Deceased
Abuk Derder Akek
Demographics
19y, female
Coroner
Deputy State Coroner Iain West
Date of death
2016-03-13
Finding date
2018-11-07
Cause of death
Stab wounds to the abdomen
AI-generated summary
Ms Abuk Derder Akek, a 19-year-old South Sudanese refugee, was fatally stabbed by her former de facto partner Makeny Banek during a violent assault at her home in Melton, Victoria on 13 March 2016. The finding identifies that Banek had a documented history of escalating domestic violence, controlling behaviour, and threats to kill. Key clinical and systemic lessons include: mental health services failed to adequately assess and manage the risk of intimate partner violence despite Banek's presentations with suicidal ideation and family violence history; mental health practitioners did not prioritise partner and child safety as required by contemporary guidelines; risk assessments were documented as 'low risk to others' without adequate reasoning or family violence-specific analysis; and specialist family violence training was absent from mental health and drug/alcohol services. The coroner emphasises the need for comprehensive family violence risk assessment frameworks, mandatory family violence education for mental health and substance use workers, appointment of specialist family violence advisors in major services, and culturally appropriate perpetrator behaviour change programs for diverse communities.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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IN THE CORONERS COURT Court Reference: COR 2016 1161
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008
Findings of: IAIN WEST, ACTING STATE CORONER
Deceased: ABUK DERDER AKEK
Date of birth: 2 March 1996
Date of death: 13 March 2016
Cause of death: Stab wounds to the abdomen
Place of death: 3/66 Unitt Street, Melton, Victoria
Background
The purpose of a coronial investigation
Matters in relation to which a finding must, if possible, be made
Identity of the deceased, pursuant to section 67(1)(a) of the Act
Medical cause of death, pursuant to section 67(1)(b) of the Act
Circumstances in which the death occurred, pursuant to section 67(1)(c)
of the Act
Comments pursuant to section 67(3) of the Act
Findings and conclusion
Ms Abuk Derder Akek (Ms Akek) was born in South Sudan on 2 March 1996. Ms Akek was one of five children in her family. She had migrated to Australia with her siblings as refugees from Sudan.
Ms Akek originally settled in Coffs Harbour, New South Wales with her siblings and attended an Anglican school in Coffs Harbour where she completed Year 11. She left Coffs Harbour in 2012 and travelled to Melbourne to live with a friend.
Ms Akek completed an Advanced Diploma of Legal Practice at Victoria University between 2012 and 2015. She had aspirations of further legal studies prior to her death.
Mr Makeny Banek (Mr Banek) was also born in South Sudan on 12 January 1992 and came to Australia with his family as a refugee fleeing the Second Sudanese Civil War.
Mr Banek struggled with schooling and securing work, although he did have some casual employment. He also became involved in illicit drug use and drinking alcohol to excess upon
leaving school and associating with troublesome peers.!
Ms Akek and Mr Banek met in 2012 in Melbourne. They commenced an intimate relationship and Ms Akek became pregnant. As a result, culturally, she was then considered to be Mr
Banek’s wife.? She moved into his family home in Kurunjang around 2013.
Ms Akek gave birth to their son, Youm Banek (Youm), on 16 January 2014. Youm was just two years old at the time of his mother’s death.
Shortly following the birth of their son, Mr Banek reportedly began to be emotionally and physically abusive towards Ms Akek and expressed jealousy over his belief that Ms Akek was socialising with her former partner.? Mr Banek also displayed controlling behaviour and explained his use of violence as being a result of Ms Akek reportedly returning home late
after being out of the house alone.* This conduct was viewed by Mr Banek as contravening
' Supreme Court of Victoria, R v Banek [2017] VSC 11 plea submissions transcript, 26
2 ibid,
3 Rv Banek [2017] VSC 11, 2]
13,
5 ibid
cultural norms, which stipulated that Ms Akek should only socialise with other married
women.?
On 22 August 2014, the police were contacted in relation to Mr Banek’s threatening behaviour towards his mother, Ms Vida Siliven (Ms Siliven). Upon police. attendance, Mr Banek was observed to be intoxicated and having afflicted damage to his mother’s residence.® Following this incident, Mr Banek was charged with criminal damage and a Family Violence Safety Notice was issued, protecting Ms Siliven and preventing Mr Banek from attending the
home.”
