ms Thompson’s death. Issues

under exploration can be summarised as follows:?

e Was the response by attending Victoria Police members appropriate to the incident of

family violence reported on I January 2014?

e Was the response of the Wyndham Family Violence Team to the incident on 1 January

2014 appropriate in the circumstances?

e¢ What was the extent of information exchanged between the Magistrates’ Court and Victoria Police following the making of the interim intervention order on 10 January

2014?

e Was the Interim Intervention Order made on 10 January 2014 served in accordance

with existing practice, procedures, protocols and training?

e Why did the Interim Intervention Order take 5 days to serve, given the severity of the

risk recorded by Ms Thompson?

e Given the nature of allegations and consent without admissions, should the Court have done more to ensure Mr Wood contacted the Men’s referral service or otherwise

received assistance and support?

8 The absence of reference to any particular aspect of the evidence, either obtained through a witness or tendered in evidence, as well as submissions and replies, does not infer that it has not been considered.

° This included any system deficiencies that had been identified and whether they had been rectified.

Property Collections occurred on 9 January, 24 January, 31 January and 7 February 2014.

em

%* Were these Collections conducted in accordance with existing practice, procedures,

protocols and training?

°

o cS

Should these Collections have generated any other follow up responses from

Victoria Police?

% Did Mr Wood threaten Ms Thompson in the presence of police on 7 February 2014 as suggested to Kelly Dibella by Mr Wood on the afternoon of 8 February 2014?

Ms Thompson reported two breaches of the intervention order as having occurred on

the 18 and 22 January 2014.

% Were these reports of breaches managed in accordance with existing practice,

procedures, protocols and training?

“+ Was Ms Thompson kept appropriately appraised of the progress of the breaches,

were the appropriate referrals made for Ms Thompson?

o fe

Should these breaches have generated any other follow up responses from Victoria

Police?

Clarification of what Ms Thompson was or had been made aware of in relation to the

behaviour and threats of Mr Wood.

Clarification of Ms Thompson’s own views regarding contacts with Victoria Police and

responses by Victoria Police.

What were the likely nature and content of contacts (38 known calls) made by and with

Ms Thompson and Victoria Police from 1 January 2014 until her death?

Did Ms Thompson contact the police after 24 January 2014?

Did Ms Thompson report any further breaches of the intervention order to Victoria

Police following the second breach?

Of the known contacts with Victoria Police, was the response from Victoria Police in

accordance with existing practice, procedures, protocols and training?

Clarification of the nature and content of the contacts between Mr Wood and the

psychologist on 16 January, 22 January and 29 January 2014.

° Was the response to the phone call made by Mr Norman Paskin to the Werribee Police

station appropriate in the circumstances?

e° Was the response of the psychologist appropriate in the circumstances?

e Did Mr Wood present, or should he have been regarded as having presented, in a

manner which Victoria Police should have acted upon?

e Why was the investigation not returned to the Homicide Squad as a first option as determined at the meeting, held on 20 February 2014, between Deputy Commissioner Cartwright and Assistant Commissioners Leane (PSC) and Crisp (North West Metro Region), or as an alternative, conducted by a Detective Sergeant from another Division?

21. I considered these matters to be sufficiently proximate to Ms Thompson’s death and the

circumstances in which it occurred.

The Witnesses called to give evidence

22. The following witnesses gave evidence at the inquest!°:

a. Ms Wendy Thompson

b. Mr Steven Hall

c. Mr Shawn Donnelly

d. Ms Catherine Low

e. Ms Julie Dibella (aka Mac)

f. Ms Jenny Le Fevre

g. Ms Rose Tonihi

h. Ms Darlene Tonihi

i. Mr Norman Paskin

j. Ms Sheryl Paskin

k. Mr Vu Kim, lawyer

1. Ms Claudia Henriquez, Court Registrar

m. Constable (Cons) Sean Pringle!

'0 Mr Jo Pirri Trifili was unable to give evidence as he was overseas.

n. First Constable (FC) Alex Riches o. Senior Constable (SC) Warren Martin p. SC John Whichello”” q. FC Emily Wallace r. Cons David Attard'3 s. SC Brendan Tyrell t. FC David Priebbenow u. FC Manase Holani v. Professor James Ogloff, Expert w. Marizanne De Bruin, Psychologist'* x. SC Darren Murrihy y. SC Kula Mayne z. Cons Aaron Bryan aa. Cons Matthew John Byron bb. DS Glenn Grandy cc. Assistant Commissioner (AC) Luke Cornelius dd. DSC Adam Sharp ee. DS Graham Ross

RELEVANT VICTORIA POLICE DOCUMENTS

23. I was provided with the following advice regarding Victoria Police documents relevant to

my investigation:

e Victoria Police policy in relation to family violence is located primarily in the Victoria

Police Manual Policy (VPMP) titled ‘Family Violence’. The VPMP is supported by the

"| First Constable at the time of the incident, Constable Pringle was granted, following application, a certificate of immunity under section 57(S) of the Act.

2 Senior Constable Whichello was granted, following application, a certificate of immunity under section 57(5) of the Act.

'3 First Constable at the time of the incident. Constable Attard was granted, following application, a certificate of immunity under section 57(5) of the Act.

'4 Video link from New Zealand

VPM Guidelines (VPMG) titled ‘Family Violence holding Powers’ and ‘Family

Violence safety Notices’.

e The Code of Practice for the Investigation into Family Violence (Code of Practice) sits underneath and complements the VPM. In the event of any inconsistency between the

Code of Practice and the VPM, members are required to refer to the VPM.

e The Risk Assessment and Risk Management Report - Form L17 (L17) is the key tool used in family violence risk assessment and management by Victoria Police. In accordance with paragraph 2.3 of the VPMP Family Violence, the L17 must be completed for every family incident reported to police. The L17 is based on the Family Violence Risk Assessment and Risk Management Framework [known as Common Risk Assessment Framework (CRAF)] which was adopted in 2007 after widespread consultation with services in Victoria and the CRAF Manual is published by the

Department of Health and Human Services.

BACKGROUND CIRCUMSTANCES

DT

Ms Thompson and Mr Wood met through a mutual friend, Ms Julie Dibella, in April 2010 at a party. Ms Thompson was living in Tasmania at the time. They commenced a relationship soon after meeting and moved into Mr Wood’s flat the same year. They subsequently rented

the Hamilton Street address when the lease on his flat expired.

Ms Wendy Thompson described two previous relationships of her daughter’s which involved violence. She said that Ms Thompson ‘was adamant and strong that she would

never endure another abusive and violent relationship again. ’!>

Mr Wood’s ex wife of 27 years said that Mr Wood ‘was never physically violent towards me or the boys."!® Mr Wood had no prior police matters apart from a single dishonesty matter in

Mr Wood was involved in a single vehicle accident on 10 December 2009, where he was said to have drifted off the highway and into a tree. There is however no evidence to suggest

that this event had an effect on him such that it would be relevant to my investigation.'7

Mr Wood couldn’t read or write or use a computer. His friend, Robert Whitewood, said that Mr Wood had a speech impediment.

'S Inquest brief p 1982, Statement of Ms Wendy Thompson, 3 June 2015

'6 They had two sons.

'7T note that Ms Thompson makes reference to the event in her application for an IO, but there is no medical evidence before the Court indicating that Mr Wood was impaired in a significant manner.

32,

33,

Ms Wendy Thompson said of Mr Wood,

‘Wayne was always a man within himself — a man that was tightly held together emotionally. He didn’t allow a lot of interaction into his personal life. He was a masked person and he would pick and choose what parts of his personality he would show to particular people.’

She described him as ‘sulky’ but not ‘aggressive’, and hard to get to know. She said that he

was ‘always around Kelly’ but that it ‘was a fairly equal relationship.’ ®

It is apparent that Ms Thompson and Mr Wood had an active social life with many long standing friends. They also played competition pool at the Sanctuary Lake Hotel in Point Cook.

In late October 2013, Ms Thompson and Mr Wood left their jobs and took out a $60,000 bank loan (jointly) in order to commence an import/export business with Mr Shawn Donnelly and Mr Joe Pirri Trifilo!?. Ms Thompson had expertise in this area and held an import export licence. There is evidence that Ms Thompson did not want Mr Wood to give

up his job until the business was on its feet, but he did so anyway.

All four went overseas for business development purposes in late 2013. Ms Thompson and

Mr Wood left on 31 October 2013. Their destinations included China and the Philippines.

It appears that Mr Wood had always been a possessive and jealous partner to Ms Thompson but the relationship deteriorated significantly while they were overseas. All the partners, except Mr Wood, were able to get along well with the local people in order to progress the business. There were reports of frequent arguments, heavy drinking by Mr Wood, and an incident in which he locked Ms Thompson in a hotel room and tried to choke her. Ms Thompson wrote of this incident:

‘We were overseas in Manila and he locked myself and a girlfriend in our hotel room. I had to yell out for help so we could get out. He also threw me across the room twice resulting in me smashing my head on the ground and covered in bruises. *°

Whilst overseas, Mr Wood told Mr Donnelly that he would kill Ms Thompson and himself.

Mr Donnelly did not take the threat seriously and thought this was an expression of his

frustration.?!

On 6 December 2013, Ms Thompson told her friend Catherine Low, by Facebook, that she

was going the leave Mr Wood, as she “was sick of being ‘Mary and her little lamb’ meaning

she couldn’t go anywhere without him’”?.

'8 Inquest brief p 1, Statement of Ms Wendy Thompson. 3 April 2014

'9 Mr Pirri Trifilo had known Ms Thompson for 20 years.

20 110 application dated 10 January 2014.

21 Mr Wood also bought a wedding ring and asked Ms Thompson to marry him whilst overseas [he also asked her to

marry him on their return to Australia (19/12/13) but she declined].

=

BT?

Ms Thompson and Mr Wood returned to Australia around 16 December 2013.

On 31 December 2013, Ms Thompson and Mr Wood attended Mr Pirri Trifilo’s house for the New Year celebration. Mr Wood assaulted Mr Donnelly by striking him with a pool cue.

He thought Mr Donnelly had touched Ms Thompson’s hair. Ms Thompson told Ms Dibella that Mr Donnelly had ‘given her a New Years’ kiss and hug.’ Mr Wood apologised to Mr Donnelly the following day. This matter was not reported to the police.

CIRCUMSTANCES LEADING TO DEATH

On 1 January 2014, Ms Thompson and Mr Wood were arguing at the Hamilton Street address, when Mr Wood broke Ms Thompson’s mobile phone and attempted to choke her.

Ms Thompson left the house on foot and was pursued by Mr Wood who was reportedly driving his car in an erratic manner. Mr Steven Hall and his girlfriend stopped to assist Ms Thompson. She told them that her partner had attempted to strangle her and whispered to the

female to call the police (she also provided her address).

Mr Hall said that a Commodore came out of the blue and nearly hit his car. He reported that Ms Thompson said to him when asked if she was okay: ‘not really my partner tried to strangle me’. He observed that she was ‘shaking and upset.’ He said that Mr Wood went up on the nature strip where she was standing and ‘more or less wedged her between both cars.” (skid marks were noted to be visible some 2 weeks later). Mr Wood was volatile

when Mr Hall tried to settle the situation (‘get the fuck out of here’).

First police contact

Mr Hall called emergency services (000) at approximately 8.47pm. This call is recorded and part of the evidence before the Court. It includes information regarding the allegation of strangulation and the request by Ms Thompson for police assistance. The police radio communications also included the following:

000 Operator: ‘Female versus male in a vehicle. The female asked the complainant to

call the police for her. The complainants not involved. She’s stated her partner's tried to strangle her. The male came around in a vehicle. He told the complainant to leave.’

[Werribee 251: 257, I'll head down there as well. ] The officers also had access to the electronic patrol duty return Form (ePDR Form) which

related similar information.

?2 Inquest brief, p 456, Attachment 1 3 Inquest brief p 236, Statement of Ms Julia Dibella 13 February 2014 *4 Inquest brief p 66, Statement of Mr Steven Hall, 23 February 2014

50,

The police arrived at the Hamilton Street address at 8.54pm. The members in attendance

were Cons David Attard and SC John Whichello (with call sign Werribee 302).

Both Ms Thompson and Mr Wood answered the door. Cons Attard said that Ms Thompson ‘looked a bit dishevelled like she had been crying or very upset’. He noted Mr Wood to be

‘calm’ however ‘upset.’*> They were spoken to separately by the officers.

Cons Attard spoke to Mr Wood near the front door and SC Whichello spoke to Ms

Thompson in the front garage area.

Mr Wood spoke of pressure on the relationship from the business which was ‘struggling’.

When asked what had occurred that evening, Mr Wood said that they had had an argument over the business and that Ms Thompson had indicated that the relationship was over and she fled on foot. He said that he had followed her in his vehicle to get her to come home.

Cons Attard observed that ‘he wasn’t violent towards us at all and he didn’t seem violent

towards her.’ He said that ‘None of them had any injuries on them.’*®

SC Whichello said that Mr Wood kept saying that ‘nothing had happened and Kelly kept saying that they were waiting for their business partner to turn up at the house before saying anything.’ He said that Ms Thompson ‘didn’t have any marks or anything. 7

Cons Attard said that following a discussion with SC Whichello, he ascertained that she had

‘given the same version of events.’

Mr Wood agreed to reside elsewhere for the night ‘to allow both parties to calm down and

prevent any further incidenis’.””

Cons Attard said ‘/iJn my opinion this incident was a verbal only. There was no threats of violence or property damage.’ He said that Ms Thompson did not disclose to either himself

or SC Whichello that he she had been choked by Mr Wood.

Cons Attard said that after Mr Wood had left:

‘Both of us spoke to Kelly again asking her what had happened but again she was just saying that it was the business partner and he needed to he there before she told us anything.’ Overall he said ‘both of them continued to say they wanted to wait until the business partner arrived and that was pretty much their answer for the majority of conversations of trying to find out what had happened. ’*°

25 Inquest brief p 69, Statement of Constable David Attard, 23 April 2014 26 Inquest brief p 69, Statement of Constable David Attard, 23 April 2014 27 Inquest brief p 74, Statement of Senior Constable John Whichello, 15 May 2014 28 Inquest brief p 70, Statement of Constable David Attard, 23 April 2014 2° Inquest brief, p 70, Statement of Constable David Attard, 23 April 2014

3° Inquest brief p 75, Statement of Senior Constable John Whichello, 15 May 2014

Dts

They gave advice to Ms Thompson that if she wanted to take out an intervention order she

should attend the Magistrates’ Court.

The officers left the Hamilton Street address at 9.24pm. They formed the view that no police action was required of an investigative nature. They did not interview the complainant (Mr

Hall) regarding the incident.

In accordance with paragraph 2.3 of the VPMP Family Violence, a L17 was completed for this incident. This document did not include the information that Ms Thompson alleged that Mr Wood had attempted to strangle her. I note that strangling (choking) is considered to be a ‘red flag’ indicator of high risk behaviour.*! The future risks of violence on this occasion however were determined to be low. The L17 also noted that the level of fear of the

Affected Family Member (AFM), Ms Thompson, was noted as ‘not fearful.’ The narrative recorded on LEAP was as follows:

The Resp is Wayne Wood. The AFM is Kelly Thompson. AFM and the Resp are in a defacto relationship. Both parties have invested money into an import export business.

On the 1/1/14 at 2030 hours the Resp and AFM were at 5 Hamilton Street, Point Cook.

They had returned from overseas recently and had some issues on trip. The AFM has told the Resp the relationship was over. The Resp and AFM began arguing and the AFM left the address on foot. The Resp followed in a car and told the AFM to come home. The Resp and AFM continued to argue on the street. Both parties returned home.

Nil further. Issues surrounding relationship breakdown and business problems. Resp spending the night away at a family members house to calm situation down. Nil previous FVIR or IVO’'s. Formal referrals made for both the AFM and Resp.”

With respect to calling the Complainant, SC Whichello said that given all the circumstances as they presented including Ms Thompson’s presentation (not ‘any marks or ripped or stretched clothing, anything to indicate she’s been grabbed as it stated in the job, or if she said she had been pushed..’)**, he didn’t think it necessary to do so.

On 2 January, Ms Thompson said of the incident on | January to her friend Jarrod Joyce,

‘my partner tried to kill me last night. %*

From that time on, Ms Thompson and Mr Wood remained living at the Hamilton Street address but were sleeping in separate rooms. Ms Thompson told Mr Wood that the

relationship was over.

After that time, Mr Wood appeared to get more possessive, was reluctant to let Ms

Thompson out of his sight and was restricting her movements.

3! The Red Flag List.

» Inquest brief p 671, LEAP Report 33 Inquest brief p 76, Statement of Senior Constable John Whichello, 15 May 2014

34 Inquest brief p 820, Statement of Mr Jarrod Joyce, 2 January 2015

Women’s Health West

Women’s Health West (WHW) Family Violence Outreach Service provides confidential support and crisis assistance to women and children in the western metropolitan region of Melbourne. This service assists women and children with information, referral, court

support, risk assessment and safety planning.

I was advised that the WHW 24 Hour Crisis Response team receives all police referrals from western metropolitan area and makes contact with women following police attendance at a family violence incident. All referrals that are received through this program are triaged and are further risk assessed by specialist family violence staff. WHW then notify that attending police officer via email of the outcome of all referrals received and what level of

support was rendered to the women.

3 January 2014

According to WHW records, Ms Thompson had direct contact with the family violence outreach service on two occasions during January 2014. She was first referred to WHW on 3

January as a result of the L17 referral,

Business Intervention Meeting

Also around 3 January, there was a meeting of the business partners to address Mr Wood’s

attitude to Ms Thompson and his violent behaviour.

Mr Wood agreed that he would seek professional help to manage his anger. He understood

that this would be vital if he was to remain as part of the business.

Attendance with the GP

On 4 January, Ms Thompson accompanied Mr Wood to his GP, Dr Munir*> to seek assistance with anger issues, alcohol abuse and depression. A GP Mental Health Plan was prepared and he was referred to Life Solutions for sessions with a psychologist, who saw

him on 3 occasions before Ms Thompson’s death.

Djerriwarrh Health Services

Djerriwarth Health Services provides the Enhanced Service Intake into Men’s Behaviour Change Service, commonly known as MARS (Men’s Active Referral Service) for Victoria Police L17 Referrals. Following receipt on 5 January by Djerriwarrh of the first referral

regarding the incident on 1 January, two attempted phone calls were made to Mr Wood on 5

35 She also attended this GP.

January. Given the classification of the incident by police as verbal only, a text was due to

be sent by the service approximately four weeks later.

Wyndham Family Violence Team

On 6 January, the incident of 1 January was followed up by FC Alexander Riches of the Wyndham Family Violence Team (WFVT). In accordance with existing processes, he was required to make contact with victims who were subjected to family violence. FC Riches reviewed the L17 and noted it was the first report of family violence between the parties and that it was characterised as a verbal argument and determined to be minor in nature. He noted the assessment of future risks between the parties was rated as unlikely (by the attending members) and formal referrals for both the AFM, being Ms Thompson and the

Respondent, being Mr Wood were marked as complete.

FC Riches called Ms Thompson’s mobile phone and left a detailed message asking her to contact the WFVT to discuss the matter further. The call was not returned by Ms Thompson

and he decided to mark the incident as complete.

In accordance with their procedures, the case was noted for a triage on 10 March.

8 January 2014

can

The information from WHW was that on 8 January Ms Thompson indicated to Collette, a WHW worker, that she did not want further support from WHW.

On the evening of 8 January, although not a couple, Ms Thompson and Mr Wood attended their local club for a pool competition. Ms Thompson complained to her friend, Ms Low that she couldn’t even go to the toilet without Mr Wood and he got upset whenever she interacted with other men. Security was eventually called and Mr Wood was asked to leave but he kept returning. Ms Thompson decided to call her brother to pick her up so she could

stay with him, at least temporarily.

Ms Thompson’s brother Patrick said of the event:

“We entered and found Kelly. I said to Kelly: ‘what's going on? Kelly said: ‘He won’t let me leave’. Kelly was in a state of fear. For her to ring me and say ‘bro you’ve got to get me out of here’ was the strongest indicator to me of her fear on that night. I saw that Kelly was genuinely scared of Wayne and relieved to see me. When Wayne saw me there he confronted me verbally and said: ‘What, are you here to belt me?’ I said: ‘No I am here to take my sister — she doesn’t want to be with you.’