On 30 August 2014, Mr Banek woke Ms Akek and began striking her to the head, causing Ms Akek to temporarily lose conscious and causing injuries to her face.® On this occasion, Mr Banek also made threats to kill Ms Akek.? Mr Banek’s family intervened during this incident and Ms Akek reported the assault to the police, advising them that it had been the fourth time in which Mr Banek had been violent towards her.'° Following this incident, Mr Banek was arrested and interviewed in relation to offences of intentionally causing injury and breaching a Family Violence Safety Notice (FVSN) by attending his mother’s property.'' A Family Violence Intervention Order (FVIO) was then issued with conditions that Mr Banek not
perpetrate family violence towards Ms Akek or attend her residence.
On 6 September 2014, Ms Akek contacted police after Mr Banek assaultcd her by biting, choking and striking her, threatening to kill her, and imprisoning her inside their bedroom.” Following this assault, police arrested Mr Banek and he was remanded in custody.'* Ms Akek
tequired medical treatment for the injuries sustained during this incident.
On 24 September 2014, Mr Banek was sentenced to seven months imprisonment at Sunshine
Magistrate’s Court for assaulting Ms Akek and other charges.’5
A FVIO protecting Ms Akek and her son was also made on 24 September 2014, which prohibited Mr Banek from assaulting Ms Akek or attending her residence.!® On 10 December
6 Victoria Police, LEAP Records for incident 140260462, 4 ? Coronial Brief, Statement of Cameron Lacey dated 17 May 2016, 141 8 Coronial Brief, Statement of Abuk Akek dated 30 August 2014, 1
ibid ” ibid
1 Above n 6, 144
2 ibid
33 Coronial Brief, Bail application brief, 574
4 ibid
1S Coronial Brief, Certified extract from Sunshine Magistrates Court, 509
2014, however, an application for variation of the FVIO was granted with limited conditions, meaning that Mr Banek was able to attend Ms Akek’s residence but was prohibited from committing family violence towards her.” This FVIO remained in place until 9 December 2015 and was not renewed.!® As such, there was no FVIO in place at the time of the fatal
incident.
Following Mr Banek’s release from prison in March 2015, Mr Banek resumed living with Ms Akek and his family.”
Whilst no further incidents of family violence were reported to police, statements from friends and family of Ms Akek and Mr Banek note several further episodes of violence. Around January 2016, Ms Akek and her son left Mr Banek’s family home and began renting a flat in Melton with her friend, Ms Ayen Lueth.?? Ms Akek confided in Ms Lueth that she had made the decision to find alternative accommodation as Mr Banek’s violence had continued to escalate and she had become concerned for her safety.2! Ms Akek also noted that Mr Banek had made threats to kill both her and their son.”?
Ms Akek’s separation from Mr Banek caused him significant distress, his brother commented
that Mr Banek had been “very emotional and he was getting angry’ 3
On 20 February 2016, Ms Akek attended Mr Banek’s family home and requested that her friend, Ms Abut Maker, pick her up following an argument with Mr Banek.”* Upon arrival, Mr Banek began to harass Ms Maker by asking her where they were going and said that he
“could kill her right now, bash her to death but you are here "425
Ms Maker discussed concerns with Ms Akek regarding her safety, but Ms Akek reportedly advised that she wished to stay in contact with Mr Banek as she wanted her son to’ have a
relationship with his father and she hoped to provide Mr Banek with support.”