36 Inquest brief p 1976, Statement of Mr Patrick Thompson, 3 June 2015

9 January 2014

73:

The following day, 9 January, police assisted Ms Thompson to retrieve personal property from the Hamilton Street address. Patrick was also present. The police members were SC Whichello and FC Emily Wallace. Ms Thompson was heard to say (not directly to the police) that she would be applying for an IO the following day.

FC Wallace said of the incident that it was ‘a public relations as there was no intervention order in place.’ She said that no words were spoken between the pair and that Ms Thompson ‘appeared determined to get in and out with her belongings quickly.’**’ The

collection took from 2.29pm to 2.45 pm.

Ms Thompson also went to the Werribee Magistrates’ with her brother to obtain an IO, but

was told to return the following day.

Interim Intervention Order

‘fat

ds

On 10 January, Ms Thompson obtained an IIO order against Mr Wood at the Werribee Magistrates’ Court (it was returnable on 23 January). As part of her application, she referred to the incident on 1 January and wrote ‘He tried to strangle me 1/1/2014. We had an argument and I went to leave the house and he wouldn't let me leave so he strangled me twice.’

The notes taken by Ms Claudia Henriquez, Intervention Order Registrar say of the incident:

‘I was on foot and he was chasing me by car for approx. 10 mins. Swearing at me and doing burnouts. Nearly hit another car. A passer by followed me as he nearly hit them and saw I was in trouble. The passer by called police and then left. Once police had been called I got back to the house and waited for police. He ret’d to the house to continue arguing. °°

Ms Thompson said ‘he is jealous and possessive and I don’t believe he will leave me alone

and I fear he may kill me.”?

Ms Henriquez gave evidence at the inquest. Ms Thompson had a scheduled appointment at 12.00pm that day. She said that she recalled that Ms Thompson ‘wasn’t really ‘panicky’ or overly concerned about getting an Interim order’ but based on the application Ms Henriquez encouraged her to seek the urgent form of the order stressing the strangulation as

reason for encouraging her to go to court.

37 Inquest brief p 60, Statement of First Constable Emily Wallace, 15 April 2014 38 Exhibit 4 Exhibit 4

4 Inquest transcript p 139

In terms of risk assessment, Ms Henriquez said that ‘there’s always some sort of risk assessment that you're doing when you're discussing with a person.’*' but not a formal

written one.

Ms Henriquez prepared the ‘Application and Summons for an Intervention Order’ document based on the application completed by Ms Thompson. The Application is intended to summarise the salient details provided by the Applicant and on this occasion recorded a full account of the incident on 1 January:-

‘Attended Police were called following this incident earlier on in the month 1/1/14 An argument started between us. The Respondent tried to strangle me so I wanted to leave the house. He refused to let me go so in an attempt to restrain me from leaving grabbed my neck and strangled me twice. I fled on foot and the Respondent followed me in his car. The Respondent was driving erratically and verbally abusing me through the car window. The Respondent almost collided into another car whilst trying to follow me and that car noticed I was in trouble and monitored me. I asked them to call police and then returned to the house to wait for police who arrived 5-10 minutes later. Police spoke to the Respondent but referred me to the Court to apply for an intervention order. I’m concerned for my safety and want him out of my life.’

The ‘Application and Summons for an Intervention Order’ did not record that she feared he may kill her but the presiding magistrate had the full application to refer to when making the decision. The Magistrate said to Ms Thompson:

“but the matters where the police were called to your house and they spoke to the respondent and referred you to the court — did they indicate there was a matter where you could lay charges against the respondent? Yes, they did.’

‘They did? And you chose not to do that? — Yes.’

Well I'll just say this to you , Ms Thompson — they are very very serious allegations and I think people need to be mindful of this fact: if somebody breaches an intervention order the court can jail them for up to two years. The nature of that allegation would lead to much longer gaol sentence if found proven against him.’?

This is consistent with what Ms Thompson told Ms Dibella - ‘Kelly said she wasn’t going to charge him for trying to strangle her.”4 She also told Ms Low that she didn’t want the police to lay charges against Wayne because she didn’t want Wayne to retaliate and that

might make him angrier.

With respect to whether the Court should advise applicants or potential applicants about the limitations of an order, I note the following exchange between Counsel Assisting and Ms Henriquez:

‘Your view is that it wouldn't be appropriate for the court to do anything that might put people off applying for orders in appropriate circumstances?---I think the court has to

4! Inquest transcript p 142 42 Exhibit 5 43 Exhibit 7

• Inquest transcript p 39

87,

be realistic in terms of giving information to parties about what an order is all about, and of course there are limitations with an order and how much it can protect them but I don't think it should be something that should be the first bit of information they receive because they probably won't proceed with it otherwise.’

Ms Henriquez emphasised that she saw Ms Thompson at the start of the process, prior to her appearance in court. As she said, it was the magistrate’s decision whether to grant an order

or not, and Ms Thompson was successful in obtaining the order she sought.

The records indicate that the Werribee Magistrates’ Court faxed a request for service to

Wyndham North at 1.14pm on 10 January.

A copy of the Order but not ‘The Application and Summons for an Intervention Order’ was

also faxed through to police records for uploading on LEAP.

Later the same day, Mr Wood contacted Ms Thompson threatening self harm. Concerned for his safety, she contacted the Wyndham North Police Station at 4.06pm and spoke to Cons Mathew Byron.

He later spoke to Mr Wood by phone (after a visit to the Hamilton Street address by Acting Sergeant Adam Pawsey found no-one home) and concluded that there were no immediate

concerns for his safety. This was relayed back to Ms Thompson at 6.20pm.

There is no evidence to suggest that this event was captured on LEAP or that it was considered in the context of a family violence continuum. A threat or attempt to commit suicide is considered a high risk factor for perpetrators. This was now known to police (and so the family violence system) but not captured or considered anywhere as part of Ms

Thompson’s risk assessment at that time.

Service of the Interim Intervention Order

Ms Thompson said to her friend Mr Joyce on 13 January regarding the IIO, ‘Feeling better thanks. Also safe, just waiting on AVO to be served so I can go home.’*° The records show

that Ms Thompson made a number of calls to police concerning the service of the IIO.

At about 12.10pm on 15 January (5 days after the order was made), the IIO was served on Mr Wood by FC Martin. This required Mr Wood to move out of the Hamilton Street address. Mr Wood disclosed that he could not read and write, so the officer went through

each condition and the process on the return of the order to court.

4 Inquest transcript p 161

46 Inquest brief p 840, Statement of Mr Jarrod Joyce, 2 January 2015

They discussed various possible scenarios, ‘such as bumping into each other at the local pub or down the street.” He also explained the order to Mr Wood’s brother, Gavin, when

he arrived to assist him.

Mr Wood moved in with his brother, who also lived in Point Cook, and Ms Thompson

returned home.

First counselling session

On 16 January, Mr Wood attended the first of three counselling sessions with Ms Marizanne De Bruin, psychologist (in accordance with the GP referral). Mr Wood admitted to choking

Ms Thompson on 1 January and expressed remorse over the incident.

He expressed no desire or intention to self harm or harm another. Ms De Bruin said that Mr Wood appeared to accept that his relationship with Ms Thompson was over but was very concermed about their joint business venture and combined finances. He also expressed a

desire to remain in the business.

17 January 2014

On 17 January, Ms Thompson changed her relationship status on her Facebook page to

‘single’.

The First Breach (Contravention) of the IO

99,

On Saturday, 18 January, Ms Thompson went to the Sanctuary Lakes Hotel for ‘dinner and drinks’ with friends, Darlene Tonihi and Katherine Prescott. At about 10.00pm, Ms Thompson noticed the presence of Mr Wood but said that she tried to ignore him.

Ms Thompson reported in a statement to police:

‘I’ve continued talking with my girlfriends trying to ignore that Wayne was there but he kept hanging around and looking over at us. The distance between my group of girlfriends was less than five metres from Wayne but there was a panel of glass separating us. Afier about what I think was five minutes I walked inside by myself and told him that he is not meant to be here when he has said to me ‘I’ve got no money, can you give me some?’ This conversation only lasted about 20 seconds.’*8

Mr Wood came up to her girlfriends trying to get information about Ms Thompson and they told him to go away, which he initially did. At about 10.45pm, he returned again and was

told by the bouncer to leave,

Ms Thompson told to one of her friends on 18 January 2014 that Mr Wood had become too

possessive, tried to strangle her and that she was concerned for her own safety.

*7 Inquest brief p 103, Statement of Senior Constable Warren Martin, 19 January 2014

“8 Inquest brief p 107, Statement of Senior Constable Warren Martin, 19 January 2014

At about 5.27pm on 19 January, Ms Thompson reported the breach of the IJO at the Wyndham North Police Station. She provided a statement about the incident (as noted above) to Constable Manase Holani. He subsequently contacted Mr Wood who attended the police station that day and was asked questions regarding the alleged breach. Mr Wood said that he attended the hotel with a friend and didn’t know she was there; that Ms Thompson approached him; that he did ask her for money; that he did approach her friends and ask about Ms Thompson and that he did return to the venue to play the poker machines in a totally different area. Cons Holani characterised Mr Wood’s response as him having ‘made

admissions to breaching the order.’?

Ms Thompson said in her statement about the hotel incident, ‘His anger issues and possessiveness caused me to end our relationship around late December 2013 and apply for an intervention order at the Werribee Magistrates’ Court.”° She did not make mention of the ‘strangling’ and other aggressive behaviour which occurred on 1 January, nor that she

feared for her life.

Cons Holani told Mr Wood that he was free to go but that he may be summoned in relation to the breach. As required by the relevant VPM, he completed a L17 noting that the AFM, Ms Thompson was not fearful. Again, the assessment of future risk was recorded as

unlikely.

The following was recorded on LEAP:

‘AFM and Resp were in a relationship for approx. 4 years. They have no children to one another. Over the 4 years together the Resp was very protective and controlling of the AFM which caused their separation in late December 2013.

Because of the controlling behaviour the AFM applied for and was granted an interim intervention order at the Werribee Magistrates’ Court on the 10" of January 2014..,...At approximately 1900 hours the AFM and her girlfriends have been in the outside smoking area of the hotel where the pool table when she has noticed the respondent standing at the inside entrance to the smoking area looking at her. When making contact the Resp had retreated back inside the hotel to a table next to the window which looks out to the smoking area where the protected person was which the AFM claims was 5 metres from where her and her girlfriends were even though there was a pane of glass separating them.

AFM has continued talking to her girlfriends for approx. 5 minutes to which the Resp was continuing to look out at the AFM. AFM has gone inside to go to the rest room and approached the Resp telling him he should not be there and to leave before continuing off to the rest room. The Resp has then started attempting to talk to the AFM saying to her ‘I’ve got no money can you give me some’ to which the AFM has ignored and continued walking.

4# Inquest brief p 113, Statement of First Constable Manase Holani, 19 January 2014

*° Inquest brief p 106, Statement of Ms Kelly Thompson, 19 January 2014

Whilst in the rest room the Resp has approached the AFM’s girlfriends in the smoking area trying to get information on the AFM of what she had been doing to be told off by approx. 2200 hours to go to the pokies to which there was no incident. 7!

Ms Darlene Tonihi said of the incident:

“...he caught my eye and then he tried to tell me that he didn’t know we were there.

When I came back out he was still there. I sort of gave him the benefit of the doubt that he hadn’t known we were there. But then about 40 minutes later he came back again. I thought ‘nah, I don’t get this’, that’s when my red flag went up. He was being dodgy, walking past.’>

Cons Holani contacted the Sanctuary Lake Hotel to request CCTV footage. He was eventually told that it had been re-used and recorded over, after 7 days. He said that Ms Thompson didn’t give him the contact details for her friends as she didn’t want them to be

involved unless it was necessary.

Cons Holani told the Court that, given the nature of the work in the Werribee Service Area, he progressed the investigation and compilation of the brief during night shift (evidenced by LEAP checks conducted in the early hours — 12.20am, 12.21am, 12.39am and 1.27am).

Mr Wood had not been charged with this breach at the time of Ms Thompson’s death.

20 January 2014

As a result of the first breach reported (and the L17 completed) WHW advised that they had received a second police referral 20" January 2014 that indicated that there had been a breach of the interim intervention order. Jessica, a crisis worker attempted to contact Ms Thompson at 12.03pm on the same day but she was unable to speak with her over the phone.

There was a message left on Ms Thompson’s phone to contact WHW.

22 January 2014

On 22 January, Mr Wood attended his second counselling session with Ms De Bruin. She noted that there was no indication of self harm and that he appeared to understand and

accept the ITO.

Also on this day, Mr Wood made a ‘friend request’ to Ms Thompson through Facebook.

23 January 2014 - Return of the Interim Intervention Order

On 23 January, the IIO was returnable and both Ms Thompson and Mr Wood attended the Werribee Magistrates’ Court. Ms Thompson was represented and assisted by Mr Vu Kim, duty lawyer, Wyndham Legal Service (WLS) and Mr Wood was represented and assisted by

5! Inquest brief p 671, LEAP Report

° Inquest brief p 22, Statement of Ms Darlene Tonihi, 13 February 2014

Ms Michelle Lothian, Victoria Legal Aid. Mr Wood consented to a final order being made, without admissions. Ms Thompson’s friend, Ms Low attended with her for support but was

unable to stay until the matter was finalised.

Mr Kim applied the WLS, ‘Intervention Court Duty Lawyer’s Advice Checklist’. Ms Thompson advised him of the two breaches of the I1O. He referred her to WHW for assistance with changing the locks at the Hamilton Street address as Mr Wood still had a set

of keys.

Mr Kim said that his notes ‘indicate Ms Thompson instructed [him] that the relevant Victoria Police officer was on leave at the time and [she] was waiting for Victoria Police to get back to her regarding the alleged breaches.’ Correspondence from WLS dated 28

January was sent to Ms Thompson setting out what had occurred that day.*?

Mr Kim said that he did not have any training in risk assessment but referred clients to the

applicant support worker or WHW for a risk assessment to be done.

Mr Kim said that he did not advise the presiding magistrate of the breaches of IIO that had

been alleged by Ms Thompson as that was not normal practice: ‘It’s just to avoid any

confrontation at the court.”*4

He said that regardless of whether the police or the applicant assisted by a lawyer makes the

application, the aim is to obtain an intervention order.

It was noted during the proceedings in Court that Mr Wood had been referred to the Men’s

Referral Service.

Ms Thompson saw the WHW worker at 3.20pm. WHW informed me:

‘WHW had a second direct contact with Kelly was on 23" January 2015 at Werribee Magistrates’ Court where she was provided information at [sic] support by WHW court support worker relating to an application for a intervention orders [sic]. Our records indicate that the rostered court support worker on that day Michelle was advised by Kelly Thompson that the final intervention order had been made by the magistrate. Our records indicate that Michelle discussed assistance WHW could provide her in regards to changing the locks at her home, Kelly indicated that she would feel safer with the locks changed. Michelle's recollection of this conversation is that Kelly was advised to contact WHW intake service who could facilitate the change of locks. Michelle conducted extensive safety planning with Kelly at the court that included the provision of contact details for WHW, Women’s Legal Service, Victim Assistance and Counselling program. Kelly was provided with information regarding breaches of intervention orders, ongoing safety planning that included the following risk management strategies; contacting 000. And using a ‘safe word’ with trusted friend that indicated she was at

3 Ms Thompson was also approached by, Owen Camilleri with respect to any financial assistance she may need and arrangements were made for this to occur at a later time.

*4 Inquest transcript p 119

risk. Kelly Thompson did not want ongoing support at the time however she was encouraged to contact WHW if she wanted support for the future.’*°

Michelle recalls that Ms Thompson was not visibly upset during the interaction and that she

stated that she was ‘over’ Mr Wood ‘harassing’ her.

I was informed that WHW court support staff work with women in relation to safety at court and upon departure, and develop risk management strategies for the immediate future in the next 24 hours. Depending on the individual woman’s circumstances a safety plan is

developed taking immediate risks into account.

Michelle did not undertake a Comprehensive Risk Assessment with Ms Thompson at the court as this is generally undertaken following a referral to WHW’s intake service and takes

approximately one hour.

Report of the second breach (contravention) of the I[O

After Ms Thompson left Court on 23 January, she attended at the Wyndham North Police Station to report the second breach of the order which had occurred on the previous day. As

noted above, Mr Wood had sent her a ‘friend request’ on Facebook.

Ms Thompson spoke to Cons Attard (who coincidentally was involved in the first incident on | January). Ms Thompson had Cons Holani’s business card from the previous breach and gave it to Cons Attard. He subsequently emailed Cons Holani advising of the new breach, asking whether he wanted to add it to the previous one or if he wanted Cons Attard to deal with it separately. Cons Holani replied the next day that he would combine it with his matters.

Cons Attard said that Ms Thompson ‘wasn’t scared. She just wanted him to pretty much

leave her alone. ’*°

Cons Holani said that Ms Thompson advised him that she didn’t want to make a further statement but agreed to provide the screen shot of the ‘friend request’, which he said would

be enough to arrest and interview Mr Wood, He said that he never received the screen shot.

The relevant VPM, as noted above, provided that a further L17 should have been completed

for this incident but this was not done by either police officer.

24 January 2014

On 24 January, police attended to facilitate a property collection requested by Mr Wood at the Hamilton Street address.°’ The officers were SC Brendan Tyrell and Cons David

Inquest brief p 1697, Statement of Jacky Tuckey, 27 May 2015

5© Inquest brief p 70, Statement of Constable David Attard, 23 April 2014

Priebbennow who arrived at about 4.56pm. Both parties were contacted prior to the property

collection taking place.

Cons Priebbennow spoke to Ms Thompson and she said that she was ‘ok’ with it going ahead. Ms Thompson had packed items in suitcases for collection. No concerns were noted by either police officers. SC Tyrell described the collection as ‘tense’ and that Mr Wood requested items that Ms Thompson did not agree to. The officers left at about 5.23pm.

29 January 2014

On 29 January, Mr Wood attended his third (and final) counselling session with Ms De Bruin. She again noted that there was no indication of self harm and that he appeared to

accept that the relationship was over, but was concerned about the failure of the business.

A fourth session was scheduled for 5 February, but he failed to attend.

Also on 29 January, Ms Thompson attended with Mr Camilleri, WLS for financial advice.

He was advised that she and Mr Wood had taken out a joint loan for $60,000 to establish a business and that she and the other partners wanted Mr Wood out of the business after he had become violent and aggressive. She sought advice as to how to get him out of the business and what could be done about the joint debt. He was able to assist with advice directly on the loan. Ms Thompson said that she would struggle with the loan repayments, as she had no income.

Also on 29 January, Jessica, Crisis Response Worker, WHW wrote to Cons Holani and advised him that WHW had spoken with Ms Thompson and provided her with support, including a discussion safety planning and support option. She was not seeking further

support from WHW at this time and they advised that they were closing this referral.

30 January 2014

134,

On 30 January 2014 Mr Wood placed two calls to 000 at 2.09pm and at 4.17pm,

respectively.

31 January 2014

On Friday, 31 January, police again attended to facilitate a property collection for Mr Wood at the Hamilton Street address.°* Mr Wood’s brother Gavin was in attendance. The officers were FC Riches and FC Darren Murrihy, both of the WFVT (as noted above FC Riches

called Ms Thompson on 6 January following the incident on 1 January). They arrived at

5794 January 2014 —Mr Wood placed calls to 000 at 8.10am and 4.20pm.

58 On 31 January 2014, Mr Wood placed calls to 000 at 9.23am and 11.35am.

about 1.30pm after both parties were contacted. There was a disagreement over whether Mr Wood would keep the van, but it was decided that this would be dealt with at a later time after Ms Thompson put one of the business partners on the phone to speak to FC Riches.

Again, no concerns were noted by police. FC Murrihy said that Ms Thompson ‘appeared to have a good rapport with Gavin and Gavin took it upon himself to act as a mediator”. He

said that he did not ‘have any safety concerns for either party. °?