Following Ms Akek’s separation from Mr Banek, it is reported that Mr Banek had disclosed.
his intentions to end his life to Ms Akek and had made one attempt to end his life.?? During
18 ibid, " ibid, 18 ibid,
'° Coronial Brief, Statement of Vida Siliven dated 18 March 2016, 84 20 Coronial Brief, Statement of Ayen Lueth dated 13 March 2016, 66
21 ibid
22 ibid,
23 Coronial Brief, Statement of Jima Banek dated 13 March 2016, 1 4 Coronial Brief, Statement of Adut Maker dated 4 May 2016, 63
® ibid 6 ibid
this period, Ms Akek appears to have provided Mr Banek with considerable support and
escorted him to hospital following his suicidal ideations.”®
On Saturday, 12 March 2016, the day before the murder, Mr Banck and Ms Akek had an argument regarding his failure to return their son from a walk in a timely fashion.”” Mr Banck had not been contactable for some hours and, when he did finally return with their son, he was drunk. That evening, Mr Banek returned to his friend Madhan Deng’s home at Rigel Street in Melton. He had met Mr Deng some weeks prior and had sometimes stayed at his home. Mr
Deng noticed that Mr Banek seemed upset at the time.*°
Ms Akek’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic) (the Act), as the death occurred in Victoria and was violent, unexpected and not from natural
causes.?!
The jurisdiction of the Coroners Court of Victoria is inquisitorial“? The Act provides for a system whereby reportable deaths are independently investigated to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death
occurred,*3
It is not the role of the coroner to lay or apportion blame, but to establish the facts.** It is not the coroner’s role to determine criminal or civil liability arising from the death under
investigation, or to determine disciplinary matters.
The expression “cause of death” refers to the medical cause of death, incorporating where
possible, the mode or mechanism of death.
For coronial’ purposes, the phrase “circumstances in which death occurred,” refers to the context or background and surrounding circumstances of the death. Rather than being a
consideration of all circumstances which might form part of a narrative culminating in the
7 Above n 18, 84
8 ibid
3 Coronial Brief, Statement of Madhan Deng dated 14 March 2016, 74
39 ibid
31 Section 4 Coroners Act 2008
32 Section 89(4) Coroners Act 2008
33 See Preamble and s 67, Coroners Act 2008 34 Keown v Khan (1999) 1 VR 69
35 Section 69 (1)
36 Section 67(1)(c)
death, it is confined to those circumstances which are sufficiently proximate and causally
relevant to the death.
The broader purpose of coronial investigations is to contribute to a reduction in the number of preventable deaths, both through the observations made in the investigation findings and by the making of recommendations by coroners. This is generally referred to as the Court’s
“prevention” role.
Coroners are also empowered:
(a) to report to the Attorney-General on a death;*”
(b) to comment on any matter connected with the death they have investigated, including
matters of public health or safety and the administration of justice;** and
(c) to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of
justice.?? These powers are the vehicles by which the prevention role may be advanced.
All coronial findings must be made based on proof of relevant facts on the balance of probabilities.° In determining these matters, I am guided’ by the principles enunciated in Briginshaw v Briginshaw.| The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about individuals, unless the evidence
provides a comfortable level of satisfaction that they caused or contributed to the death.
In conducting this investigation, I have made a thorough forensic examination of the evidence including reading and considering the witness statements and other documents in the coronial
brief.
Identity of the Deceased, pursuant to section 67(1)(a) of the Act
born 2 March 1996.
3? Section 72(1)
38 Section 67(3)
Section 72(2) .
Identity is not in dispute in this matter and requires no further investigation.
Medical cause of death, pursuant to section 67(1)(b) of the Act
34,
On 14 March 2016, Dr David Ranson, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy upon the deceased’s body. Dr Ranson provided a written report, dated 1 September 2016, which concluded that Ms Akek died from
stab wounds. to the abdomen.
A full toxicological analysis was negative for alcohol and other detectable substances.
Dr Ranson commented that:
(a) the main injuries to Ms Akek included stab wounds to the abdomen, right hand, left wrist
and neck;
(b) external examination showed bruising and abrasions to the head which indicated that multiple applications of force had been applied to the head, upper part of the face, cheeks and top of the head;
(c) an avulsion-type laceration to the scalp in association with the hair braids was likely a
result of Ms Akek’s hair being pulled; and
(d) the three incised stab wounds to the front abdomen all featured deep penetrating injuries
and were the immediate cause of death.
I accept the cause of death proposed by Dr Ranson.
Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act
On Sunday, 13 March 2016, Ms Akek was at home with her housemate Ms Ayen Leuth.
Ms Leuth left the house at approximately 2.10 pm to visit her in laws who lived in Derrimut.*” Mr Banek’s mother, Ms Vida Siliven arrived at the house at the same time Ms Leuth was departing to pick up Youm. Ms Siliven took Youm back to her home in Kurunjang for the
afternoon.
Mr Banek was staying at a friend’s house, Mr Madhan Deng, on the day of the fatal incident
and at approximately 2.30 pm he went to Ms Akek’s home to confront her about issues in
their relationship. Mr Banek went to the lounge room and sat on the couch to watch television. As soon as he sat down, an argument ensued between Ms Akek and Mr Banek.*
The argument escalated and became violent.
Mr Banek used his fists to strike Ms Akek on the head and body, he kicked her and choked her. The assaults took place throughout the unit, at the front door, the hall, kitchen and Ms Akek’s bedroom.
During the course of his attack on Ms Akek, Mr Banek picked up a stereo speaker and tried to hit her with it but it was ineffective: While Mr Banek and Ms Akek were both in the kitchen, Mr Banek obtained a knife and began to stab Ms Akek.? Ms Akek tried to defend herself to no avail, as Mr Banek stabbed her three times in the abdomen and once to her neck.® One
stab wound to the upper abdomen penetrated the aorta.
Mr Banek then proceeded to carry Ms Akek’s body to her bedroom, placing her on the bed and covering her with a blanket.*’ He then cleaned the unit. He put the cleaning items and the
stereo speaker into a plastic garbage bag.
Mr Banek left the unit taking the garbage bag and knife with him. He walked north along Emil Court, Melton stopping at a park at the end of the court. He put the garbage bag into a bin and threw the knife towards a fence.** He then continued walking towards his friend’s
home, arriving at approximately 4.30pm.”
During the course of his attack on Ms Akek, Mr Banek had lost his mobile phone so he retuned to the park to see if he could locate it there. He did not locate the phone, and subsequently returned to Ms Akek’s home.° He went inside but could not find his phone. He saw Ms Akek’s phone, and took it. He also saw an imitation single rose that he had bought for Ms Akek on Valentine’s Day. He picked up the rose and placed it on the bed beside Ms Akek’s body.!
Mr Banek then returned to Mr Deng’s home for a second time, showered and went to sleep on
the couch.>? At some point after taking Ms Akek’s phone, he used it to ring his mother but
“4 Coronial Brief, Transcript of interview with Makeny Banek on 13 March 2016, 389 *% ibid, 421
4? ibid, 422
48 ibid, 401
50 shid, 427
51 ibid, 422
2 Above n 43, 430
said nothing when she answered.’ He declined to answer any calls made to the phone until his brother Jima Banek rang at 6.38pm.*4 Mr Banek’s brother questioned why he had Ms
Akek’s phone, he said he was going to return it to her later.
Shortly thereafter, Mr Banek’s brother and mother, troubled that something was awry, went to Ms Akek’s flat. They found Ms Akek on her bed, noticed she was not breathing and had no pulse, and rang for an ambulance.> When performing CPR at the direction of the triple-zero operator, Ms Siliven lifted the blanket and to her horror noticed blood and the stab wounds.® Emergency services arrived at 6.57pm and after checking Ms Akek’s body, they found no signs of life.>”
Later that evening, police found Mr Banek asleep on the couch at Mr Deng’s home. He
confessed immediately and was arrested and charged with Ms Akek’s murder.*®
expected to be a place of trust, safety and protection.
wounds to Ms Akek’s abdomen and causing her death constitutes ‘family violence.’
53 Above n 18, 82
5 Above n 18, 83
%6 ibid, 84
*? Coronial Brief, Statement of Peter Crane dated 13 March 2016, 92
58 Coronial Brief, Statement of Detective Senior Constable Scott Riley dated 2 June 2016, 135
*° Family Violence Protection Act 2008, section 9(1)(b)
6 Family Violence Protection Act 2008, section 5(1)(a)(i)
61 The Coroners Prevention Unit is a specialist service for Coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety
® The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths.