FC Riches said:

‘At no stage did Wood make any threat, act of violence or allude to anything that would cause concern. Additionally, at no stage did Thompson approach police or state at time that she was in fear of Wood. As a result, I did not hold any safety concerns for Thompson.

5 February 2014

On Wednesday, 5 February Mr Wood attempted to arrange another property collection.®!

The police attended the Hamilton Street address but Ms Thompson advised them that she was not feeling well, so the property exchange did not proceed. Police left the property at 11.10am.

At about 12.09pm, Ms Thompson made contact with the WLS for urgent advice. Mr

Camilleri said:

“The circumstances were that Mr Wood and police were on their way to Ms Thompson’s house to remove property that Mr Wood claimed as his. Ms Thompson wanted to know what her rights were and whether she was compelled to hand over property that she considered hers. I advised that Mr Wood was not entitled to remove any property other than his personal property and any other items Ms Thompson agreed to him taking. I Jurther advised that the police were not able to adjudicate in respect of any items that were in dispute, which items would remain at the house in Ms Thompson’s possession."

Also on 5 February, Mr Wood failed to attend the 4" session with psychologist.

On the evening of 5 February, Mr Wood visited the home of Ms Jenny Le Fevre. She said

she could ‘see he was messed up, disturbed and hurt.’°

In the course of a long conversation, Mr Wood made a number of admissions, including

that:

e he was in financial trouble as a result of their import export business which he had

borrowed from the bank and his sister to establish;

*? Inquest brief p 125, Statement of ??, 1 May 2014

6 Inquest brief p 129, Statement of ??, 1 May 2014

6! On 5 February 2014, Mr Wood placed calls to 000 at 8.57am and 10.35am.

® A letter was sent to Mr Wood by WLS dated 30 January 2014 with respect to the ‘business’ loan.

% Inquest brief p 42, Statement of Ms Jenny Le Fevre, 18 February 2014

145,

e that regardless of the separation and the IO he wasn’t giving up the business; e that he had tried to strangle Ms Thompson during a fight about the business;

e that he had assaulted another man with a pool cue because he had kissed and cuddled

Ms Thompson; e that he had been smoking cannabis; e that he had been following Ms Thompson and her friends;

e that on the weekend of 1-2 February he had been hiding in the backyard of the Hamilton Street address and had been watching Ms Thompson when she let a man in to the house;

and

e that he had built something at the house before he left that would enable him to get in ‘7 am smart. I built something before I left to get in the house.’ Ms Le Fevre said she was frightened of him and did not let him into the house.

Mr Wood said to Ms Le Fevre of the strangling,

‘I do realise now that I may have put too much pressure around her neck but I was just trying to restrain her as she lost her temper. I should have just pinned her up against the wall. I know I have a temper. I am seeing a counsellor for that now and it is helping. ©

He also said with reference to the male he observed coming to the house on the previous

weekend: ‘..it is over. I could never trust her again.’*

Ms Le Fevre said,

‘I was concerned about Kelly’s safety after what Wayne had told me as I worried about Wayne’s demeanour especially when he told me the relationship was over and emphasised it twice, It was the cold look on his face that made me feel uncomfortable.

Wayne was stalking Kelly, being in her backyard and following her friends, I knew he had issues and wasn’t going to let go.”

6 February 2014

147,

A further L17 was received by Djerriwarrh Health Services regarding the breach of the IO which meant the response was now classified by that services as a priority. An attempt was made to contact Mr Wood on 6 February 2014 but the number was noted to be disconnected

or no longer in use. This was reported to Cons Holani on the same day.

“ Tnquest brief p 47, Statement of Ms Jenny Le Fevre, 18 February 2014 65 Inquest brief p 44, Statement of Ms Jenny Le Fevre, 18 February 2014 6 Inquest brief p 47, Statement of Ms Jenny Le Fevre, 18 February 2014

57 Inquest brief p 47, Statement of Ms Jenny Le Fevre, 18 February 2014

7 February 2014

On 7 February, the final police assisted property collection occurred before Ms Thompson’s death. It was also apparently the last of Mr Wood’s property (furniture). The police officers were Cons Kula Mayne and Cons Aaron Bryan, both from Werribee Police and they

arrived at about 1.58pm after both parties had been spoken to.

Ms Thompson had put a large amount of items and furniture in the garage for Mr Wood to take. Ms Thompson indicated to the officers

‘that the left side of the garage (as you look from the street) had all his items, and that he was not to take anything on the right side that was separated by two large mattresses’.

Gavin Wood was also present and ‘acted as a bit of a go-between for Wayne and Kelly and

also Wayne and the police.’

Mr Wood was upset about a number of items which he believed Ms Thompson had unfairly retained and words were exchanged between them. Police on this occasion described Mr Wood’s behaviour as erratic (‘passive aggressive’), and described Ms Thompson as visibly upset at having to deal with him again (‘a little shaky in her voice and hands’). However, as before, attending police said that they did not witness any threatening or violent behaviour from Mr Wood, and Ms Thompson did not appear to be fearful of him, nor did she express any safety concerns. Ms Thompson said she wanted him out of the house and ‘to be done

with him. ’7°

Ms Thompson said to police that she was ‘sick of Wayne coming around to collect property’ and that she had done it on multiple occasions recently. She was told that she didn’t have to consent to a property collection. Ms Thompson’s friend Ms Low said of the frequency of the

property collections: ‘Kelly still felt trapped.’ Gavin Wood said of the property collections ‘There were no issues on those met [sic] ups.’

Later at Gavin Wood’s house, Gavin made the following observation,

‘we were unpacking items back at my place, Wayne’s disappointment in what we got back kept festering until he broke down...After that time Wayne was looking through some of the boxes that Kelly had packed up for him and he made a comment to me saying ‘Look at this Gay. She has given my hunting knife back, I didn’t think she would do that.’”!

8 On 7 February 2014 — Mr Wood placed three calls to 000 at 8.27am, 10.51am and 11.43am.

® Inquest brief p 131, Statement of Senior Constable Kula Mayne, 15 May 2014 79 Inquest brief p 131, Statement of Senior Constable Kula Mayne, 15 May 2014

| Inquest brief p 261, Statement of Mr Gavin Wood, 13 February 2014

Tas:

On both 7 and 8 February, Ms Le Fevre spoke with Ms Thompson by phone and relayed to her the details of her conversation with Mr Wood on 5 February 2014. Ms Thompson asked her whether she should report the breach to police and Ms Le Fevre advised her to do so. Ms Thompson said she was not concerned about Mr Wood’s claim that he had a way to the get

into the house as she was confident he was referring to the dog door, which she could lock.

Ms Le Fevre advised her to tell the neighbours what was happening and to ask them to call

police if they saw Mr Wood in the area.

Ms Le Fevre also said that Ms Thompson advised her that she relayed the information about Mr Wood following her friends and being in the backyard to Wayne’s brother, but he said ‘J

can’t control him anymore’” and was unable to keep him calm.

Ms Thompson spoke to her parents by telephone on the evening of 7 February. Her mother

observed:

“She told us that she had everything locked and John told her to make sure that she double checked everything. She said that she feared for her life as she was scared of him’?

Also on the evening of 7 February, Ms Thompson spoke to her neighbour, Ms Pauline Cauchi at about 8.45pm. Ms Cauchi said:

‘She started telling me about her life and her ex-partner. She told me that she had recently separated from her partner after ongoing problems. She that on one occasion driving past when I told her that I had she told me that it belonged to her ex-partner. I could tell by the way she was talking and her body language that she was in fear.’

Ms Thompson also visited Rose Tonihi at about 9.30pm. She said that Ms Thompson had been drinking and just chatted until about 1.00am the following morning. Rose said:

‘When she came over to tell me that (referring to Ms Le Fevre’s information), she was panicking. She couldn’t believe what Jenny told her. She was panicking, even with the intervention order on it hadn't stopped him from being in her back yard”.

Mr Pirri Trifilo said

‘she told me that Wayne had been hiding in her back yard and she had told police about that. It appeared that everywhere Kelly went Wayne would turn up. He was stalking her.

She told police all this but he was not arrested. She told the police that on numerous occasions. 7°

There is however no record of Ms Thompson reporting any further breaches of the IO.

” Inquest brief p 49, Statement of Ms Jenny Le Fevre, 18 February 2014

® Inquest brief p 4, Statement of Ms Wendy Thompson, 3 April 2014

™ Inquest brief p 283, Statement of Ms Pauline Cauchi , 11 February 2014 ® Tnquest brief p 36, Statement of Ms Rose Tonihi, 14 February 2014

7© Inquest brief p 9, Statement of Mr Joe Pirri Trifilo, 12 February 2014

8 February 2014

167,

During the day of 8 February, Mr Wood travelled to a hotel in Ferntree Gully to attend a reunion of friends from a group known as the Melbourne Sharps (it was the anniversary of a friend’s death). In the course of the day he spoke to several people about his recent separation, his frustrations about the division of property and his financial troubles arising from their business venture. He was not drinking and was observed by many to be sad,

depressed, ‘devastated’ and sweating profusely, despite being inside with air-conditioning.

Mr Wood told one friend, Robert Whitehead, that he was ‘going to do the business partners, Kelly and then himself.’ Mr Whitehead said of that discussion that Mr Wood’s speech

impediment appeared to be more pronounced.

Mr Wood told Ms Dibella of the business that ‘When I know we're not getting the money, I will get them and then I will kill myself.’ She said that he looked her in the eye and said ‘you

know I mean it’. He went onto to say: ‘I’ve lost everything.’ ’”

Mr Wood was upset that Ms Thompson would not give him certain items of property and that at a property collection attended by police he had told her in front of police that ‘she would keep’. He told Ms Dibella ‘I will get her you know.’”

Ms Dibella said that he

‘mentioned again how upset he was that the people he thought he was visiting reported back to Kelly especially because he had recently confided in them that he had been raped as a teenager and he thought he had a bond with them. At first he just kept saying. ‘something bad happened to me....I was raped.’”?

Mr Wood told her that he was following Ms Thompson because he needed to protect her from men who would take advantage of her. She ‘thought it was really because he would

worry she would start a sexual relationship with someone else.’®°

Between 10.00am and 2.30pm on that day, Ms Thompson had lunch with Mr Pirri Trifilo and his wife at their house. They encouraged her to stay with them and told her that they would help her move so that Mr Wood could not find her. Ms Thompson agreed to the suggestion, but said she needed to go home to do a couple of things first. It appears that she

was concerned about arrangements for her much loved dog, Roxie.

77 Inquest brief p 239, Statement of Ms Julie Dibella, 13 February 2014 78 Inquest transcript p 37 ” Inquest brief p 240, Statement of Ms Julie Dibella, 13 February 2014

80 Inquest brief p 240, Statement of Ms Julie Dibella, 13 February 2014

Mr Wood left the gathering and dropped a friend home (Noel Wills) between 7.00-7.30pm.

Mr Wood returned to his brother’s house for a short time reportedly with his mood

unchanged. He left again around 8.30pm saying that he was going to visit a friend ‘Ray’.

Somewhere between 8.30 and 9pm, Mr Wood visited the Tonihi home and again appeared

to be profusely sweating. Rose Tonihi and her husband were home. Rose said that, ‘in

hindsight the way he said goodbye to us was like he was saying a final goodbye. ’*!

Observations of Mr Wood on 8-9 February 2014 and Mr Paskin’s call

Over the next few hours on the evening of 8 February, the white van which was being driven by Mr Wood was observed in Ms Thompson’s neighbourhood (driving up and down repeatedly) by several people. Chantelle Cauchi said the van drove past every 10-15 minutes

— about 9 times in a couple of hours.

The van also caught the attention of Norman and Sheryl Paskin who lived across the road from Ms Thompson (opposite on Etchel Court). Their house faced the side of the Hamilton Street address, allowing them to see windows along the side of the house. There was a fence

but it was lower than the windows.

They had known both Ms Thompson and Mr Wood, as neighbours for about 3 years and it

was a friendly relationship.

Ms Paskin was aware that the couple had separated because she had seen Ms Thompson’s Facebook post to that effect (I note that a Facebook message from Ms Thompson to Ms Paskin clearly records her full name as ‘Kelly Thompson’). She said that this fitted in with what was going on at the house

‘T had seen Wayne turn up to the house under police escort to collect belongings and things. I noticed that Wayne and his brother and the police were there on I think it was Friday just gone, getting some furniture out of the house or garage and that would fit with the fact that they has [sic] separated.’

Somewhere between 9.00pm and 10.00 pm, Mr Paskin noticed Mr Wood drive into Hamilton Street, then Etchel Court and out again. He was tending his garden at the time. Mr Wood did this four times without looking at Mr Paskin, but was instead staring intently at Ms Thompson’s house.

‘Norman said it was strange because Wayne just walked straight past him without any kind of acknowledgement. Norman indicated to me that he thought Wayne was drunk.

Norman said Wayne was staggering and seemed unaware of the things around him.”

51 Inquest brief p 37, Statement of Ms Rose Tonihi, 14 February 2014 82 Inquest brief p 288, Statement of Ms Sheryl Paskin, 11 February 2014

83 Inquest brief p 289, Statement of Ms Sheryl Paskin, 11 February 2014

180,

Mr Wood continued to drive around the area and at one point parked some way from the house and approached Ms Thompsons’s house on foot. Ms Paskin said

“We found that really odd and suspicious that he would park so far away and walk to Kelly’s house on foot. That kind of cemented the fact in my mind that he was not meant to be in the area or at Kelly’s house.’

Mr Paskin said that Mr Wood ‘peeked’ through the wooden paling fence in Etchell Court apparently looking into Ms Thompson’s backyard. Mr Paskin observed him walk back to his

car.

Two receipts dated 8 February were located in Mr Wood’s vehicle. One for fuel from a BP service station at Point Cook with the time recorded as 22:30 and the other was for food

from McDonalds at Point Cook with the time recorded as 22:31:16.

Mr Paskin asked his wife to text Ms Thompson. The following text was sent at 11.56pm:

‘Hi Kelly, It's Sheryl your neighbour. Norman has noticed that Wayne has driven past the

house a few times. Is everything ok? **, but received no response.

Ms Paskin said that her children came home after 11.30pm and,

“By this time Norman and I were becoming quite concerned as Wayne was still milling around Kelly’s house. I noticed that the lights of Kelly’s house were off and it was in complete darkness. In fact I had not noticed a light on in the house the whole night. °°

Over the next few hours, Mr Paskin observed Mr Wood do further laps of the street in his car, again approach the house on foot momentarily, before finally returning closer to midnight, parking his car at the entrance to the street, approaching the house on foot and disappearing out of sight. At this point Mr Paskin thought that he must be inside the house

and thought he saw his silhouette walk across the frosted bathroom window.

At 12.15am, Mr Paskin rang the Werribee police station to report what he had seen and his concerns. Ms Paskin observed that while

“Norman was on the phone to the police, I noticed the ensuite light at Kelly’s house came on. I saw movement inside the house as I saw a silhouette in the ensuite. I think it was Wayne but I cannot be sure. I saw what looked like a bald head and assumed it was Wayne because he has a bald head.’*

Mr Paskin’s call was taken by Cons Sean Pringle. According to Mr Paskin he explained the situation and that Mr Wood might be breaching an IO but was told,

‘that because I wasn’t certain that he was in the house as it may not be the case and he gave me an example. He went on to tell me that the police do assist in disputes with couples when they are sorting out their assets. He went on to say that he would not send

84 Inquest brief p 290, Statement of Ms Sheryl Paskin, 11 February 2014 §5 Inquest brief p 290, Statement of Ms Sheryl Paskin, 11 February 2014

86 Inquest brief p 290A, Statement of Ms Sheryl Paskin, 11 February 2014

184,

the police out based on what I had told him and that they didn’t have enough to act on...and then he asked me if I could monitor the situation and that if I notice anything untoward such as shouting, removing of property or violence, to ring the police on 000...°°’.

Mr Paskin was confident that he explained the lead up to Cons Pringle including the ‘peeping through the fence.’** Cons Pringle said he was advised by Mr Paskin that it was the house on the corner of Hamilton Street and Etchell Court (although couldn’t provide the house number) but that he had not seen any violence and did not know for sure whether

there was an IO.

Cons Pringle said to Mr Paskin:

‘Can you do me a massive favour pal and keep an eye on the address? If the circumstances change, you notice anything untoward or if you hear any yelling or screaming coming from that particular address please do not hesitate calling back and I'll send a van around to have a look.’®

He said there were too many unknowns for police to respond to.

Mr Paskin said that if he was asked to get the number of Ms Thompson house he would

have done so.

Telephone records indicate that the call was received at 00:15:39 on 9 February 2014 and it

was 529 seconds (8 minutes and 48 seconds) in duration.

10 - 11 February 2014

On Monday evening, 10 February, having not seen his brother since 8.30pm on Saturday and unable to contact Mr Wood by phone or through friends, Gavin Wood rang the Wyndham North police station to report Mr Wood missing.

He rang police again on the morning of Tuesday 11 February inquiring whether his brother

had been located and to conduct a welfare check on Ms Thompson.

At 8.50am that morning, police attended at the Hamilton Street address where they observed

Ms Thompson’s vehicle in the driveway and a dog could be heard barking from the inside.

Sergeant Lorie Stein and members of the Wyndham CIU, including DSCs Sharp, Oakley and Allan Hill) made a decision on the information that they had to hand, that forced entry was justified. DSC Hill and DSC Sharp entered at about 9.10am and discovered the body of a female and male in the master bedroom located immediately to the right of the front door.

They left the premises and a crime scene was established.

87 Inquest brief p 296, Statement of Mr Norman Paskin, 1] February 2014 88 Inquest brief p 296, Statement of Mr Norman Paskin, 11 February 2014

89 Inquest brief p 300, Statement of Mr Norman Paskin, 11 February 2014

Crime Scene

Ms Thompson was found lying on her back on her double bed with multiple stab wounds to

her upper body.

Mr Wood was found kneeling on the floor face down with a rope attached to the bed post

tied around his neck.

Members of the Homicide Squad, including DS Ross arrived at the scene which was processed by the Major Crime Scene Unit and a Fingerprint Expert. Fingerprints matching those of Mr Wood were located on the external side of the toilet window as well as the

handle of the toilet door.

A blood stained Muela brand hunting knife and a Muela sheath were found on top of the doona which was located on the bed. A right thumb print matching Mr Wood’s fingerprint was located on the hunting knife. DNA from both Ms Thompson and Mr Wood was located on the blade of the hunting knife.

Located on a bedside table adjacent to Ms Thompson were two kitchen knives. A third kitchen knife was located in the top drawer of her bedside table. The light switch in the

bedroom was smeared with blood.

The flywire screen from the toilet window and an air freshener module were located on the path beneath the window with a can of airfreshener located in a bush nearby. The base of the toilet window was fixed in an open position that could not be opened any further. The top of the sliding window and the lock had however been dislodged from the main window with the top part of the window wedged against the main frame. It was noted that

‘the absence of tool marks and the position of the sliding window suggested that manual force had been applied to the sliding window, dislodging it from the top railing and then replaced. °°

A partial shoe impression was located on the toilet seat with two partial shoe impressions located on the window sill. All the other windows and doors in the house were locked with

no signs of forced entry.

A pair of Evani thongs were located in the bedroom next to Mr Wood.

‘The general patterning on the outsoles of the thongs displayed characteristics which appeared to be broadly similar to the shoe impressions located on the window sill and the seat of the toilet. ?!

° Inquest brief page 335, Statement of Michael Hradek dated 17 May 2014

*! Inquest brief page 336, Statement of Michael Hradek dated 17 May 2014

The rear sliding door was also locked but showed signs of use with blood staining present

on the inside and outside of the main door lock and the top bolt lock.

Forensic tests determined that the length of rope used as a ligature by Mr Wood was cut

from the rope used in the shade sail which was fixed in the backyard of the house.

It appears likely that Mr Wood sustained an injury during the attack on Ms Thompson and

he subsequently

‘dripped blood from his wound onto surfaces between the master bedroom and the internal garage door, inside the garage, the wardrobe in the garage, the kitchen (both sides of the island bench) and to the back door. While moving throughout these areas, there was evidence of him taking specific actions such as having a cigarette, opening the fridge door, opening and closing the back door, opening the toilet door, and obtaining paper towel from above the cook top in the kitchen to possibly stem his bleeding wound before putting the blood stained paper towel in the bin nearby. At some stage he has entered the ensuite where he has turned the lights on or off, contacted the door and the sink, and possibly opened the cupboard door”.