The CPU identified the presence of a number of risk factors known to increase the risk of fatal family violence between intimate partners. Mr Banek had a history of perpetrating family violence against Ms Akek, including controlling and possessive behaviour and physical violence. Furthermore, Mr Banek displayed high risk behaviour such as multiple instances of
physically assaulting Ms Akek and threatening to kill her and their son.
At the time of Ms Akek’s death, Mr Banek was also unemployed, had experienced long period of unemployment in the years leading up to the fatal incident and had expressed his inability to maintain employment as a stressor. These perpetrator specific risk factors
indicate an increased risk of a victim being killed.
Family violence and cultural issues
$2.
The CPU further identified that cultural factors may have contributed to Ms Akek’s death.
Based on the information provided by his family and friends, Mr Banek held traditional cultural beliefs about marriage and gender roles. He believed that men should be head of the household and women should be submissive. Such attitudes may have contributed to, but
certainly do not excuse, his perpetration of family violence against his former partner.
Research undertaken with Sudanese communities in Australia identified that the changed gender and family roles that occur on resettlement in Australia can contribute to family violence.“ Some Sudanese men felt that they were disempowered and no longer respected by women. Australia was seen as giving more rights and freedoms to women through the social and legal systems, which threatened what they believed to be patriarchal norms and led to
male authority being undermined.®
Consistent with this research, Ms Akek appears to have held more westernised views about matriage and her social and economic rights in Australia. Whilst Ms Akek and Mr Banek were not married, their relationship breakdown resulted from a number of conflicting values held by both parties. Ms Akek had an independent source of income, had completed further
tertiary study, and was not willing to allow Mr Banek to return to the family home when it
Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community
8 Orygen Youth Health medical file, Total Care Progress Notes, Volume 2 8 Association for Services to Torture and Trauma Survivors. Research Report: Exploring the Nature and
Understanding of Family and Domestic Violence within Sudanese, Somalian, Ethiopian, Liberian and Sierra Leonean Communities and its Impact on Individuals, Family Relations, the Community and Settlement (2009)
55 Family violence within the Southern Sudanese community: Project evaluation report (2008). Migrant Information Centre, Eastern Melbourne
54,
pleased him. This was inconsistent with Mr Banek’s cultural expectations that he was head of
the house and will make decisions for the family.
The Royal Commission into Family Violence (the Commission) received submissions on existing prevention and early intervention initiatives within culturally and linguistically diverse (CALD) communities. Some of these initiatives involve the development of community based projects aimed at addressing gender equality and respectful relationships within certain cultural groups including, the Sudanese community.“° I support the development of such community based prevention initiatives, although this case does not
provide the basis for a formal recommendation on this point.
In addition to forms of family violence experienced in all communities, there are some specific forms of family violence experienced by women in some CALD communities, including dowry-related violence. The stress of saving up to pay a dowry to Ms Akek’s family and long periods of unemployment were significant stressors for Mr Banek.®” This was a contributing factor in Mr Banek’s violent outbursts towards Ms Akek but did not excuse his
behaviour.
I note that both mainstream support services and specialist family violence services struggle to provide culturally appropriate, responsive services for CALD victims, and the services that are designed specifically for CALD victims are limited. There are also limited opportunities for perpetrators from CALD communities to participate in behaviour change programs that
are culturally specific or in their own language.
Support service engagement
Ms Akek and Mr Banek were both engaged with several support services in the lead up to the fatal incident. Studies into women experiencing violence within CALD communities have identified lower rates of engagement with family violence support services. These studies suggest that this may be due to beliefs that the involvement of these organisations may increase the level of violence the individual is experiencing or that the service may not be
accustomed to or appropriate to their particular cultural needs. Ms Akek may have been
66 Royal Commission into Family Violence: Report and Recommendations (March 2016), Volume V, Chapter 26, 103 8? Above n 1, 25
68 Royal Commission into Family Violence: Report and Recommendations (March 2016, Summary, 34
6 Fisher, Colleen. The exploration of the nature and understanding of family and domestic violence within Sudanese, Somalian, Ethiopian, Liberian and Sierra Leonean Communities and its impact on individuals, family relations, the community and settlement. Perth, Australia: Association for Services to Torture and Trauma Survivors, 2009
more receptive to engaging with a family violence support service if those services specialised
in culturaily appropriate support.