EVIDENCE OF PROFESSOR OGLOFF

I sought expert advice from Professor James Ogloff regarding certain aspects of my investigation including risk factors of intimate partner violence/homicide and the risk assessment frameworks that were in place at the time of Ms Thompsons’s death. In a report

dated 25 August 2015, Professor Ogloff noted the following:

That research with respect to intimate partner homicide (IPH) was in its infancy and

knowledge on the topic is scarce.

Only a very small fraction of intimate partner violence (IPV) results in homicide (0.03%), and as such risk assessment tools designed to predict IPV will necessarily over predict the likelihood of IPH. No IPV risk assessment measure has been found to

reliably predict IPH.

Most of the characteristics associated with IPH are also associated with IPV, and

differentiating between the two is an impossible task.

The process of risk assessment and risk management must commence with an appraisal of risk employing a validated IPV risk assessment measure. Management and interventions should then be commensurate with the level of risk identified, and the patticular risk factors that are elevated should be addressed in order to help ameliorate

the level of risk over time.

® Statement of Mark Gellatly dated 30 June 2014 3 Director, Centre for Forensic Behavioural Science, Swinburne University and Victorian Institute of Forensic Mental

Health (Forensicare)

As it is impossible to:

‘knowingly differentiate who will be killed, from who will be repeatedly victimised, ...the best practice would be to actually identify those who are in the higher risk categories of repeat violence, knowing that within that group, some of the people would, in fact, become the victims of ultimately homicide. So by managing the broader group in a way that they're treated to be high risk, we will probably be able to save some women from being killed by their partners and, certainly, the research would indicate that the majority of people who do commit intimate partner homicide fall in the higher risk level of these sorts of risk tools.’** [My emphasis]

The risk factors in this case were that Ms Thompson:

“was receiving mental health care and had depression, also the fact that Mr Wood had threatened to kill her; that Mr Wood had previously abused her physically and that he had also engaged in stalking behaviour, even post having an intervention order and, ..., the relationship had been characterised by a degree of instability following, or during, the trip to the Philippines and, subsequently, and, ..., the couple had separated a short time before her demise.”

Using the SARA (spousal assault risk assessment) risk assessment model and applying it to Mr Wood and the factors that would have been known prior to the 8th or 9th of February, he concluded:

‘that based on the information that was known, or could have been known, prior to the 8th or 9th of February, that Mr Wood presented a high risk of re-offending in a family violence incident. Not a high risk of homicide by any stretch, but that a high risk of repeating family violence incidents. °°

The assessment however relied upon having all the information available at one time.

With respect to arrest and charging of respondents and the extent to which this may ameliorate or reduce the risk of future violence, he said

‘On balance the contemporary research indicates that ...in and of itself an arrest can have an effect, particularly if it leads to consequences and, in particular, that the peculiar or particular circumstances of the perpetrator and the victim are taken into account; so, for example, in a situation such as this, it may be ensuring that the perpetrator is now not residing at the house and doesn't have access to the house. It may be that the victim has a degree of support and an awareness of the potential risk that she's in. So, the first is really their —... situation. The second is that... — if there is a breach it needs to be acted upon quite quickly and obviously as we see in this case, matters unfold relatively rapidly, and so if a behaviour occurs which seems to be a breach, if there's not an immediate consequence, or a consequence soon thereafter, well, matters can quickly get out of hand before there's an opportunity for any say judicial action to occur. So it's really a complex question and the police arrest and intervention orders need to work together in order to help manage these sorts of situations.”?!

4 Report of Professor Ogloff >> Inquest transcript p 645 96 Inquest transcript p 646

57 Inquest transcript p 648

In terms of how quickly a breach should be acted on, he said that it needs to be rapid enough that the individual realise that there is a consequence and certainly within a matter of a day or days, at most, otherwise it can reinforce for the person that they can continue without consequence and ‘they potentially ... don’t have a sense of how

serious these can be.’*®

With respect to the Form L17 he noted that it was intended to be an aide memoire for

the police to make sure that they were canvassing relevant information.

He noted that many of the items on the L17 are the correct items, and they're the items that should be considered but there are some items that probably are included that might not have much empirical support, and then there would be other items that aren't included that potentially should be. He said that of more concern was that there is ‘no good explanation for what the items actually mean’® and no guide as to how to assess the factors (for example, what weight should be given to an item and how to balance one against another), to determine the level of risk. Such as with the SARA and the Be

Safer risk assessment tools.

He was an advocate for informing a victim that they are at high risk of future violence as they may not realise the danger, but only if you have a validated tool for determining

the risks.

He was supportive of a single reference page of risk factors to support police while at

family violence incidents and this was a work in progress.

l accept Professor Ogloff’s evidence on these matters.

ANALYSIS OF ISSUES

Duty to Inquire — Victoria Police

In his evidence, AC Cornelius spoke of a police officer having a ‘duty to inquire’, as an

appropriate lens through which to view and consider the actions and responses of police.

‘Every police officer has incumbent on them, from the point where they take their oath of office, to pursue and discharge their duty to inquire.’'°°

It is clear that the duty to inquire encompasses, a requirement to actively rather than passively engage with a situation. AC Cornelius spoke of the development of professional

curiosity which should be pursued in the discharge of a members’ professional duties.

58 Inquest transcript p 664 ° Inquest transcript p 651

100 Inquest transcript p 864

With respect to how to train an officer to develop a ‘duty to inquire’, AC Cornelius issued a clarion call, and a cogent one, to police officers to develop and then demonstrate the duty to inquire. He said:

‘Well that need to cultivate a professional sense of curiosity and to pursue that in the discharge of your duties is something that is highlighted from the very beginning of every police officer's career. It's initially highlighted in training and then it is a piece that supervisors regularly attend to with - with their members, and I had the benefit of hearing the evidence from the officer who was previously here, and you know, that piece around more experienced members testing the thinking of more junior members, less experienced members, invariably that conversation goes to how they're exercising judgment. A key aspect of that is whether or not they have - they have appropriately activated their professional curiosity.’'"!

The response by attending Victoria Police members appropriate to the incident of family violence

reported on I January 2014

An allegation of strangling was reported by Ms Thompson to Mr Hall. Mr Hall conveyed this information to the 000 operator and this was related to the divisional van by radio and electronic dispatch. I accept in full the evidence of Mr Hall as to what he observed and what was said to him and his partner by Ms Thompson at the scene. Ultimately, there was a clear disparity between the incident that was reported by Mr Hall and the incident that was eventually recorded by the attending officers, who subsequently completed the L17.

Ms Thompson did not disclose the extent of Mr Wood’s behaviour including the strangling to the officers who went to her home after the incident, even when spoken to separately, but she indicated repeatedly that she wanted to wait for her business partner to arrive. It was open to the attending officers given Ms Thompson’s repeated references to wanting to wait until her business partner arrived to infer that there was a message she was trying to give.

They did not wait for this to occur.

AC Cornelius noted the importance of building a rapport to allow a family violence victim to disclose matters:

‘And a key part of creating that safe space and that environment where a victim feels

confident and safe in telling their story, that's a piece that we are very much

highlighting with our members and our investigators’ .!°

The attending officers appeared to place significant weight on the fact that they did not observe any injuries to Ms Thompson, when that was not surprising given the allegation was

one of choking.

'0l Inquest transcript p 885

102 Inquest transcript p 886

211. Given that the officers did not talk to Mr Hall, the fact that Mr Wood had pursued Ms Thompson, who was on foot, by driving in a dangerous and erratic manner did not appear to be understood by the attending officers. According to Ms Low, the skid marks from Mr Wood’s vehicle mounting the footpath in pursuit of Ms Thompson, were still visible some

two weeks later and were pointed out to her by Ms Thompson.

212. The way in which the incident (the first contact with police) was responded to, significantly, and detrimentally, affected the trajectory of the matter. There was no further investigation of Mr Wood’s conduct and therefore no further consideration of whether charges might be laid.

There was no thought of obtaining an intervention order on Ms Thompson’s behalf, as the seriousness of Mr Wood’s behaviour was not uncovered. AC Comelius agreed that on the basis of the strangulation and the conduct of Mr Wood with the car, it would have warranted

police seeking an IO.

213. Also there was no opportunity for Mr Wood to be characterised as a high risk person! or for these offences to constitute the first offence for the purpose of Mr Wood being later

characterised as a Recidivist Offender.

214. It is unclear however whether Ms Thompson would have disclosed more had the officers

waited for the business partner to arrive or if she had been interviewed at the police station.

215. It appears that the early characterisation of the incident even influenced the later missing person’s response. SC Colleen Spiteri who initially responded to the missing person report made by Gavin Wood on 10 January said

‘T had concerns that the MP would harm himself due to his depressed state but I did not at the time hold concerns for Thompson. From my enquiries I found there was no evidence in any recorded incidents that the MP displayed any threats towards her.’!%

103 A/C Cornelius said on the basis of all the available information he would have considered Ms Thompson to be at high risk — ‘the requirement to prepare a PTMP as it's called both for victims and for offenders arises out of the Victoria Police Intelligence Doctrine which is an organisation-wide set of guidelines which govern and direct the operation of our tasking coordination process, the means by which we prioritise jobs for focus and attention uh, and the means by which we direct our members to focus on areas of most critical risk and - and greatest need. Now, the VPID requires our Divisional Intelligence Units to consider the development of PTMPS or Offender Management or Victim Management Plans in cases where either there have been - either you're dealing with a recidivist or repeat victimisation - so that's three incidents within a 12 month period or you're dealing with a case where the risk factors are such that although the individuals concerns might not yet be repeat offenders or repeat victims, the circumstances are such that, um, the risks attendant to the victim or the risks attendant to re-offending by the perpetrator are such that a PTMP - an Offender Management and a Victim Management Plan ought to be prepared and this is a doctrine that applies to all crime and all activities and there is, within the latest iteration of the VPID, a specific component that now deals with family violence but it's always been the case that the VPID since it was introduced a couple of years ago, covers the field and, you know, I have a very clear expectation of my people in Southern Metro that if we're dealing with, uh, repeat offenders and repeat victims in the family violence space or we're dealing with individuals to whom we've - we've identified a serious level of risk, well I want to see that they're the subject of an Offender Management and a Victim Management plan.’

'4 Tnquest brief p 1425, Statement of Ms Colleen Spiteri, 7 January 2015

It is clear that Ms Thompson did not want Mr Wood charged out of the incident arising on 1 January, as that is what she told friends and the Magistrate at the hearing of the IIO, Her motivation at that time appeared to be she did not want to aggravate Mr Wood and escalate

his behaviour.

It is clear, that objectively, the officers were in fact responding to a report of ‘an attempted strangulation’. Cons Attard said that he thought Ms Thompson had denied the strangulation allegation (‘it was my understanding at the time...that she denied that allegation of strangulation’)!°. SC Whichello said that Ms Thompson wanted to wait for the business partner but had not confirmed the ‘strangulation.’ There seems to be confusion between the

officers regarding an extremely important matter.

Neither officer had notes which could be introduced into evidence (such as in a notebook) regarding their attendance, other than the running sheet and the L17. Whilst I accept that the allegation of strangling would have most likely been put to both Mr Wood and Ms Thompson, it was important that the denial of Mr Wood be noted somewhere. On the basis of the information before the officers, there was no reason to positively exclude the

occurrence of a strangulation.

It is difficult to understand why the responding officers didn’t make further inquiries with the complainant, consistent with their duty to inquire. I agree with AC Cornelius that they

should have done so.

I note that at the relevant time, the VPMP Family Violence provided in Part 2 under 2.2

Managing the incident

° All reports of family violence must be investigated, no matter where they originated

from.

e Members must investigate with or without the consent of the AFM.

In addition, at the relevant time, the VPMG Family Violence provided in Part 2 under 2.2

Attending the Scene.

e Investigate all offences by gathering background information and physical evidence, including photographs, clothing a statements from all available witnesses. Members are to investigate regardless of whether the Affected Family Member (AFM) makes a complaint or a written statement.

Consistent with these themes , at the relevant time, the Code of Practice provided at 2.3 that

105 Tnquest transcript p 474

223).

226,

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 is based on risk assessment and risk management, regardless of whether the AFM makes a verbal complaint or written statement. In meeting this policy of compulsory action, police will:

• investigate all family violence incidents coming to their notice by gathering background information and physical evidence, including photographs, clothing and statements from direct and indirect witnesses.

I note that the Form L17 failed to record the attempted strangling, in either the narrative or as part of the risks recorded. Cons Attard said he thought the narrative recorded ‘the outcome’ of the investigation. If there was some doubt as to whether there was a

strangulation, it clearly should have been in the narrative.

Other matters which could have been recorded include whether the respondent was on

medication and ‘Controlling behaviours’ (which was conceded as an omission).

Clearly the attending members did not conduct an ‘investigation’. AC Cornelius characterised the response of the members as ‘an initial response’ which could have led to an investigation. He outlined several aspects of the police response that concerned him:

e ‘The first of these is the nature of the engagement with both the alleged perpetrator and with Ms Thompson, and my concern around that is that it ought to have been clear to both of those members that there was a story to be told, and their duty to inquire at that initial action stage should have been triggered. And both parties had provided to those members a clear view that they wanted to wait for a third person to arrive.'!"° (My emphasis).

e The failure to make contact with the complainant and given what he had observed: ‘would absolutely ought to have triggered in the minds of those attending members the need to inquire further and in particular the need to take active and positive steps to secure the safety of Ms Thompson’ ;'""

° ‘Upon attendance the members deal with the circumstances that confront them. That may very quickly escalate into a full-blown investigation, but as a minimum it's a process that ought to trigger their duty to inquire and their duty to satisfy themselves that if there is evidence at the scene that an offence has been committed, that the initial action, which might later lead to an effective investigation, is undertaken. !®

In her submission, Counsel Assisting said:

‘Had members Attard and Whichello spoken to Mr Hall they would have:

e Obtained his direct evidence of Kelly’s demeanour and behaviour at the time she disclosed the strangulation attempt

© Obtained his direct evidence of Wayne's erratic driving and attempt to pin Kelly between 2 cars, evidence warranting its own investigation into potential driving charges and which cast a very different slant on Wayne's account of following Kelly to try and get her to come home; and

e Learnt of the context in which Kelly asked for police attendance —namely, that she whispered the request, giving her address, after Wayne had arrived

106 Inquest transcript p 859 107 Inquest transcript p 860

108 Inquest transcript p 861

229,

All of that information would have assisted them in the assessment they made of what they were told by Kelly and by Wayne. They could not properly investigate the matter without that information.’

l agree.

I refer also to the Chief Commissioner’s submission on the point, consistent with that of

Counsel Assisting:

‘the failure to record the allegation of attempted strangulation, which would have informed police who had later dealings with Ms Thompson and Mr Wood, such as Constable Holani on 19 January 2014, was a critical omission. The failure to properly investigate meant that the opportunity to charge Mr Wood with assault (at least in respect of the attempted strangulation) was missed, and resulted in the Wyndham Family Violence Team not conducting a comprehensive review of the case. The combination of the allegations of the attempted strangulation and the assault with the vehicle could have led to arrangements being made for an effective management plan to address risks posed by Mr Wood.”1!°

Lalso agree with this.

I note also the submission by the Chief Commissioner of Police, conceding that the police response to the incident on 1 January 2014, was ‘inadequate’, and pointing out that Cons Attard conceded that the box for ‘controlling behaviours’ should have been ticked and, with the benefit of hindsight, both members conceded that they should have spoken to Mr Hall,!!!

Their submission notes that SC Whichello conceded that there should have been a reference in the L17 to the attempted strangulation and that Cons Attard agreed that, at the very least,

‘the attempted strangulation should have been referred to in the narrative section of the L17 which would have assisted other police who would have future involvement with Ms Thompson and Mr Wood."'!?

AC Cornelius further said that the police should not rely on the information related through

D24 as being the complete story:

‘Call takers are not police officers. They are engaged with an organisation external to Victoria Police. Their role is to take the call, take the details from the complainant as best they understand them, and convey those particulars to a van that might ultimately accept that job. It's not the role of members to take that information merely at face value and not look beyond it. It's their role, once they take the call, and undertake their attendance, it's their role to inquire. And that absolutely does mean that as a professional police officer, we have a reasonable expectation that upon attending a scene, that you wouldn't just limit your activities to the parameters that have been set by the despatcher, you would in fact activate your professional judgment and your duty to inquire and see where that takes you.’!3

Of the advice that should be given to victims, AC Cornelius said:

10 Submission of Counsel Assisting, p 6-7

110 Submission on behalf of the Chief Commissioner of Police, p 12 111 Submission on behalf of the Chief Commissioner of Police, p 10 "2 Submission on behalf of the Chief Commissioner of Police, p 11

13 Inquest transcript p 862

aie

‘T don't hold with a view that we shouldn't be telling victims that... we have concerns because ... to my mind the key piece to a victim-centric approach is that you're engaging the victim in a partnership whereby we put ourselves in the best position possible to both identify risk and management and manage those risks - and that comes down to the police having some responsibility - but it also comes down to the victim having some responsibility. But you can't expect a victim to take responsibility for their safety unless you're communicating clearly with that victim what those safety risks look professional judgment of a police officer a victim might have regard to.’'"*

lL accept the evidence of AC Cornelius in respect of each of these points.

It was DS Grandy’s view that the officers did their job to the minimum standard and it was a training issue as well as being reflective of their experience. His view was that they should

have done more.

The members made submissions that:

‘No supervising Sergeant queried the members about their approach to the information contained in the 000 call, the way in which information was recorded on the L17, or any other way the adequacy of the L17."1°

Superficially, this appears to be a fair point, however, the Chief Commissioner’s submission in reply notes:

‘Victoria Police members always have access to at least their sergeant and senior sergeant supervisors (known as the 251 and 265 supervisors) as well as section sergeants back at their police station. Senior Constable Whichello and Constable Attard made their own determination as to the appropriate course of conduct and did not seek advice. No adverse comment can be made as to lack of access to supervisors. ”!!°

And the submission further highlights that:

‘the L17 forms the cornerstone of the police response to family violence incidents as its risk assessment tool.’'"’ | accept these submissions.

Talso note that:

‘ neither Senior Constable Whichello nor Constables Attard and Pringle gave evidence that they did not receive adequate training. ”!"°

The response to the incident on 1 January reveals significant deficiencies and a ‘critical omission’ with respect to the non-recording of the alleged strangulation. It reveals a need to reinforce an understanding of the high risk factors associated with family violence

incidences, with attention to the proper completion of the L17.

In fairness to SC Whichello and Cons Attard, I note the submission made on their behalf:

'4 Tnquest transcript p 916-918

"3 Submissions on behalf of police members

''6 Submissions in reply on behalf of the Chief Commissioner of Police, p 27 ''7 Submissions in reply on behalf of the Chief Commissioner of Police, p25 "8 Submissions in reply on behalf of the Chief Commissioner of Police, p25

“Both Whichello and Attard conceded frankly, that having heard the evidence of Riches they now appreciate the value of including in the narrative why police were called there in the first instance even if the allegation was not corroborated at the scene. Whichello understood that the information “would have benefitted Constable Riches in regards to making his risk assessment in regards to the family violence side of things.”"!!9

Response from the Wyndham Family Violence Team

241,

243,

244,

The role of FC Riches was to triage the L17 for the incident on 1 January involving Ms Thompson. In doing so, he was relying solely on the information in the L17 recorded on LEAP.'° However the narrative did not properly reflect what occurred between the parties on that date. As AC Cornelius said the failure to record the attempted strangling on the L17 was a ‘critical omission’. The manner in which the L17 was recorded set the tone for the

further dealings by police regarding this matter.

In her submission on the point, Counsel Assisting said

‘The failure to record the allegation of strangling on the L17 was, as AC Cornelius characterised it, a critical omission, because it prevented subsequent police members Jrom knowing about the presence of what they would have understood to be a red flag.

The whole trajectory of the matter as a relatively low risk case was set by the L17 and it is not only with hindsight that its flaws are apparent.

This case indicates the fundamental weakness of any family violence specialist response which is based on L17s; if the L17 is flawed, everything that follows will be too.

Although L17s are checked by supervisors, those supervisors have no independent knowledge of the background facts and, as in this case, cannot identify substantive failings in the evidence collection process.’ |*!

T agree that in this case the L17 were ‘flawed’.

FC Riches said that the purpose for contacting applicants was:

‘To see how things were panning on generally after the incident to see whether or not they had been in touch with an organisation called Women's Health West, which is a referral agency, to see if there had been any further breaches or any further offences committed by the respondent and to see if I can assist with anything further.’

He indicated that if he was aware that the incident involved strangling, Mr Wood chasing Ms Thompson in her car or wedging Ms Thompson between his car and another car, it would have been a different incident. He said that he would not have marked the tisk management complete and there would have been further attempts to get in touch with Ms

Thompson.

FC Riches said that if he had spoken to Ms Thompson, and has been aware of the attempted strangling, that he would not tell her that she was at risk of being killed.

'? Submission on behalf of police members, p 16 20 Inquest transcript p 254 "21 Submission of Counsel Assisting, p 6-7

'22 Inquest transcript p 241

247,

249,

‘I would fear that would perhaps scare her and a situation. My role would be to comfort her in the knowledge that police will do anything they need to do in terms of investigation and holding him to account, and I believe that's reflected in the policy and procedures. I wouldn't want to scare her and tell her that she's going to be killed.’'*

He said that he would explain to her the seriousness of the situation but it was not part of training to let people ‘that they were going to be killed.”!**

I agree with the submission of the Chief Commissioner!’ and make no criticism in relation to Cons Riches assessment. He made, as the submission put it, “4 proper assessment of the

level of risk as he was required to do, based on the information provided to him in the L17.”

The L17 is central to the police response to specific family violence incidents. As was pointed out by the Chief Commissioner’s submission ‘The L17 is a structured guide to assist members of Victoria Police...to engage in the complex and dynamic process of family violence risk assessment. ’!*° The submission went on to set out the purposes of the L17:

‘Its purpose is to assist members to:

(a) Identify and record the most relevant evidence-based risk factors and indicators;

(b) Ensure that decisions by police and others regarding the safety and welfare of victims are well informed;

(c) Make a structures assessment on the likelihood of future family violence; and

(d) Determine the most appropriate risk management strategy in the circumstances. ’!*”

The submission then went on to note that ‘The chief attribute of the L17 is that it functions

as an aide-memoire...’!*8

The submission referred to the statement of AC Cornelius”? in relation to changes to the L17 system. It made the point:

‘Whilst the L17 had made a useful contribution to the capacity of police to identify and respond to risk within families, it is no more than a mechanism to facilitate such an evaluation. Victoria Police continues to reassess and improve upon the L17 process to enable it to be completed well, to be accessed by all who need to see it, and to improve upon the capacity to respond to it.

The introduction of the LEDR Mk-2 program throughout Victoria Police in recent times has improved access to information contained within completed L17s.

The LEDR Mk-2 program minimises, if not eradicates, the possibility of information from the L17 not being recorded on LEAP. Prior to the introduction of the LEDR Mk-2 program, police members filled out L17s by hand and then faxed the completed form to CDEB to have the data entered onto LEAP manually. In contrast, the LEDR Mk-2

'23 Inquest transcript p 259

'24 Inquest transcript p 261

25 Submission on behalf of the Chief Commissioner of Police, paragraph 39: ‘There should be no criticism or adverse comment in relation to Cons Riches’ assessment conducted on 6 January 2014. Cons Riches presented as a dedicated and diligent officer who made a proper assessment of the level of risk, as he was required to do, based on the information provided to him in the L17.’

!26 Submission on behalf of the Chief Commissioner of Police, p 33

127 Submission on behalf of the Chief Commissioner of Police, p 33

!28 Submission on behalf of the Chief Commissioner of Police, p 33

'29 Exhibit 80

“44

program allows police members to fill out L17s electronically and automatically upload the information entered into L17 onto LEAP. 1°

The submission then went on to describe the ‘L17 Ready reckoner’.

Importantly the submission further outlined the review of the L17 being conducted by Victoria Police. This is an important review. The submission referred to:

‘Key issues being explored by those involved in the L17 Review include:

..how best to identify the CRAF risk and vulnerability indicators; and

...how best to triage family violence incidents to ensure that sufficient resources are directed the highest risk cases.’ !*!

Ihave set these passages from the Chief Commissioner’s submission out in detail because of the importance of the L17 in this and other cases. Given the review referred to above, there is no need to make a specific recommendation about that in this case. I simply note that the

review is ongoing.

I note the Chief Commissioner’s submission in reply where it is said

“...it is important to remember that the L17 is not a psychometric tool or an expert risk prediction instrument. Police are not psychometricians or mental health professionals.

They need a straightforward means of having their minds directed toward factors relevant to identification of risks that may be posed by family violence. This, together with its flexibility, is the principal attribute of the L17.’!°?

This is a succinct and cogent argument for the continuing work on enhancing the L17.

The Magistrates’ Court

Ms Thompson attended the Werribee Magistrates’ Court on 10 and 23 January, and obtained the necessary orders she was seeking against Mr Wood. In fact she was encouraged to seek

the interim order on the first occasion.

I was informed that Family Violence Registrars have regard to the Family Violence CRAF to enable them to identify risk factors relating to the parties. The Registrar does not however identify a risk level or ‘rating’. In a formal sense. The CRAF is used as a guide to assist

Registrars to identify risk factors relevant for:

e inclusion in the narrative within the Application and Summons; e° the management of any safety or security issues at Court; and

e referrals to services at Court.

As noted above, Ms Henriquez did not formally assess Ms Thompson and assign her a risk

rating but assisted her to complete her application and prepared the ‘Application and

130 Submission on behalf of the Chief Commissioner of Police, p 34 5! Submission on behalf of the Chief Commissioner of Police, p 36 ‘32 Submission in reply of the Chief Commissioner of Police, p 15

Summons for an Intervention Order’ to enable her to go before the Magistrate. She did not see it as her role to tell her that the order may not be effective — particularly at the

commencement of the process and prior to giving evidence before the magistrate.

At the Werribee Magistrates’ Court, the Registrar may refer applicants in intervention order proceedings to either the Applicant Support Worker (ASW) or a community based support services (such as WHW). The usual practice is that clients who are already engaged with WHW will not be referred to the ASW. I was told that this approach maximises the number of clients who have access to services and reduces the need for clients to re-tell their story to multiple agencies. Ms Thompson was a client of WHW and therefore not a client of the

ASW.

The information provided to the police on 10 January for service on Mr Wood included a copy of the Application and Summons. The Application and Summons includes the narrative which is based on the information provided by Ms Thompson in the Information Form (including two attempts to strangle, recent separation, being followed and concerns for

her safety). The IIO also includes conditions which indicate the level of protection ordered.

Clearly, all relevant information held by the Court was provided to the police, although the fact that Ms Thompson thought that Mr Wood might kill her, was not. There was no reason however, given that the police attended the incident on 1 January, for the Court not to assume that this incident had been investigated and a L17 appropriately completed (which recorded the AFM’s level of fear).

There are existing mechanisms for police to share breach information with the Magistrates’ Court through enforcement action such as criminal charges and associated bail or remand

procedures, as well as processes to vary or strengthen an IO.

Three significant issues arise at this point:

e Firstly, that the magistrate on the return date of the order was not aware of the alleged breaches. This information should be provided to the presiding magistrate. This is an opportunity to reinforce the seriousness of these matters with the Respondent and possibly engage with relevant police regarding the progress of the breaches. The parties appearing on this occasion were represented by solicitors. Orders were made by consent. There was no contest as to any of the facts. In cases such as this without the involvement of police, there is a risk that matters such as breaches will not be mentioned and the presiding magistrate will therefore not be aware of them. This is

unsatisfactory.

e Secondly, that the information (i.e. the full narrative of the incident) from the Application and Summons is not recorded on LEAP. By contrast when it is a police initiated IO those details are recorded. AC Cornelius said that they were working on an Information Communications Technology solution to this with Courts but until that is found, the resourcing implications of uploading the additional IVO’s is too great (a doubling of resources). Submissions by Counsel Assisting:

It is open to the Coroner to recommend that a system be adopted whereby police are made aware of, and have access to, the details of the reasons underpinning applications for intervention orders made directly to the court. AC Cornelius’s evidence is that this would impose a significant administrative burden on Victoria Police since it would increase, by a substantial percentage, the amount of information which needs to be uploaded or otherwise input into the Victoria Police data system. That evidence is noted.

However, at present, police only account for about 70% of intervention order applications in Victoria. This leaves 30% - many thousands — where police are responsible for enforcing the order once made but have no access to relevant information about why the order was granted. As in Kelly’s case, that lack of information can profoundly influence how police members assess the risk posed by those who allegedly breach orders. It is a gap which ought be remedied. '*?

I agree that this ‘gap’ is unsatisfactory. It should be closed. I note the submissions relating to the substantial resources that will be required to bring that about. I will make

a recommendation on the point.

e ‘The third issue relates to the service of the orders, which is discussed below.

Service of the interim intervention Order

262. The HO was served 5 days after it was made by the Magistrate, despite the serious circumstances which gave rise to it being urgently granted. In the ordinary course the IIO is faxed to the relevant station by the Court for service, with no particular attention paid to the

content of the order.

263. The evidence was that on this occasion the process undertaken for the service of Ms Thompson’s order was considered within the normal operating for any Order as received by the Wyndham Files Office. If however the police assist with obtaining the intervention order, it is likely that the order is served relatively expeditiously (presuming that the

respondent can be located).

264. In my opinion it is unacceptable that an IJO and in particular, one of this nature is served 5

days after its making, and that this is ordinary practice in Victoria.

'33 Submission of Counsel Assisting, p 9

The lengthy time of service defeats the purpose of an interim order and the recognition by the magistrate that a person (the Applicant) is in need of urgent protection. An IIO is in

effect an urgent injunction. Service of the Order should be correspondingly expeditious.

The family was critical of the delay in the service of the 110.134

I note that during the 5 day gap between the making of the order and its service on Mr Wood, Ms Thompson was not at her home — she was awaiting confirmation of the service before she returned. The submission by the Chief Commissioner notes that the service of Ms Thompson’s IIO ‘considered to be a routine file with no degree of urgency indicated upon its receipt at the Wyndham Files Unit.'*5 The submission goes on

‘While the delay of 5 days in serving the interim intervention order was not a matter that had any bearing on Ms Thompson's death, Victoria Police recognises that intervention orders need to be served at the first available opportunity. Accordingly, since that time and as a direct result of Ms Thompson’s death, there have been key improvements implemented to ensure intervention orders, both interim and final, are served in a more timely fashion. °°

The submission details the ‘key improvements’ implemented to expedite service of these orders. It also notes the current review of the Victoria Police manual policy and guidelines on family violence and a consideration of whether the current practice of intervention orders ‘being faxed by courts to non-24 hour police stations for service results in avoidable delay in service of intervention orders.”!%’ I note these reviews. It is important that there be change in this area, Noting the current Victoria Police review on this point, it is not

appropriate to make a further recommendation.

Property Collections occurred on 9 January, 24 January, 31 January and 7 February 2014.

Property Collections occurred on 9 January, 24 January, 31 January and 7 February 2014.

The primary purpose of a police facilitated property collection appears to be to prevent any breach of the peace including any conduct that could constitute a breach of the intervention

order (should one exist) or to prevent any criminal offences from occurring.

AC Cornelius said:

‘the role of police in property hand-over transactions is to secure the peace, maintain the peace, and prevent a breach of peace. Their mere presence in fact can be useful in the sense that it can reasonably be expected to modify the behaviour of the parties present,’ 8

'34 Submission on behalf of the Thompson Family, p 86

'35 Submission on behalf of Chief Commissioner of Police, p 18 136 Submission on behalf of Chief Commissioner of Police, p 18 '57 Submission on behalf of Chief Commissioner of Police, p 19

‘38 Inquest transcript p 863

271. The evidence suggests that officers did not always conduct a LEAP check before they

attended, although it was the practice of some,!*?

272. The members on all occasions contacted Ms Thompson to ensure that she was consenting to

the collection taking place.

273. It appears that it was also routine practice, where an order was in place, to remind the

Respondent of their obligations under the order.

274. Clearly property collections are attendances where an officer’s duty to inquire would be engaged. AC Cornelius commented on the officer learning that Ms Thompson would be applying for an order on day following their attendance, that his expectation was:

‘if a potential victim of family violence indicates to a police officer, "Look, I'm considering or I'm going to be seeking an intervention order", I'd expect the police officer hearing that to take the time to understand from that person the circumstances and satisfy him or herself that that person, that potential victim, is safe.’

275. The evidence is that the police in attendance at the property collections in this case were primarily focussed on their role as keeping the peace, rather than considering the event as a part of the continuum of a family violence incident; unless something warranted it being characterised as a family violence incident there would not be a routine L17 nor would the

attendance be recorded on LEAP.

276. I was told, and accept, that police are assessing risks all the time as part of preventing a breach of the peace. However, the officers in this case clearly did not know what had happened in the past (eg. how many collections have taken place) and whether there were any breaches of orders on foot. They were obviously not aware of the attempted strangulation on 1 January, but all said that this would not have made any difference to the

manner in which they applied themselves to the task.

277. The repeated requests by Mr Wood for police to assist him in retrieving property from Ms Thompson’s premises is likely to have been a demonstration of his controlling behaviours. It

is also significant that he consistently utilised 000 to arrange property collections. Mr Wood

139 A/C Cornelius said: ‘that members would undertake some basic safety checks. That members would in fact check on LEAP to understand whether there are any holdings on the individuals involved, whether there are any firearms registered, for example, to any of the parties. Whether there are any issues that go to the safety of the members attending and the safety of the parties involved. And it's certainly the case right across VicPol, particularly in the last 12 months where we've had a very strong focus on zero harm and safety first, it is absolutely our expectation that members participate in safety briefings at the start of their shift and that where the police attendances are planned, that a safety briefing is conducted before that attendance is executed so that members understand what they need to know in relation to the - any potential threats or safety issues. And it's my expectation that if there's anything in LEAP that goes to the question of the safety of the attending police or the safety of parties involved, that that would have been looked at and that information would have been shared and then an appropriate plan prepared to provide for and support an effective attendance and an effective discharge of whatever it is the members are set to do in that attendance.’

140 Inquest transcript p 864

~ 49

may have utilised police to maintain some control and once that option was taken away with the collection of the undisputed items (on 7 February) the risks increased but this could not

be discerned by police as there was effectively no history recorded to refer to.

If a property collection is not recorded on LEAP, it is difficult to monitor a Respondent’s ‘use’ of police in these activities and the broad picture of the family violence incident as a

whole.

Clearly, by the final property collection on 7 February, Ms Thompson was distressed by the frequency of the collections and expressed that to police, who indicated to her that she did not have to consent and that the property collection could be ‘halted’. Police said that there wasn’t an indication to Mr Wood that there could be no more property collections, but he

would have to go through the courts for the disputed items.

AC Cornelius said that the requests for:

‘repeated property exchanges should've rung some alarm bells uh, and um, in my view it wasn't appropriate to leave it there. Now it might not have occasioned um, putting an L17 at that point but I would've expected this issue to be the - the subject of some discussion back at the station. It's a piece that I would've wanted to see, for example, canvassed with the supervisor.’ '*!

I agree that this would be a good practice. It would enhance police understanding of the

continuum of a particular family violence incident.

As to the threats suggested by Mr Wood to Ms Dibella, the officers indicated that they were always in earshot of Mr Wood and Ms Thompson and if a threat had been heard, the property exchange would have been stopped and a breach initiated (with L17s).

Victoria Police Response to breaches of intervention orders

Ms Thompson reported two breaches of the I[O as having occurred on the 18 and 22

January. Mr Wood was not charged in relation to either alleged breach.

At the relevant time, the VPMG Family Violence provided in Part 3 under 3.2, amongst

other matters, that a contravention of an order:

e Is acriminal offence.

e The offence of a contravention is against statute not the victim.

e Orders are to be strictly interpreted and enforced.

e There is no such thing as a ‘technical’ breach.

'41 Tnquest transcript p 937

At the relevant time, the Code of Practice provided, at 4.8 that:

‘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.’

Ms Thompson told her friend that she was advised:

‘that she had to build evidence...before she could ring the police that he had breached, evidence like taking a photo of the numberplate if he was driving around. Like she had to be her own detective...She had to be her own detective in order to have enough evidence to say he has breached.’

In addition, that it took ‘70 breaches’ before they can arrest someone for breach of an intervention order and that the police had told her that. Whether this was an accurate

reflection of her understanding, will never be known.

At the relevant time, the Code of Practice provided, at 5.4.2.4 that ‘Police should advise

AFMs how to collect evidence to assist to prove when an order is contravened.’ Mr Kim said in relation to breaches:

‘I've been hearing from my clients..., even though there's orders in place, it's difficult to get the police to lay charges where there's allegations of breach of the order. What police tend to ask is - when the applicant comes forward and reports breaches is they tend to ask for evidence and I found it difficult to understand. The incident happened in

a family violence context and there was hardly any evidence. ... I think the police should look into changing the approach, to believe the applicant more, to believe their story more, !#

Cons. Holani said of the first breach that he was not satisfied that he had enough to charge Mr Wood following a statement being taken from Ms Thompson, such as to prove that he was within five metres of Ms Thompson. It does not appear that he turned his mind to whether Mr Wood’s observations of Ms Thompson constituted keeping her under

surveillance was a breach of the order, regardless of the distance.

He said that the decision to release rather than to charge and bail was based on many factors including the severity of the incident, Mr Wood’s cooperation with police and his lack of priors as well as the further investigations to be undertaken. I note his evidence that it would have been impossible to conduct a DVD interview as the station was only staffed by two

officers and when doing a tape record interview there must be two persons present.

Cons Holani said that Ms Thompson denied ‘that he’d laid a finger on her.’ Ms Thompson told him that as he was an Islander, she felt comfortable around him. And further, that she

'42 Inquest transcript p 128

294,

was more concerned about Mr Wood’s welfare: "He's not gunna get locked up, is he for

this?" .... "I just want him to leave me alone so we can go our separate ways,""®.

Ms Thompson didn’t provide the details of her friends as she didn’t want them to be involved at the time. It was Cons Holani intention to speak to Ms Thompson’s friends as the next step but he said that he didn’t have a chance because he was on night shift and then had

days off.

AC Cornelius said:

‘I would also have expected Constable Holani to say to Ms Thompson, "Look, it's going to be very difficult for me to prevent further breaches and hold Mr Woods accountable unless I have an opportunity at the earliest to speak to your two witnesses because that will put me in a position to corroborate and strengthen the case."”'*

The approach preferred by AC Cornelius’ would indicate, and would promote, good

practice.

It appears that Cons Holani did not know about the lack of availability of the CCTV footage until 5 February.

As to the L17 completed by Cons Holani, the risks relating to recent separation, financial difficulties, controlling behaviours or medication were not marked. He admitted that he

missed the recent separation and controlling behaviours.

As to the second breach, I was told that it was common practice to refer those charges to the

original investigator to consolidate charges and avoid fragmentation.

Cons Attard said that he didn’t take a screen shot at the station of the Facebook request and should have probably taken a statement from Ms Thompson at the time. He did not appear to take active steps to recover evidence that was immediately available to him. He also said that he was responsible for making sure that a L17 was submitted, which didn’t occur. Cons Attard said that if he had taken a statement from Ms Thompson, he could have charged Mr Wood with breach of the IO.

Cons Holani says he definitely spoke to Ms Thompson about the second breach but he has no notes of the discussion. It is clear that Ms Thompson should have been kept appraised of

the progress of the investigation.

It is reasonable to conclude that information about the attempted strangulation on 1 January

may well have altered the response of members to the alleged breaches, and about whether

'3 Inquest transcript p 587, 588

144 Inquest transcript p 943

299,

Mr Wood should be regarded as a recidivist offender, particularly if the L17 had been

completed and completed accurately.