Mr Banek had engaged with a number of mental health support services, including drug and alcohol referrals in the two month period immediately prior to the fatal incident. Following suicidal ideations, Mr Banek was taken to his GP by Ms Akek and his brother Jima Banek and referred to Sunshine Hospital for assessment. Following assessment at Sunshine Hospital, Mr
Banek received a referral to Orygen Youth Health for mental health treatment.
Throughout the course of his mental health treatment, Mr Banek was assessed as being of no risk of harm to others.” The CPU investigations identified that while risk assessments had been performed, the extent of these assessments and reasoning behind assessing Mr Banek as
a low risk of harm to others were not provided.
I note that guidelines published in 2011 to support Victorian mental health services in responding to family violence state that when working with an individual who uses violence against a family member, mental health practitioners are required to “consider the safety of the partner and children as the priority’.’”! The guidelines further require mental health services to acknowledge the disclosure of violence and then work to raise the perpetrators awareness of their behaviour and to assist them to work “towards accepting their behaviour and then agreeing on actions to change their behaviour’.” Mental health services are also
required to refer all information relating to the violence to the clinical treatment team.”
I further note that whilst the engagement of mental health support services provided to Mr Banek met the required guidelines and professional responsibilities in place at the time of his treatment, this case highlights the need for family violence-specific education to be undertaken in the mental health sector.
In light of the findings from the Royal Commission, in which it was identified that the
v4 and
“mental health sector is currently ill-equipped ta identify and address family violence often fails to employ a system-focused family violence analysis. A more comprehensive family violence risk assessment may have assisted in the establishment of ongoing family
violence specific safety plans and coping strategies for Mr Banek.
7 Statement of Dr Brian O’Donoghue (Orygen Youth Health) dated 8 January 2017, 2-3
” ‘The Department of Health, Service guideline on gender sensitivity and safety: Promoting a holistic approach to wellbeing, (Victoria, 2011), 12
? ibid, 11
*3 ibid, 11
% ibid, 30
I take this opportunity to support the Royal Commission’s conclusions and related recommendations in relation to risk assessment and risk management of family violence in
mental health and drug and alcohol services.
Specifically, I endorse the Royal Commission’s recommendations that organisations should adopt minimum standards and core competencies in identifying, risk assessment and risk management practice in all mainstream and specialist services. This includes providing training to medical, mental health, drug and alcohol workers in the provision of services to
family violence affected clients.”
Further to this, Recommendations 97 and 98 provide for the establishment of specialist family violence advisors within major mental health and drug and alcohol services” and guidelines on family violence risks associated with discharging or transferring care of a person receiving
mental health services. 7”
Recommendation 99 focuses on collaboration between agencies to share casework models and ensuring that mental health and drug and alcohol services are represented on risk
assessment and management panels.”
In an effort to address effective interventions for perpetrators of family violence, the Royal Commission also identified that further research, trials and evaluation needed to be done to help perpetrators understand the effects of violence on their children and to become better fathers.” This includes adopting practice models amongst services like men’s behaviour change, mental health, drug and alcohol, to better coordinate family violence interventions
and deliver programs to perpetrators from diverse communities and with complex needs.
In light of the comprehensive nature of the Royal Commission’s work in this regard, I support the recommendations put forward, specifically in this case as they relate to the issue of assisting mental health and drug and alcohol services with education and training to identify
family violence risks and manage these risks appropriately.
% ibid, Recommendation 98
7 ibid, Recommendation 97
78 ibid, Recommendation 99
9 Ibid, Recommendation 87
He was sentenced to 23 years’ imprisonment with a non-parole period of 18 years.®°
required.
a) the identity of the deceased was Abuk Derder Akek, born 2 March 1996;
b) the death occurred on 13 March 2016 at 3/66 Unitt Street, Melion, Victoria, from stab
wounds to the abdomen; and c) the death occurred in the circumstances described above.
the internet.
Signature:
IAIN WEST ACTING STATE CORONER Date: 7 November 2018
8 R y Banek [2017] VSC 11, 32
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