Counsel Assisting made this observation about this aspect of the case:

‘It is open to the Coroner to find that there would have been a proper basis to charge Wayne with the first breach offence, or with the more substantive offence of stalking, given that Wayne:

° Attended a hotel where Kelly was present;

e Kept watching her from a distance despite being told he could not be there; and

• When confronted by her, asked for money, suggesting an intention to contact her.”!*

Lagree. There was a proper basis for charging Mr Wood with the first breach and the second

breach was easily provable with a print out from Ms Thompson’s Facebook page.

I understand the reason for referring and consolidating charges, but I do not think that this is necessarily an appropriate practice in cases for breaches of orders, as demonstrated in this case. The second breach, which was easily provable, was delayed and joined with the first breach. There was no proper recognition that a subsequent breach had occurred. Breaches are contraventions against court orders (unlike general offending) and should be treated as such to allow for this distinction to be made. Otherwise the gravity of what has occurred is

diminished and the consequences are not reinforced with the perpetrator.

The ideal time frames for breaches being enforced, as suggested by Professor Ogloff, were not met in this case. He expressed the opinion that if there is a breach it needs to be acted

'46 “certainly within a matter of a day or days at most, otherwise they'll

upon quite quickly have really no consequence.*’ As a general proposition I agree with Professor Ogloff’s view on the matter. However it will, at least to a degree, depend on the circumstances of each case. The family submission made the point:

‘Allowing 28 days to elapse before prosecuting Wayne for his alleged breaches of the IVO had the consequence that there was no consequence for him of his breaches of the IVO before he killed Kelly.”!®

In submissions on the issue, the Chief Commissioner put it that there should be:

‘no criticism or adverse comment in relation to the decision by Constable Holani not to charge Mr Wood on 19 January 2014 or to seek to remand him in custody.’!”

This relates to the first breach, namely the attendance at the Sanctuary Lakes hotel. The

submission made the point that he was:

'45 Submission of Counsel Assisting, p 10

'46 Tnquest transcript p 662

'47 Inquest transcript p 664

'48 Submission on behalf of Kelly’s family, p 64

149 Submission on behalf of the Chief Commissioner of Police, p 21

53°

‘conducting a criminal investigate for alleged breach of an intervention order. There was no physical or threatening conduct alleged again Mr Wood.’'*° It also makes the point that ‘Legal questions arose as to the fact that it was Ms Thompson who approached Mr Wood and whether that sort of contact could constitute a breach of the intervention order.’'>!

These are fair points to make. I accept that the decision to release Mr Wood pending further investigation, such as speaking to witnesses and obtaining CCTV footage were appropriate

in that case.

In relation to the second breach (the Facebook ‘friend request’), the Chief Commissioner’s submission accepts that Cons Attard should have taken a complaint from Ms Thompson and completed a L17. It argues that the decision by Cons Attard to refer the matter to Cons Holani was appropriate but that Cons Attard, as noted, should have completed a L17. The submission refers to Cons Attard’s evidence to the effect that he was

‘at a loss to explain by he did not take a statement, obtain a screenshot or the ‘friend request’ or complete the L17 and acknowledged in hindsight that this is what he should have done.” '**

The submission accepted that the failure to submit what would have been a third L17 was a ‘key oversight’*?. In conjunction with the other two L17s for the incidents on 1 and 18 January, it could have resulted in Mr Wood being classified as a recidivist family violence

154 The submission legitimately makes the

offender and Ms Thompson as a recidivist victim point that it would be speculative to predicate what might have been done, given resource constraints, but that:

‘Victoria Police accepts that this oversight resulted in the opportunity for the Wyndham Family Violence team to develop a recidivist offender management plan and victim management plan being lost.’!*°

The response from to the phone call made by Mr Norman Paskin to the Werribee Police station

on 9 February 2014

Mr and Mrs Paskin had been observing Mr Wood’s behaviour with increasing concern over a number of hours on 8 February and into 9 February. Mr Paskin rang the Werribee Police station and spoke to Cons Pringle. J note and accept that Cons Pringle was a relatively junior officer, who had limited training in family violence. I am also aware that there was a siege

occupying police resources in the area at the time:

150 Submission on behalf of the Chief Commissioner of Police, p 21 151 Submission on behalf of the Chief Commissioner of Police, p 21 182 Submission on behalf of the Chief Commissioner of Police, p 23 153 Submission on behalf of the Chief Commissioner of Police, p 23 ‘54 Submission on behalf of the Chief Commissioner of Police, p 23 155 Submission on behalf of the Chief Commissioner of Police, p 23

‘a male with a hammer and it became a siege’. Cons Pringle said: ‘Whether the siege with the gentlemen... — with the hammer had some influence over my decision making, who knows?’57,

In addition, he said there was a reluctance or shame in getting it wrong and having an incident attended, when it was unnecessary:

‘but I think I would have been criticised had I sent the job through based on the information I was given, from a more superior member....it’s easy to send every job through...!°°.

Tam satisfied that during the ‘8 minutes and 48 second’ conversation with Cons Pringle, Mr Paskin gave him sufficient information (including details of the events that led up to him

making the call) for him to have acted upon that call.

I am also satisfied that there are a number of thing Cons Pringle could have done:

. A LEAP check on the address or on Ms Thompson’s name would have established that there was an IO in place. Cons Pringle said that if he had established that an order was in place ‘there would be absolutely no discretion a van would have been sent’’’?, which would have led to call to 000 for dispatch. Cons Pringle conceded that if he had found out the street address through a Google search which he could have done, there would have been sufficient information as the LEAP check would

have revealed the existence of the IO.

° Cons Pringle could have sought further details such as Ms Thompson’s full name (which Mrs Paskin had access to through Facebook), googled the street address or asked Mr Paskin to locate the street address. In my view however, he had sufficient

information to act on without further details.

° Cons Pringle could also have spoken to a supervisor in relation to the call to seek

guidance.

The Standard Operating Procedures at Werribee Police Station reveal there are no detailed instructions about how phone calls are able to be handled other than to be answered in a

professional manner.

There is no accountable record, document or book for the recording of incoming or outgoing telephone calls and phone calls received at the Police Station are not recorded. Record

keeping is left to individual members to manage.

156 Inquest transcript p 180 '57 Inquest transcript p 221 158 Inquest transcript p 222

'S9 Inquest transcript p 185

AC Cornelius said ‘the failure to follow-up on Paskin's call was a very significant oversight’'!©, Members know that they can secure an attendance by a van, even if their local

vans are tied up, as they can ring 000. Conversations are recorded which ‘creates a highly accountable chain from the call to service delivery.’ !%!

There was a conflict in the evidence between Mr Paskin and Cons Pringle as to aspects of the content of their conversation. In respect of that issue, the submission made by the Family

states:

“Mr Paskin’s evidence as to the content of the phone call with Constable Pringle ought to be accepted by the Court, in preference to the evidence of Constable Pringle about the content of the call for the following reasons:

(a) Mr Paskin had only one telephone call to recall that night, whereas Constable Pringle took part in many calls that night;

(b) some of the content of the call as recalled by Mr Paskin is corroborated by his wife, Sheryl Paskin, ...

(a) Constable Pringle’s notes do not contain most of the matters that Constable Pringle later agreed were discussed, such as the possibility of an IVO being in place and Mr Paskin informing Constable Pringle that Wayne was in the

‘property’; and

(e) Mr Paskin was more persuasive in the witness box regarding his recall of the

phone call than Constable Pringle was.”'™

In that submission the very brief hand written contemporaneous note made by Cons Pringle of the telephone call was set out. As the submission points out, the notes do not contain most

of the matters that Cons Pringle later agreed were discussed.

The submission made on behalf of Cons Pringle, focused the conflict in the evidence on:

‘...(a) Details of the relationship between Ms Thompson and Mr Wood; “what I knew of the background of the relationship of Wayne and Kellie” and that their relationship had broken down.

(b) the full details of Mr Wood’s movements in the hours leading up to Mr Paskin’s telephone call: “Mr Paskin didn’t articulate any of that, previous movements or hours leading up to it or anything like that?.”'®

Having observed both witnesses and considered their evidence, I prefer the account given by Mr Paskin to the extent that there is a conflict between them. He was in my opinion a clear, forthright, honest witness with a good memory. He was ultimately, as the family submission argues, ‘more persuasive in the witness box regarding his recall of the phone calls than

Constable Pringle was.’**

The family submission went on to state:

160 Inquest transcript p 882

'6! Inquest transcript p 882

18 Submission on behalf of the Thompson Family, p 50 ‘63 Submission on behalf of Police Members, p 42

164 Submission on behalf of the Thompson Family, p 50

‘Constable Pringle did not send a police car to the house. This conduct by Constable Pringle indicates of a lack of training of police to recognise family violence incidents

Constable Pringle agreed that in the setting where the man had been removed from the house and where there had been property exchanges attended by police, family violence was a likely situation.

Constable Pringle stated that he was trained that if there was a suspicion of family violence, he should act on it. During the phone call with Norman Paskin, Constable Pringle had a suspicion that the situation might be family violence. Constable Pringle agreed that he ought to have acted on his suspicion of family violence in regard to the information given to him by Norman Paskin...

However, Constable Pringle stated that he may be criticised by his seniors if he sent a van when there was man who had been seen in police presence, with no witnessed crime and no indication of anyone being in danger. This operated on his mind when he made the decision not to send a police van,

Constable Pringle told Norman Paskin during the 9 February 2014 phone call to call back if he heard shouting, and told the Court that ‘ifa neighbour had reported yelling, screaming or anything like that a van would be sent’. Constable Pringle said that screaming or audible altercation was a factor to into consideration...

The conduct of Constable Sean Pringle on 9 February 2014 in responding to the call by Norman Paskin indicates poor training and poor supervision within Victoria Police.’ !®

I agree with the final proposition in particular — that the conduct of Cons Pringle indicted ‘poor training and poor supervision within Victoria Police.’ AC Cornelius described the failure to follow-up the Paskin call as “a very significant oversight.'©” I agree with this

assessment.

In reaching the conclusions about this, I have taken into account that: ‘an assessment of the reasonableness of a police officer’s conduct must be made in a

“realistic matter” taking into account “the reality that the officer has to make decisions

quickly, often in emergencies and under pressure”.”!%7 18

I also take into account that Cons Pringle was acting in good faith and endeavouring to triage the matter. However his actions fell short. I note the submissions on Cons Pringle’s behalf and I make no adverse comment as to his bona fides or his honesty. It is a matter of alertness to the requirements of the situation, and a thorough adherence to procedures applicable at the time. AC Cornelius outlined what he could have done in the light of the requirements and expectations of police officers in this position at that time and I agree with that assessment. I accept at the same time that he took his job seriously, and that his experience was very limited. But even allowing for all of this he should have acted far more pro-actively and sent a vehicle to the Thompson address. He certainly should not have said:

‘Can you do me a massive favour pal and keep an eye on the address? If the circumstances change, you notice anything untoward or if you hear any yelling or

'65 Submission on behalf of the Thompson Family, p 51-52 '66 Inquest transcript 882 ‘6? Submission on behalf of the Chief Commissioner of Police, p 2

168 Smith J in Walker v Hamm, [2008] VSC 596

screaming coming from that particular address please do not hesitate calling back and I'll send a van around to have a look."

319. Laccept the submission made on his behalf:

‘that the absence of a supervising sergeant in the watch house on the night of & February 2014, meant that the opportunity for input from a more attuned ‘antenna’ was not available,*!”

320. I note also that Cons Pringle made, in evidence, sensible concessions. As the family

submission on this matter:

‘Constable Pringle agreed that in the setting where the man had been removed from the house and where there had been property exchanges attended by police, family violence was a likely situation.

Constable Pringle stated that he was trained that if there was suspicion of family violence, he should act on it. During the phone call with Norman Paskin, constable Pringle had a suspicion that the situation might be family violence. Constable Pringle agreed that he ought to have acted on his suspicion of family violence in regard to the information given to him by Norman Paskin.”'".

Sadly it is likely that even if Mr Paskin’s call had been responded to appropriately, Ms

Thompson would not have been reached in time.

321. ILagree that state of the evidence does not permit me to find or infer a causal relationship or

connection between the timing of Mr Wood’s death and the likely timing of the arrival of a

van if one had been sent. It is common ground in the submissions, and I agree that the

evidence does not provide a ‘comfortable level of satisfaction’ that the actions or omissions

of Cons Pringle caused or contributed to Ms Thompson’s death.

Ms Thompson’s contact with Victoria Police

322. The following telephone calls were made by Ms Thompson to police:

09/1/2014 - 10 calls made to Werribee Police Station. These calls may relate to the

assisted property collection which occurred before Ms Thompson obtained the IIO.

10/1/2014 - 5 calls made to Wyndham North Police Station. These calls occurred after Ms Thompson obtained the [IO and may relate to the threats .of self harm made by Mr Wood on that day.

11/1/2014 - 2 calls made to Wyndham North Police Station. These calls may relate to the service of the ITO.

12/1/2014 - 1 call made to Wyndham North Police Station. This call may relate to relate

to the service of the IO.

169 Inquest brief p 300, Statement of Mr Norman Paskin, 11 February 2014 170 Submission on behalf of Police Members, p 41

1 Submission on behalf of the Thompson Family, p51

3235

324,

e 13/1/2014 - 1 call made to Wyndham North Police Station. This call may relate to the

service of the IIO.

14/1/2014 - 1 call made to Wyndham North Police Station. This call may relate to the

service of the IIO.

15/1/2014 - 3 calls to Wyndham North Police Station. These calls may relate to the

service of the I[O which was served on this day.

® 19/1/2014 - 1 call to the Wyndham North Police Station. This call may relate to the first breach of the IVO reported on this day.

e 20/1/2014 - 5 calls to Wyndham North Police Station. These calls may relate to the first breach of the IVO reported on this day.

24/1/2014 - 9 calls to Werribee Station. These calls may relate the property collection

which took place on this date.

Ms Thompson’s family has noted that the:

‘failure to contemporaneously record the content of these calls will forever deny Kelly’s family and the Victorian community actual knowledge of the full extent and acuity of Kelly's attempts to seek Police responses on a short period of time prior to her murder!”

I agree but I cannot speculate as the content of the calls and the evidence does not permit findings to be made as to the nature and outcomes of the calls. I note also the evidence that

incoming calls to police stations are not routinely electronically recorded.

Counsel Assisting submitted that:

‘There are no calls made after 24 January 2014. Whilst it is tempting to speculate about why that is, there is no evidence permitting any particular conclusion to be drawn.

Although several of Kelly’s friends gained the impression that she was constantly contacting police and that police were doing nothing (and that may well have heen Kelly's perception too), the evidence does not support that impression. For reasons only Kelly could explain, she chose not to involve the police after 24 January 20147173.

After considering all the evidence, I conclude that Ms Thompson did not make any calls to police after 24 January 2014. Consistent with this, there is no evidence to suggest that Ms

Thompson reported a third breach of the IVO.

As to Ms Thompson’s view on the police response, her friend Ms Susan Barrow indicated that Ms Thompson had not complained to her about her treatment by police.

‘Kelly told me that the police had been good towards her when this first started and she first came into contact with police...The only other things Kelly mentioned to me about

'? Submission on behalf of the Thompson Family

3 Submission by Counsel Assisting, p11

the police was that she had the police at her house for property pick ups with Wayne, she never mentioned anything to me about being annoyed about the police or that they were not doing their job..."

Health professional responses to Mr Wood — Psychologist

Mr Wood was referred to Life Resolutions at Point Cook on 3 January 2014 by his GP, Dr Munir who prepared a GP mental health care plan.

“54 year old Mr Wayne presented to em [sic] with his partner for the repeat script of his medication Lovan that he is taking for the last few months for his depression. Pt explained that he lost his house 4 year [sic] back to his X wife and then had a horrible truck accident foe [sic] which he was admitted in hospital about 4 weeks. His partner gives hx that he has anger issues, he gets very aggressive at times and is very possessive of her. Un employed at the moment, taking 40 mg of Lovan which [doesn’t seem] to work anymore although it did work in the beginning. She explaints [sic] that she want to hel [sic] him but their relationship is almost over.”!”

As already noted, Mr Wood saw Clinical Psychologist, Marizanne (Lily) de Bruin on three occasions being 16 January, 22 January and 29 January 2014.

I note that on the first occasion Mr Wood made reference to the incident on New Year’s day — where he grabbed his former partner by the neck for which he said he was very sorry and regretted what had happened. She said of that occasion that there were a lot of changes in Mr Wood’s life including, being recently unemployed, his relationship had ended, he was

living with his brother as well as no longer being part of the business.

At the second session they discussed the IJO which was returnable the next day, which Ms

de Bruin said he was accepting of.

Of the third session, Ms de Bruin said that he appeared hopeful and had started to look for jobs. He also said that he accepted that the relationship was finished and that he wanted to concentrate on anger management in his next session (which was scheduled for 5 February

but he did not attend).

Ms de Bruin agreed that he was grieving the end of the relationship and what it meant for him. She also said that there were no indicators that Mr Wood was a harm to himself or

others.

She noted that he was a voluntary patient and it was his psychological issues that were being

dealt with.

'74 Inquest brief p 60-64, Statement of Ms Susan Barrow

'5 Tnquest brief p 1653, Statement of Dr Munir, 20 May 2015

Ms de Bruin had limited direct involvement with people involved in family violence but did indicate to the Court that she had been given some training in the SARA risk assessment

model.

Ms de Bruin said that during the sessions she did consider the risk of future harm that Mr Wood may pose to Ms Thompson but it was her view that he understood the terms of the

order and that the relationship was over.

Ms de Bruin said that if she thought Ms Thompson was in danger she could have acted despite confidentiality arrangements, which Mr Wood was aware of when they commenced her engagement. As noted by Professor Ogloff,

‘there is an exception if the - and including in the Australian Code of Ethics for Psychologists, if the clinician has reason to believe that the person presents an immediate risk of harm to themselves or others, then information can be shared and, ...

typically, that's something the psychologist explains to people at the beginning of the contact, you know, what is the limits of - what are the limits of confidentiality.’\”

Professor Ogloff considered the professional service provided by Ms de Bruin, and the referral by the GP including the mental health plan, and was of the view that she did act

appropriately under the circumstances of her engagement.

He said that she did what a clinical psychologist

‘would typically do. In the first session it was around a mental state examination and identification of problems. In the second, he had particular issues going on in his life, including the intervention order hearing, and so it focused on that, and then the third, looks like a session that was really focusing more on the problem areas and future work, and then as we know, Mr Wood didn't attend on the fourth session.?!™

l accept Professor Ogloff’s expert opinion on this matter.

Victoria Police response to Mr Wood —A Recidivist Family Violence Offender

The Code of Practice defines a ‘recidivist offender’ as any person who has committed three or more offences within a 12 month period. Responsibility for the identification and management of a recidivist offender lies firstly with the front line members who respond to the family violence incident. This responsibility encompasses the completion of a L17, the formulation of a response, implementation of that response and appropriate protections

being put in place for the victim as well as the FVT being notified.

'76 Inquest transcript p 672

'77 Inquest transcript p 657

If a person is identified as a recidivist offender, a red flag appears on LEAP. The FVT’s have a responsibility for the identification and management of recidivist offenders.'? They

are expected to investigate alleged breaches.

‘High risk clients’ on the other hand, may be identified after one incident. A/C Cornelius gave evidence that Mr Wood could have been considered a ‘high risk client’ had the fact of

the attempted strangling been known.

He said:

‘One of the key points I'd make under the VPID is that if you're a perpetrator you don't - you don't qualify for a PTMP, an offender management plan, only after you've had three crimes or three breaches, You can be the subject of a PTMP if an assessment's made that on the first breach you're actually a high risk individual.’'”

I accept that if the incident on 1 January had properly identified the attempted strangling and the dangerous behaviour with the car, the second breach would have brought Mr Wood into

the category ofa RO.

Police Investigation and Oversight of the Investigation

Victorian Coroners are assisted by members of Victoria Police, who are generally regarded as experts in death investigation. This presents an issue where the actions of police are under scrutiny as part of the coronial investigation, as in this case. It brings to the forefront the independence of their investigation. The current procedure is for PSC to oversight the investigating officer in accordance with nine oversight principles, including ‘managing

conflicts of interest’ .'®° Oversight is put in place once a possible conflict is identified.

In its submission, the family made the following points:

‘From 11 February 2014 Professional Standards Command oversight of the investigation into the deaths for Kelly and Wayne was undertaken because of the involvement of Victoria Police with Kelly and Wayne in the five weeks prior to their deaths...

Kelly’s family does not say that the perceived conflict of interest had an effect on the conduct of the investigation. However, the perception of conflict of interest and its management by Victoria Police, and in particular the lack of any adequate explanation by Victoria Police for the investigation staying at the same Police Station, where police

"78 Cons Holani said: ‘So when a person is marked as a recidivist offender, I'm not sure who marks them down, or the criteria for them to be marked on LEAP as a recidivist, but we're allocated by the Officer-in-Charge of family violence at the time, a recidivist offender. All breaches which other members may attend to, are investigated by that particular member. That member also conducts welfare checks on the AFM, whether it be phone calls on - when that member deems it necessary to call or check in on their welfare.’

1 Inquest transcript p 881

180 PMP Death and Serious Injury/Ilness Incidents Involving Police and VPMG Death and Serious Injury/Illness Incidents Involving Police — initial action and VPMG Oversight of Death or Serious Injury/Illness Incidents involving

Police.

349,

worked who were involved with Kelly and Wayne prior to their deaths, has caused Kelly’s family distress. ’1*!

In response, the Chief Commissioner’s submissions were:

‘The adequacy of the investigation conducted by Detective Senior Constable Sharp and the potential for a conflict of interest was questioned in this inquest. Victoria Police acknowledges that, whilst no actual conflict of interest was identified, the fact that Detective Senior Constable Sharp remained the primary investigator whilst attached to the Werribee CIU was a terrible look. Victoria Police concedes it was unfortunate that Deputy Commissioner Tim Cartwright’s decision to have Detective Senior Constable Sharp transferred to the Homicide Squad was not carried out, However, the fact remains that the investigation by Detective Senior Constable Sharp was thorough and commendable. The report of the Officer in Charge of the Homicide Squad, Detective Senior Sergeant Michael Hughes confirms this position when he stated that in terms of the quality of the coronial brief of evidence, it had been assessed by Detective Senior Sergeant Shane O’Connell and Detective Sergeant Graham Ross and was of a high standard...

No criticism or adverse comment should be directed against Detective Senior Constable Sharp in respect of his investigation of this matter. It is noted that two experience local detectives, Detective Senior Constable Alan Hill and Detective Sergeant Dennis Williams assisted Detective Senior Constable Sharp in his investigation. Detective Senior Constable Sharp signed conflict of interest forms to confirm no close affiliation with any person involved in the investigation and the Professional Standard Command oversighted the investigation. Further, at a very early stage of the investigation Detective Senior Constable Sharp had ready access to Detective Sergeant Ross of advice. "1°?

It is clear that a conflict was identified on the day Ms Thompson’s death was discovered, at least in terms of the call from Mr Paskin to Cons Pringle. I note that PSC were notified from

the scene of this incident at 1205 hours on 11 February 2014.

Under the Victoria Police Crime Department Accountability and Resource Model all murder-suicides are determined as category 2 investigations, where regional investigators take investigative primacy and Crime Command provide support with case priority.

Accordingly, the investigations into Ms Thompson and Mr Wood’s deaths were assessed as

Category 2 investigations and Wyndham CIU assumed the initial investigations.

I was initially assisted in my investigation by DSC Sharp, Wyndham Criminal Investigation Unit and later by DS Ross, Homicide Squad. DS Grandy was the oversight officer from

PSC.

At a meeting conducted on 20 February 2014, between Deputy Commissioner Tim Cartwright, Assistant Commissioner Andrew Crisp and Assistant Commissioner Stephen Leane it was determined that the investigations should be returned to the Homicide Squad as

a first option, or as an alternative, conducted by a Sergeant from another Division.

18! Submission on behalf of the Thompson Family, p 101, 102 182 Submission on behalf of the Chief Commissioner of Police, p 37, 38

Notwithstanding this, the investigation remained with Wyndham CIU. There appeared to be a later intention for DSC Sharp to be seconded to the Homicide squad, but this did not

occur.

No actual conflict was identified with DSC Sharp carrying out the role of Coroner’s Investigator, but it was acknowledged by the CCP that this does not resolve the possible

perception of a conflict of interest. I agree with that assessment.

The fact that this matter was not rectified exacerbated suspicion concerning possible police involvement in the matter, even where there may have been none, and caused considerable additional grief to the family. I express my regret that the family was caused additional grief

by this.

It is important to note however that there is no evidence to suggest that the perceived conflict of interest issue actually impaired my investigation. I am satisfied that it did not.

Changes were implemented as a result of a review conducted into this matter including that unless exceptional circumstances exist, there must be geographical separation between the three relevant parties (subject member, investigator and oversighting officer) associated with the incident. I was told, and accept if a similar situation was to arise today, the investigation would still remain at local level (ie. Not be referred to the Homicide Squad); however, it would, for example, be allocated to the Geelong CIU rather than the Wyndham CIU and the Oversighter would be from an area other than Geelong or Wyndham. The change was made

to address concerns regarding perceived conflicts of interest. '

Detective Senior Sergeant Shane O’Connell and DS Ross were appointed to independently assessed the coronial briefs and were of the view that the briefs were of a high quality. I

agree with that assessment.

The family raised concerns that statements from key police officers (Attard, Wichello and Holani) were not prioritised and, that given the time it took for their statements to be made,

the evidence was diminished as the officers could not recall details of key conversations.

The evidence indicates that a bulk email was sent to various officers on 21 March 2014 (Wallace, Byron, Tyrell, Priebbenow, Murrihy, Riches, Mayne, Bryan, Estrafiadis and Spiteri). Cons Attard’s statement was made on 23 April 2014. SC Whichello’s statement was made on 15 May 2014. Both required a PSC officer to be present.

I heard consistent evidence from police investigators, including from the Homicide Squad, that statements of civilians (and there were many in this case) are prioritised over police

statements. The family was highly critical of this approach. Their submission says:

“Police investigators were tardy in taking statements from police that were known on 11 February 2014 to have had direct involvement with Kelly and Wayne in the five-week period prior to their deaths...

The lack of handwritten notes by LSC Whichello and Constable Attard regarding the 1 January 2014 incident proves that any approach that deliberately seeks to obtain civilian witness statements before police statements, on the basis that police take notes, is flawed. The contention that police will have made notes of an incident is a false assumption, as DS Ross agreed. It is more likely that the memory of any particular incident is likely to quickly fade for front line police as they attend multiple incidents every day of their working lives. This compares with civilians, who are usually not involved in police incidents...

The failure to take statements from the three critical police officers promptly, particularly when 25 civilian witnesses had statement taken in the first four weeks after the deaths, may give rise to a prescription by a reasonable person that the detectives were investigating the death were not actively pursuing the issues of police involvement prior to the deaths. ”!*

In reply, the Chief Commissioner’s submission was:

“..Jt is an entirely appropriate investigative technique to prioritise the taking of statements from civilian witnesses before police witnesses because police should and will have notes from which to refresh memory. The fact that statements were taken from Constable Attard on 23 April 2014, Senior Constable Whichello on 15 May 2014, and Constable Holani on 12 January 2015, did not adversely affect this coronial investigation or in any way taint the evidence. ’!*4

I can understand why the family makes the point that it does here. I don’t accept however that there may be a perception that the police were not ‘actively pursuing the issues of police involvement’. The quality and the outcome of the investigation does not bear this out.

Ultimately I accept that it is ‘an appropriate investigative technique’ to prioritise the taking of statements from civilians for the reasons given by the Chief Commissioner of Police.

However it of course depends upon police making adequate contemporaneous notes and they should have done so in this case. Fortunately the coronial investigation was not

compromised by that particular flaw.

DSC Sharp said that in order to identify the witnesses generally there was a door knock, there was the revelation of the social function on 8 February which Mr Wood attended and he said:

‘an intelligence analyst in my office put together a flow chart of involvements between both Wood and Thompson and the police and as a result of that flow chart I was able to identify police members who had been involved through family violence related matters that many witnesses lived on the other side of Victoria in the eastern suburbs. There were some witnesses who live interstate and there were witnesses who were local. So we prioritised the civilian witnesses mainly because I felt at the time they needed to be interviewed because their information or their memories were likely to go first, not

'83 Submission on behalf of the Thompson family, p 98, 99 '84 Submission on behalf of the Chief Commissioner of Police, p 38

being professional police witnesses they would have not made notes of the incident so we tried to get them interviewed first.’ !*®°

And further:

‘that's generally standard procedure mainly because we know that it's accepted that witnesses — civilian witnesses generally won't make notes so we try and get to them as quickly as we can to get information while their memories are still quite fresh.’!*®

Upon reflection DSC Sharp said that he should have retained the computers and mobile phones belonging to both Ms Thompson and Mr Wood and if he did so he ‘probably would have been able to get a better examination of their social media and emails accounts.’ He said that the family of Ms Thompson requested the computers ‘so we had a concern from the family and also a belief there was no value in holding the computers so I returned the

computers. '°7

I accept DSC Sharp’s evidence.

COMMENTS

What follows are comments pursuant to section 67(3) of the Coroners Act 2008, are in addition to any comments I have made in the body of the finding dealing with submissions

on specific topics.

This is another shocking family violence killing.

Mr Wayne Wood killed Ms Thompson after he had gained entry to the Hamilton Street address shortly after midnight on 9 February armed with his hunting knife, with the intention of killing Ms Thompson, and he did so viscously whilst Ms Thompson lay

sleeping.

Mr Wood was considering killing Ms Thompson (as well as himself) at least as early as October/November 2013, whilst they were overseas. It is apparent that he had always been

controlling, possessive and jealous

Mr Wood told people (including friends) of his intentions of killing on at least two occasions from that time until the day before Ms Thompson’s death, and a number of people including Ms Thompson thought him capable of doing so. This was despite an absence of

any history of violence including family violence.

Whilst Mr Wood told police, the Magistrate, his lawyer and his psychologist that he

understood the orders (both interim and final), he clearly had no regard for them and no

185 Inquest transcript p 957-958 186 Inquest transcript p 958.

'87 Inquest transcript p 962

372,

intention of complying. In fact he admitted to people that he had breached the order. There were no repercussions from those in authority in response to the formal breaches reported by

Ms Thompson, which may have served to constrain his behaviour.

What is apparent is that there was little self-reflection or true understanding of how unacceptable his behaviour was or an appreciation of the affect it may have had on Ms Thompson. Despite Mr Wood being witnessed chasing after Ms Thompson and wedging her with his car, he still angrily confronted Mr Hall. Despite Ms Thompson’s brother being called to pick Ms Thompson up from Point Cook as Mr Wood wouldn’t let her leave, he was aggressive. He admitted to various people that he strangled Ms Thompson (but on reflection said he should have pinned her against a wall). He admitted to hiding in her backyard and that he was ‘clever’ and had built something so he could get back in the house.

Despite all these disclosures he sought to draw sympathy from people, and complained that

mutual friends were choosing sides.

Ms Thompson on the other hand had experienced family violence before and was undoubtedly shocked and disappointed (and expressed as much to the Family Violence Registrar) that she found herself in that position again. In terms of her interaction with the family violence system, Ms Thompson took all the right steps. Without police assistance, she obtained her own IIO and eventually a full order. She interacted with the family violence service provider she was referred to (albeit to a limited extent), she used the state provided duty solicitor service at court and she reported all breaches of the orders that she became aware of, at least before 7 February. She did not disclose to the police on 1 January that Mr Wood had attempted to strangle her but she did ask that they wait for her business partner to arrive. She also did not disclose this to the police on 19 January when reporting the first breach of the order, but she didn’t need to, at least for the purpose of reporting the breach.

She did not return the call of the Wyndham FVT related to the incident on 1 January - it is unclear why this is so. She also did not take up the offer of further assistance from WHW —

again it is also unclear why this was her preference.

In the early stages, Ms Thompson appeared to be concerned about the impact Mr Wood’s violence (and the consequence on their relationship) would have on the business and the other partners — probably loathing to cause any trouble. Ms Thompson would also have been acutely aware of how serious the attempted strangling was — and was reminded of this by the magistrate at her first time before the Court. But she also didn’t want to exacerbate the

situation with further reprisals from Mr Wood. She was, in reality, managing her own safety.

athe

379,

In addition, Ms Thompson’s mother said that ‘Kelly would not overstate her fear. She was more likely to understate her fear."'** This may explain why she did not always

communicate her level of fear.

Ms Thompson also had that ‘sense of fair play’ when dealing with Mr Wood — she took him to the doctor, she hoped he would get the psychological help he needed and she gave him

money.

Mr Wood on the other hand appeared to be motivated by jealously and self-interest.'®?

Darlene Tonihi said that Ms Thompson had told her that Mr Wood said ‘if I can’t have you,

no-one will.’

An examination of the response of the Victorian family violence system to Ms Thompson over the 39 day period from | January has highlighted inadequacies in the response by police (particularly in respect of investigation standards and the completion of the L17), deficiencies in the system and a siloed approach which allowed almost no opportunity for the sharing of information amongst entities in the sector. Maximisation of this sharing of information was essential to help secure Ms Thompson’s safety. It also would have helped monitor Mr Wood’s behaviour and provide opportunities to intervene, where possible. The Royal Commission noted that sharing information about risks within and between organisations, is crucial to keeping victims safe. It is necessary for assessing risks to a victims safety preventing or reducing the risk of harm, and keeping perpetrators ‘in view’

and accountable. !°°

Family violence risks fluctuate and change over time which makes it critical that each interaction with the family violence system provides an opportunity to assess the safety of the victim and reinforce the accountability of the perpetrator. This case was replete with missed opportunities for risks to be known and properly assessed - ranging from the critical omission on | January, Mr Wood’s threat of suicide, the multiple property collections and the lost opportunity for the Court to be made aware of the breaches at the return date of the order. The IIO was served 5 days after it was made, consistent with practice at the time for non-police initiated orders. The reported breaches were not acted upon in a manner that deterred Mr Wood. The offending behaviour (related to the first breach) was not being seen

through the prism of the intervention order. The family violence system, as it operated at the

188 Inquest brief p 1994, Statement of Ms Wendy Thompson, 3 June 2015

189 T believe Wayne killed Kelly because of jealously, possessiveness and control. Kelly may have been killed after the last property transfer because that indicated finality in the separation. I think Wayne wanted to punish Kelly for going through with the separation.’ (Ms Wendy Thompson)

190 Report of the Royal Commission into Family Violence

time of Ms Thompson’s death, failed to recognise that the risks were escalating for Ms

Thompson.

Critical information was not known across the system and in particular, Ms Thompson’s level of fear. Ms Thompson’s mother said that ‘J knew she was fearful but the thought of the depth of her fear as to need three knives close to her bed shocked me.’!! It is clear that Ms

Thompson was in fear for her life at the time of her death.

It is not clear whether a full risk assessment would have changed the outcome, although it is likely to have reinforced for Ms Thompson the serious risks she was facing. In this context it is important that any opportunity for engagement with the victim provides an opportunity for a different and possibly new level of disclosure to help inform levels of risk and carty

out safety planning.

There is no evidence to suggest that any individual related to this matter acted other than in

good faith. *

Mr Paskin’s earnest call for assistance to police on behalf of Ms Thompson was not

adequately responded to but Ms Thompson was unlikely to have been saved however even

had police been despatched!”

191 Inquest brief p 1994, Statement of Ms Wendy Thompson, 3 June 2015 2 this impossible to determine whether Mr Wood would have been saved, had police been despatched.

Specific Findings

I find that Mr Wood caused the death of Ms Thompson, who was born on 29 April 1970.

I find that the death occurred shortly after midnight on 9 February 2014 at 5 Hamilton Street, Point Cook.

I find that the cause of Ms Thompson’s death was ‘Stab wounds to the chest’.

Whilst it is difficult to say to what lengths Mr Wood would have undertaken in order to kill Ms Thompson, on balance, I find that Ms Thompson’s death was preventable.

Having found that Ms Thompson’s death was preventable, sole responsibility for Ms

Thompson’s death lies with Mr Wood.

Conclusions

Soe.

I am satisfied that there is no validated risk assessment tool that can accurately predict the risks of intimate partner homicide but I am satisfied find that there are validated risk assessment tools which can accurately predict the risk of intimate partner violence and in this case, the factors associated with Mr Wood were such that he presented with a high risk

of re-offending in a family violence incident.

There are many reasons why Mr Wood may have caused Ms Thompson’s death but the evidence suggests that he did not want the relationship to end and, once ended, he did not want Ms Thompson to live her life, which included the possibility of other intimate

partnerships, without him.

SC Whichello and Cons Attard should have spoken to the complainant in relation to the incident on 1 January 2014 and that their failure to record the allegation of strangulation on

the L17 was a critical omission.

There was a proper basis for Mr Wood to be charged with breach of the IIO arising out of his conduct on 18 January 2014.

Mr Wood should have been promptly charged with breach of the IIO arising from his friend request on Facebook on 22 January 2014, and that a L17 should have been lodged for this

incident.

Cons Pringle should have responded to Mr Paskin’s call on 9 February 2014 by arranging for the despatch of police assistance or referring the call to 000 for this purpose.

Contribution

395. While it is not mandatory to make findings of ‘contribution’ in the coronial jurisdiction, such findings will be appropriate in some cases. Making a finding of contribution requires the coroner to apply common sense to the facts of a case. The test of contribution is whether a person’s conduct caused the death. A coroner should consider whether the outcome was the logical progression of events which would reasonably follow from the conduct under consideration.!73

396. Having considered all the evidence as it relates to the police officers, to the extent that there were failures or deficiencies of process, policy or practice revealed in the evidence as part of my investigation, the evidence does not reach the level where I am able to find that those failures or deficiencies were causative, that is that they directly caused or contributed to Mr Thompson’s death.

RECOMMENDATIONS

397. The family submitted that I should make specific recommendations in respect of 8 topics:- 9.1 Funding 9.2 That high risk AFMS are identified by use of the Red Flag List by front-line workers with later Follow-up by specialist family violence teams.

9.3 The IVO Application Process 9.4 The process by which interim IVOs are served 9.5 That property collections supervised by police be limited to one per party 9.6 That action be taken when IVOs are breached 9.7 Public and AFM education 9.8 Management of conflicts

398. The Chief Commissioner of Police made this submission:

‘The State Coroner can be satisfied on the evidence before this Court that Victoria Police had demonstrated an ongoing commitment to tackling family violence head-on. It has consistently and persistently (both before, during and since the conduct of this

193 In Record of Investigation into Death of Nathan John Jackson Stewart (2 December 2008), Judge Coate (now Justice) reviewed Commissioner of Police v Hallenstein [1996] 2 VR 1 and other cases on when a person contributes to a death and concluded: Endeavouring to distil the essence of these cases to come up with a test for contribution which requires the coroner, in the application of common sense to the facts, I conclude that one would have to find that the act or acts departed from the reasonable standards of conduct applicable to the circumstances of the case.

Inquest) engaged in processes of consultation, review and reform to improve the police response to the full gamut of family violence incidents.

For the above reasons it is submitted that this Court should be hesitant to make any recommendations of a specific or prescriptive nature. It may well be more constructive and informed to make system-wide reforms based on consideration of several cases across a broad spectrum of incidents of family violence, such as will be undertaken by the Royal Commission into Family Violence.”"4

Victoria Police has engaged in significant and ongoing review and reform in an effort to continually improve the handling of family violence matters and service of intervention orders by police since Ms Thompson's death.

The evidence of Assistant Commissioner Cornelius is unequivocal about the seriousness with which Victoria Police takes family violence. Victoria Police is committed to prioritising family violence and ensuring that its response to this complex social problem is robust, consistent and weil informed.”!”*

I note and commend the commitment to reform by Victoria Police. I accept the evidence of AC Cornelius that Victoria Police is ‘unequivocal about the seriousness’ with which it takes family violence. The challenges it faces are highlighted in this case by the flaws I have identified. Perhaps the greatest challenge is to match the high level of commitment of Victoria Police to responding to family violence appropriately, with the performance of the police officers on the ground as they respond to specific family violence incidents. Their

adherence to the specified procedures, as they go about their task, is critical to achieving the

I am conscious that during the course of my investigation including the inquest the Royal Commission into Family Violence commenced and was finalised on 30 March 2016. I note

that 127 recommendations were made and it is important that my recommendations are

I propose to make recommendations on a number of matters put forward by the family and

to note where the issue appears to have been adequately covered by the recommendations

results Victoria Police clearly aspires to.

consistent, where appropriate.

401, made by the Royal Commission into Family Violence.

I set out below, in tabular form, the submission of the family (Column 1), the relevant recommendations of the Royal Commission into Family Violence (Column 2) and my recommendations (some with comments) arising from this case (Column 3), taking into

account the recommendations of the Royal Commission.

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

Paragraph 336. That funding for family violence services be significantly increased.

Recommendation 11: The Victorian Government provide additional funding for specialist family violence support services to deal with the current crisis in demand and to ensure that victims of family violence receive appropriate support [within 12 months].

This has been recommended by the FVRC’s in their report (see Recommendation 11).

194 Submission in Reply on Behalf of the Chief Commissioner of Police, p 28 - 29 '95 Submission on behalf of the Chief Commissioner of Police, p 29

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

Paragraph 337. That front-line workers in family violence services, including police, registrars of the Magistrates’ Court, solicitors at legal services and workers at community family violence centres:

(a) carry the Red Flag List to assist with their assessment of the risk of future violence;

Recommendation 1: The Victorian Government review and begin implementing the revised Family Violence Risk Assessment and Risk Management Framework (known as the Common Risk Assessment Framework, or the CRAF) [by 31 December 2017] in order to deliver a comprehensive framework that sets minimum standards and roles and responsibilities for screening, risk assessment, risk management, information sharing and referral throughout Victorian agencies, The revised framework should incorporate:

• a rating and/or weighting of risk factors to identify the risk of family violence as low, medium or high

~ evidence-based risk indicators that are specific to children

• comprehensive practice guidance.

The framework should also reflect the needs of the diverse range of family violence victims and perpetrators, among them older people, people with disabilities, and people from Aboriginal and Torres Strait Islander, culturally and linguistically diverse and lesbian, gay,

This is covered by the FVRC’s in their report (see Recommendation 1).

bisexual, transgender and intersex communities.

(b) are provided with training in the assessment | Recommendation 3: The Victorian | I refer to paragraphs 246 -251 earlier in these

of assessment of the risk of future violence, including training in the completion of the Form L17 or CRAF, whichever form is used;

Government implement the revised Family Violence Risk Assessment and Risk Management Framework and develop a sustained workforce development and training strategy as part of the recommended family violence industry plan [from | January 2018]. The framework should provide for:

~ minimum standards and core competencies to guide identifying, risk assessment and risk management practice in family violence specialist services, mainstream services and universal services

• whole-of-workforce training for priority sectors—including general practitioners and hospital, mental health, drug and alcohol, child protection, aged care and disability workers— that takes into account and aligns with their roles and standards of practice.

findings. There is an ongoing review by Victoria Police of the L17. Given that, I do not propose to make recommendation about it.

T note the introduction of the ‘Ready Reckoner’ based on the risk assessment issues in the L17.

(c) are trained to identify AFMs at high risk of future violence by written guidelines that stipulate the assessment of the tisk by means other than the worker’s judgment; and

Recommendation 1 (stated above)

This has been recommended by the FVRC’s in their report (see Recommendation 1),

(d) are trained to include uncorroborated allegations in the narrative of the Form L17 or

CRAF.

Recommendation 1 (stated above).

This could be included in the comprehensive Practice guide noted referred to the FVRC’s Recommendation 1.

Paragraph 338. That supervisors who check a tisk assessment of a front-line worker be required to discuss the family violence incident with the front-line worker.

Volume I, Page 25: These inconsistencies and shortcomings must be remedied by improving training and processes in relation to L17 risk assessments, reviewing and strengthening police practice in identifying the primary aggressor, and establishing a Family Violence Centre of Learning with external academic governance. A revised approach to education and training, with an emphasis on welltrained supervisors, on-the-job learning and better access to specialist family violence teams for support, advice and quality assurance, will increase members’ understanding of the nature and dynamics of family violence and the importance of accurate risk assessment and risk management. Jt will also improve their ability to deal sensitively with family violence in the general population and among marginalised groups.

The family proposal is quite specific. There may be practical obstacles to rigid implementation of it. I believe it could be implemented in the comprehensive practice guide noted referred to the FVRC’s Recommendation 1. It could also be covered in Recommendation 3 regarding minimum standards and core competencies to guide identifying, risk assessment and risk management practice in family violence specialist services, mainstream services and universal services

Paragraph 339. That Family Violence Teams in

Recommendation 1 (stated above).

I believe that it may be appropriately covered

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

Victoria Police be required to investigate every report of an attempted strangulation.

by elements of the FVRC’s Recommendation 1 regarding risk factors identified as high risk, of which strangulation is one. For example, - a rating and/or weighting of risk factors to identify the risk of family violence as low, medium or high.

Paragraph 340. That specialist family violence teams, such as the Family Violence Units at Police Stations, undertake ongoing management of AFMs at high risk of future violence.

Volume I, Page 5: the development of Risk Assessment and Management Panels to proactively monitor perpetrators in family violence cases identified as high risk.

Recommendation 13: The Victorian Government give priority to supporting victims in safely remaining in, or returning to, their own homes and communities through the expansion of Safe at Home-type programs across Victoria [within two years]. These programs should incorporate rental and mortgage subsidies and any benefits offered by advances in safety devices, with suitable case management as well as monitoring of perpetrators by police and the justice system.

This has been mentioned by the FVRC’s in their report under the heading Strong Foundations and addressed in Recommendation 13.

Paragraph 341. That in every family violence interaction with services, the focus ought to be the safety of the AFM. Services ought not to be expending resources on issues such as financial concerns in circumstances where safety, with assessment of the risk of future harm, has not been addressed first.

No specific recommendation.

The family submission stresses safety as a priority. | agree with that emphasis. However it must also be recognised that there be situations where other issues need to be resolved / addressed where it is established that they are a significant source of conflict and trigger for violence, for example alcohol misuse and child custody disputes.

Paragraph 342. That Victoria Police members record on LEAP each interaction with parties to [VOs, including at property collections, so that the wider context of a particular relationship is available to other members.

No specific recommendation.

There is no specific recommendation in the FYRC as to this, however I note that the report acknowledges inadequacies in data recording by Victoria Police. Specifically in Volume I, page 25 where it is stated:

‘However, the police response to family violence is inconsistent in relation to, for example, risk assessment and management, charging perpetrators for contraventions of intervention orders, and data-recording and data- sharing. Problems associated with cultural norms and attitudes among some police members are also apparent.’

/without making a formal recommendation I agree that it is a good practice for police officers to identify and record interactions which indicate family violence or potential family violence.

Paragraph 343. That AFMs at high-risk of future family violence are so informed, and options to reduce the risk be discussed with them, including hiding from the perpetrator where indicated.

No specific recommendation.

There is no recommendation in the FVRC regarding this matter, however the report strongly advocates for improved information sharing. Specifically in Volume I, page 20 where it is stated:

‘The Central Information Point would provide information, primarily about perpetrators, to the proposed Support and Safety Hubs and other key agencies so that they can engage in safety planning with the victim.’

It is a question of who/which agency would be obliged to have the discussion with the AFM.

This is an important matter and such information should be provided. Given the tecommendations of the FVRC in relation to information provision and information sharing, 1 will not make a prescriptive recommendation about this matter, simply note that it is clearly important that such information be conveyed to a AFMs without over elevating fear and anxiety,

Paragraph 344. That a copy of each and every tisk assessment undertaken by front-line worker is provided to:

(a) the applicant;

(b) his or her legal representative, including

No specific recommendation, however could be inferred from following recommendation.

Recommendation 2: The Victorian Government amend the Family Violence Protection Act 2008 (Vic) [within 12 months] so that it:

Again I note that there is no specific recommendation in the FVRC about this particular matter, however FVRC_ report strongly advocates for improved information sharing regarding the outcomes of risk

assessments. This is a key matter. | support the

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

local legal services;

(c) local community family violence services, such as Women’s Health West;

(d) the magistrate during any [VO hearing; and

(e) Victoria Police.

• empowers the relevant minister or secretary to approve a Family Violence Risk Assessment and Risk Management Framework (and roles and responsibilities, standards and practices under it) for family violence risk assessment in Victoria

• sets out the principle that ‘prescribed organisations’ and agencies contracted by the Victorian Government to provide family violence services (if not otherwise prescribed organisations) are required to align their risk assessment policies, procedures, practices and tools with the Family Violence Risk Assessment and Risk Management Framework as approved by the relevant minister or secretary,

family’s proposal as a general proposition — that is the provision to front-line workers of risk assessments and up-dated risk assessments.

I recommend that in aligning risk assessment policies, as a consequence of the recommendations for the Royal Commission, family violence service providers be required to adopt the practice proposed by the family — that a front line worker provide each and every risk assessment to the applicant, the applicants legal representatives, the local community family violence services, the magistrate during an [VO hearing and Victoria Police.

Paragraph 345. That communications between the Courts, Victoria Police, community legal services and community family violence services be upgraded to computer-based electronic communications. This would have the result that information need to be typed into a computer once only and communications would be speedy and more reliable than fax.

Recommendation 7: The Victorian Government establish a secure Central Information Point.

Led by Victoria Police, it should consist ofa co-located multi-disciplinary team with representatives from Victoria Police, the courts (registry staff), the Department of Health and Human Services and the Department of Justice and Regulation (Corrections Victoria) who are authorised to obtain information from their respective databases [by 1 July 2018]. A summary of this information should be available to the Risk Assessment and Management Panels, the recommended Support and Safety Hubs, the 24-hour crisis telephone service Safe Steps and the Men’s Referral Service to permit effective assessment and management of risk in individual cases.

This has been recommended by the FVRC’s in their report (see Recommendation 7).

Paragraph 346. That in addition to the IVO, a copy of the handwritten and typed [VO application be electronically sent by the Court:

(a) to the relevant Police Station with the request for service; and

(b) to CDEB for uploading onto the LEAP.

database.

Recommendation 7 (stated above).

This has been recommended by the FVRC’s in their report (see Recommendation 7).

Paragraph 347. That the details of the allegations contained in the TVO application be uploaded to LEAP,

Recommendation 7 (stated above).

This may be covered by the FVRC’s in their teport (see Recommendation 7). However to ensure there is no doubt, J will make a specific recommendation about this. I note the evidence of AC Cornelius about a current project on this and the resources likely to be required to achieve the desired result.

Paragraph 348. That interim [VOs be sent to police immediately after being granted by a magistrate by electronic means such as a PDF document emailed to the officer in charge of the relevant Family Violence Team.

Recommendation 7 (stated above).

This has been recommended by the FVRC’s in their report (see Recommendation 7),

I note the improvements implemented to expedite service of orders referred to by the Chief Commissioner of Police.

Paragraph 349. That Victoria Police attempt to serve each interim [VO within 72 hours of it being made.

Recommendation 55: In order to improve the supervision of the service of family violence intervention orders, Victoria Police [within 12 months]:

-amend the Victoria Police Manual and Code of Practice for the Investigation of Family Violence to provide clearer guidance on and increased supervision of service of family violence intervention orders

• establish procedures for giving priority to the service of family violence intervention orders on high-risk perpetrators or those suspected of avoiding service—including tasking family violence teams to effect service or seeking relevant court orders, or both

• provide training at all appropriate levels on the amended requirements relating to service of orders regularly and publicly report on performance in the service of family violence intervention orders.

This has been recognised as an important issue by the FVRC's in their report (see Recommendation 55).

Paragraph 350. That Victoria Police process

Recommendation 55 (stated above).

This issue has been recognised by the FVRC’s

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

and attempt to serve each interim [VO where the circumstances indicate that the AFM is at high risk within 24 hours at the direction of the Magistrates’ Court.

in their report (see Recommendation 55).

Paragraph 351. That there be only one property collection per party supervised by police where an IVO is in place, and that any items not collected during that property collection are forfeited by the person who failed to collect them.

No specific recommendation, however see the recommendations 114 and 115 that touch on the issue of personal property.

Recommendation 114: The Magistrates’ Court of Victoria consider [within 12 months]:

• issuing a practice direction to encourage the use of personal property conditions in family violence intervention orders

• including specific questions about personal property conditions in the information form

that precedes the application for a family violence intervention order (FVIO1 form), Recommendation 115: Victoria Police amend the Victoria Police Code of Practice for the Investigation of Family Violence to provide guidance and examples in relation to when it is appropriate to seek personal property conditions in family violence intervention orders [within 12 months].

The issue of recovering personal property was recognised by the FVRC’s in their report (see Recommendations 114 and 115).

Paragraph 352. That further property collections may be authorised by a Family Violence Team police member of or above the rank of Sergeant having regard to prior risk assessments.

As above.

As above.

Paragraph 353. That property collections where the AFM has been assessed to be at high risk be directly supervised by Family Violence Team police members only,

As above,

As above.

Paragraph 354. That police members who attend property collections where an [VO is in place:

(a) be required to review available information in relation to the parties before attending including past L17 assessments, LEAP notes, the [VO application and whether there have been previous property exchanges;

(b) undertake a triage Red Flag List assessment during the property collection;

(c) actively utilise the property exchange as an opportunity for risk assessment and risk management, if indicated by the circumstances;

(d) give consideration to whether completion ofa Form L17 is required and complete the Form L17 if so required; and

(e) record the fact of their attendance and their observations of the parties on LEAP.

As above.

In my opinion this is a sound proposal.

I recommend that Victoria Police who attend property collections were an IVO is in place, be

(a) be required to review available information in relation to the parties before attending including past L17 assessments, LEAP notes, the IVO application and whether there have been previous property exchanges;

(b) undertake a triage assessment during the property collection;

(c) actively utilise the property exchange as an opportunity for risk assessment and risk management, if indicated by the circumstances;

(d) give consideration to whether completion of a Form LI7 is required and complete the Form L17 ifso required; and

(e) record the fact of their attendance and their observations of the parties on LEAP.

It may be appropriate to allow some flexibility in situations where members are attending property collections at very short notice and are not able to fulfil all of these requirements.

Paragraph 355. That a system be developed within Victoria Police for making a record that a party to a family violence incident has telephoned a Police Station, such that it is visible to members subsequently looking at LEAP regarding each party.

Recommendation 7 (stated above).

I agree with this proposal and recommend that examine the feasibility of developing a system for making a record that a party to a family violence incident has telephoned a Police Station, a record that is visible to members who subsequently check the parties on LEAP,

Paragraph 356. That, where there is supportive evidence, perpetrators of family violence should be charged by Victoria Police with relevant offences in relation to each and every incident of violence within seven days of the incident,

No specific recommendation.

Given the terms of the Code of Practice, I do not believe it appropriate to make a prescriptive recommendation on this matter, creating a record that is visible to members who subsequently check the parties on LEAP.

Paragraph 357. That perpetrators who breach an IVO should be:

(a) promptly subjected to a recorded interview;

No specific recommendation.

I agree with the submission that breaches of TVOs should, generally speaking, be treated as an escalation of the situation and that the consequences of this should be that there is a quick response. However it would not be appropriate _to prescribe precisely what the

Submission of the Thompson Family

Royal Commission into Family Violence

Recommendation in Finding

nature of the investigative response should be and within what timeframe.

(b) charged within seven days, as opposed to No specific recommendation. As above.

being released on summons for an

undetermined period pending charges; and

(c) in the event of a second and subsequent No specific recommendation. As above.

breach where the AFM is at high risk of future violence, charged and remanded or charged and released on bail.

Paragraph 358, That the AFM be informed by police if the perpetrator is not charged with breach of the [VO within seven days.

No specific recommendation.

T agree with this proposal and recommend that the AFM be informed by police if the perpetrator is not charged with breach of the IVO, I will not prescribe a precise time for that but I agree that seven days is reasonable.

Paragraph 359. That AFMs are educated to call 000 to report breaches of an [VO, as supported by AC Cornelius.

No specific recommendation.

I agree with this proposal and recommend that AFMs be educated/advised to call 000 to report breaches of an IVO.

Paragraph 360. That members of the public are educated to inform police, as supported by Professor Ogloff, when someone:

(a) threatens to kill a current or ex-domestic partner; and/or

(b) is stalking an ex-partner.

No specific recommendation.

I note my recommendation in the matter of Nicole Millar (COR 2010 2064) that Crime Stoppers has developed the Say Something campaign, which urges young people who witness acts of violence to be brave and look out for their friends by reporting incidents of violence confidentially. A website and iPhone app are available to help empower young people to report crime easily and online without identifying themselves. I therefore recommend that Victoria Police, together with Crime Stoppers, conduct a trial extending the Say

Something campaign to family violence.

Paragraph 361. That the investigation of a death not be undertaken by police at the same Police Station where members had significant contact with the deceased prior to the death.

No specific recommendation.

Paragraph 362. That Victoria Police develop and implement a system that provides oversight of the management of identified conflicts.

No specific recommendation.

I note that there is a specific system to oversight cases where there appear or appears to be a conflict. There is no need to make a further recommendation on this matter.

Paragraph 363. That Victoria Police and/or the Coroners Court appoint a Family Liaison Officer in relation to every Coronial investigation, including murder/suicides that are not investigated by the Homicide Squad.

No specific recommendation.

I note that there is already Family Liaison Officers at the Coroners Court. These officers are available to deal with matters such as this.

Paragraph 364. That the statements of police and civilians are sought concurrently in the investigation of a death where police were in substantial contact with the deceased prior to death.

No specific recommendation.

It is necessary to make a recommendation as to this. I note the evidence of the current practice.

I simply make the comment that it is clearly desirable that when in a situation where a conflict is identified, the statements of police officers are taken as soon as practicable.

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

connected with the death:

he following recommendation(s)

‘be I recommend that the Victorian Government, in implementing the recommendations of the

Royal Commission across the family violence sector, adopt the practice proposed by the

Thompson family i.e. that front line workers provide each and every risk assessment to the

applicant, the applicants legal representatives, the local community family violence services,

the magistrate during an IVO hearing, and to Victoria Police.

2. I recommend that Victoria Police implement, if necessary by changes to the Victoria Police Manual and/or the Code of Practice for family violence, a practice that requires police officers who attend property collections where an IVO is in place, to:

(a) review available information in relation to the parties before attending including past L17 assessments, LEAP notes, the [VO application and whether there have been previous property exchanges;

(c) actively utilise the property exchange as an opportunity for risk assessment and risk management, if indicated by the circumstances;

(d) give consideration to whether completion of a Form L17 is required and complete the Form L17 if so required; and

(e) record the fact of their attendance and their observations of the parties on LEAP.

It may be appropriate to allow some flexibility in situations where members are attending

property collections at very short notice and are not able to fulfil all of these requirements

3. I recommend that Victoria Police and the Magistrates’ Court of Victoria develop an information exchange system that will enable the details of the information contained in the intervention order applications made by self-represented, or privately represented parties, to be uploaded to LEAP in the same way as the information is uploaded in cases were police

are making the intervention order application.

4. I recommend that Victoria Police examine the feasibility of developing a system for recording a telephone call to a police station by a party to a family violence incident,

creating a record that is visible to members who subsequently check the parties on LEAP.

oF I recommend that the AFMs be informed by police if the perpetrator is not charged with breach of the IVO. I will not prescribe a precise time for that but I agree that seven days is

reasonable.

6. I recommend that AFMs be educated/advised by Victoria Police and other family violence

agencies to call 000 to report breaches of an IVO.

Pursuant to rule 64(3) of the Coroners Court Rules 2009, I order that the finding be published on the internet.

I direct that a copy of this finding be provided to the following: e® The Senior Next of Kin e Shine Lawyers on behalf of Wendy Thompson, John Thompson and Patrick Thompson

e The Victorian Government Solicitors Office on behalf of the Chief Commissioner of

Police

e Russell Kennedy on behalf of behalf of Constable Attard, Senior Constable Whichello and Constable Pringle

e Detective Senior Constable Adam Sharpe, Coroner’s Investigator

e Detective Sergeant Graham Ross, Coroner’s Investigator l express my condolences to the family and friends of Ms Kelly Thompson.

Signature:

He

JUDGE IAN GRAY Date: