Finding into death of Risto Pedevski

IN THE CORONERS COURT Court Reference: COR 2014 5946

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

Findings of: CAITLIN ENGLISH, ACTING STATE CORONER

Deceased: RISTO PEDEVSKI

Date of birth: 15 July 1935

Date of death: 23 November 2014

Cause of death: I(a) Head and Neck Injuries

Place of death: 66 Fehon Street, Yarraville, Victoria

TABLE OF CONTENTS

’ 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

HER HONOUR: BACKGROUND

1. | Mr Risto Pedevski (Mr Pedevski) was born in Macedonia on 15 July 1935. He married Ms Danica Pedevska (Mrs Pedevska) in Macedonia in 1964 and their son, Slave Pedevski (also known as George), was born in 1965. Mr Pedevski migrated to Australia with his wife and

son, George, in approximately 1967.

2. A second child, Valentina Pedevski, was born to the relationship in August 1980 and she

unfortunately passed away in approximately 1999 due to a fatal motor vehicle collision.

3. Mr Pedevski had lived most of his life in Williamstown, Victoria and later moved to Yarraville, Victoria in approximately the early 1990s. Mr Pedevski worked as a labourer in

the western suburbs of Melbourne until he retired in approximately 2002.

4. George was aged 49 years old when he killed Mr Pedevski. He did not complete his secondary school education and commenced training within the field of catering and hospitality. He did not complete his training in this field. He was employed briefly as a factory worker for Kraft Cheese and as a wool tester when aged in his 20s. Since finishing employment as a wool tester, George has been unemployed and on a disability support

pension.

5. George was diagnosed with schizophreniform disorder and schizoid personality disorder in January 1988.' He has had ongoing delusional beliefs that his parents were ‘imposters’ and displayed aggressive behaviour towards them. George also experienced olfactory hallucinations, often believing that he could smell gas.” For approximately 20 years, Dr Rob Peterson of the Saltwater Clinic of the Mercy Mental Health Service primarily managed

George’s illness.

6. On 4 December 1996, George threatened to kill his parents if they informed psychiatric services that he was not taking his medication.? During this incident, Mr Pedevski contacted psychiatric services who attended the family home with the assistance of police and George was involuntarily admitted to hospital for mental health treatment. George was described on

this occasion as being aggressive towards police and ‘wielding weapons, including a claw

! Psychiatric report of Dr Lester A. Walton dated 27 July 2015, 1

2 An olfactory hallucination (also known as phantosmia) makes you detect smells that aren't actually present in your environment

3 Medical records for George Pedevski provided by the Royal Melbourne Hospital

hammer which he had concealed in a plastic shopping bag’. Medical staff described George’s parents as being fearful and afraid of George following this incident. Reports of similar threats were also recorded throughout George’s engagement with mental health services,

indicating that this was an ongoing form of violence used by George against his parents.‘

7. On 8 August 2002, whilst in South Australia, George was found not guilty of the sexual assault of three women by reason of mental impairment and placed in the forensic psychiatric hospital, James Nash House, in Adelaide. At the time of his confinement within James Nash

House, George was treated with antipsychotic medication and his condition improved.>

8. George was then transferred to Glenside Psychiatric Hospital in July 2003 and by

approximately 2004, he was released and returned to Melbourne.°

9. Following his return to Melbourne, George was hospitalised with involuntary admissions for psychiatric care and subject to numerous community treatment orders.’ A psychiatric review leading to his psychiatric admission found that George was experiencing an exacerbation of his chronic paranoid schizophrenia related to his noncompliance with his medication.

George’s admissions to psychiatric care were often associated with aggressive and threatening

behaviour towards his parents, Mr Pedevski and Mrs Pedevska.*

10. As a result of his mental illness, George experienced both auditory and olfactory hallucinations. During these hallucinations George was convinced that he could smell toxic gases emanating from the water heater. These beliefs would frequently cause him to turn the gas off when living with his parents and prevent his father from turning it back on. This was a

cause of repeated conflict between Mr Pedevski and George.

11. On 10 August 2012, George presented to Western Health and was observed to be experiencing a ‘deterioration of mental state, poor self-care [sic] and delusions of persecution (tv channels watching him) *9 George was transferred to Werribee Mercy Hospital, Mental Health Program (Werribee Mercy) where he was admitted as an inpatient

and placed on a Community Treatment Order.

4 Medical records for George Pedevski provided by the Royal Melbourne Hospital, Werribee Mercy Hospital and Western Health

5 Psychiatric report of Dr Lester A. Walton dated 27 July 2015, 1

6 Psychiatric report of Dr Lester A. Walton dated 27 July 2015, 1

7 A treatment order is made by the Mental Health Tribunal in Victoria and enable a patient to be treated in the community or to be taken to, detained and treated in a designated mental health service.

8 Psychiatric Report for Slave (George) Pedevski prepared by Dr Grant Lester dated 19 August 2015, 4

9° Medical records for George Pedevski provided by the Werribee Mercy Hospital

72;

George primarily received case management and psychiatric care whilst engaged with Werribee Mercy and staff were made aware of the violence he had perpetrated towards his parents.'° In August 2012, Mr Pedevski had informed Werribee Mercy staff that George ‘calls to the house unannounced/unexpectedly to basically intimidate them into giving him money’ and Werribee Mercy records note that ‘he (George) has visited his parents and threatened

them with violence’ ."'

On 18 June 2013, George was discharged from Werribee Mercy and his Community Treatment Order was revoked. Records from Werribee Mercy indicate that the reasons for the discharge included that George was reluctant to engage with any case management services and expressed a strong preference to be managed by his private psychiatrist, Dr Rob Peterson,

who agreed to accept him.”

Records from Werribee Mercy however, also provided conflicting accounts of the assessment of George’s risk to himself and others. Reports made to the Mental Health Review Board in support of revoking his Community Treatment Order, noted that George ‘denies violent or suicidal ideas’.'3 Tn contrast, the June 2013 discharge summary notes that George’s parents were unable to manage him and that ‘he will attend their house unannounced and uninvited and demand food/money. The parents are frightened and unable to refuse’. There were also

notes in the discharge summary about George assaulting his mother in the past. \4

Between June 2013 to August 2013, George was managed by private psychiatrist, Dr Peterson. Whilst George initially engaged with Dr Peterson following his discharge from Werribee Mercy, his last contact with Dr Peterson was on 29 August 2013 and he subsequently failed to attend two appointments after this date. Dr Peterson indicated in a statement to the Court that he reported George’s non-attendance after 29 August 2013 to Werribee Mercy Mental Health clinicians on 24 October 2013, however this is not reflected in

the medical records provided by Werribee Merey.!5

On 1 November 2013, Mr Pedevski was admitted as an inpatient at Western Health due to

chronic back pain problems.'® Social workers within Western Health involved with preparing

10 Medical records of Risto Pedevski provided by Werribee Mercy Hospital

"ibid

!2 Statement of Associate Professor Dean Stevenson dated 12 March 2019, 2

3 ibid \4 ibid

15 Medical records for George Pedevski provided by the Werribee Mercy Hospital; Letter from Dr Rob Peterson dated 15 March 2017, 2 16 Medical records of Risto Pedevski provided by Western Health

Mr Pedevski for discharge conducted risk assessments but appeared to focus on the risk posed

to staff by George rather than the safety of Mr Pedevski.

Notes from Western Health records indicate that Mr Pedevski’s social workers were aware that he had experienced aggressive behaviour and verbal abuse from George in the past.'7 In particular the Western Health in-home support services were concerned about the safety of their staff entering Mr Pedevski’s home following his planned discharge on 29 January

2014.18

On 29 January 2014, Mr Pedevski was discharged from Western Health with support provided by several Western Health services including the Royal District Nursing Service, Western Aged Care Assessment Service (ACAS), Hospital Admission Risk Program (HARP) and the Immediate Response Service (IRS).

Upon his discharge from Western Health on 29 January 2014, Mr Pedevski was still providing intermittent support to George by providing him food, money and accommodation

in his home.

By the middle of 2014, the only services from Western Health that were supporting Mr Pedevski were .the HARP and the IRS. In July 2014, Mr Pedevski was discharged from the

HARP and the Salvation Army were providing case management support to Mr Pedevski.

In review of George’s mental health, it appears that George did not have or develop any insight into his illness. He did not believe he had a mental illness, resisted ongoing service

involvement and believed that he did not require medication." George was offered multiple

opportunities to engage with case management but failed to do so.

George lived an itinerant lifestyle up until the fatal incident, alternating between sleeping on the street, in motel accommodation and staying with his parents. Several attempts were made to secure housing for him from 2012 until the fatal incident, however George either disengaged with these services or absconded from the properties, claiming that he could smell

gas and that it was unsafe for him to remain.

17 This behaviour included throwing and breaking property within Mr Pedevski’s household and verbal abuse ; Medical records of Risto Pedevski provided by Western Health

18 ibid

'9 Medical records of Risto Pedevski provided by Werribee Mercy Hospital; Psychiatric Report for Slave (George) Pedevski prepared by Dr Grant Lester dated 19 August 2015

As a result of a lack of alternative housing options and George’s reluctance to remain in public accommodation, Mr Pedevski and Mrs Pedevska continued to regularly provide

housing for George up until the fatal incident.

THE PURPOSE OF A CORONIAL INVESTIGATION

Mr Pedevski’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.??

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 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:

20 Section 4 Coroners Act 2008

21 Section 89(4) Coroners Act 2008

22 See Preamble and s 67, Coroners Act 2008 23 Keown v Khan (1999) 1 VR 69

24 Section 69 (1), Coroners Act 2008

5 Section 67(1)(c), Coroners Act 2008

(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.

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

On 23 November 2014, Danica Pedevska visually identified the deceased to be Risto Pedevski, born 15 July 1935.

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

On 24 November 2014, Dr Yeliena Baber, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy upon the deceased’s body. Dr Baber provided a written report, dated 4 February 2015, which concluded that Mr Pedevski died

from head and neck injuries.

%6 Section 72(1), Coroners Act 2008

27 Section 67(3), Coroners Act 2008

28 Section 72(2), Coroners Act 2008

29 Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152

39 (1938) 60 CLR 336

a7.

Toxicological analysis of the post mortem samples taken from Mr Pedevski identified the presence of paracetamol?! (11 mg/L), pregabalin®? (5.2 mg/L), irbesartan®® (1.6 mg/L) and hydrochlorothiazide™ (0.7 mg/L).

Dr Baber commented that:

(a) the main injuries comprised of at least 12 separate injuries to the face and neck with two underlying skull fractures, bruising to the skin of the neck and underlying strap muscles

and fractured hyoid bone, C7 vertebra and jaw; and

(b) there was also evidence of defense type injuries to the dorsum of both hands and a

fractured left clavicle.

L accept the cause of death proposed by Dr Baber.

Circumstances in which the death occurred, pursuant to section 67(1)(c) of the Act

On Friday 21 November 2014 at approximately 10.12am, George checked in at the Palms Motel in Footscray. He stayed there for most of the day. At 9.52pm, he attended the reception desk and returned the room key.*> George returned to his parents’ home in Yarraville at some point after leaving the Palms Motel because Mrs Pedevska could hear him

snoring in his bedroom.*°

In the early morning of Saturday 22 November 2014, George left his parent’s home in Yarraville and at approximately 9.37am, he returned to the Palms Motel and had a brief conversation with a staff member at reception before leaving again. He did not book a room

for that night.>”

On the same day between approximately 6.30pm and 7.00pm, George was seen walking towards his parent’s home in Yarraville by his neighbours.** At some point after his return to his parent’s home in Yarraville, he switched off the gas hot water system. He had repeatedly

done the same thing in the past as he believed he could smell gas. This was a constant source

31 Paracetamol is an analgesic drug available in many proprietary products commonly by itself

32 Pregabalin is an analog of the inhibitory neurotransmitter gamma-aminobutyric acid and is used clinically as an analgesic, anticonvulsant and anxiolytic agent

33 [rbesartan is a synthetic angiotensin II receptor antagonist used to treat high blood pressure

34 Hydrochlorothiazide is a thiazide derivative used as a diuretic and antihypertensive agent

35 Coronial Brief, Appendix 4 — Palms Motel booking records, 187-188; Coronial Brief, Appendix 5 — Palms Motel CCTV logs, 190

36 Coronial Brief, Statement of Danica Pedevska dated 10 December 2014, 97

31 Coronial Brief, Appendix 4 — Palms Motel booking records, 187-188; Coronial Brief, Appendix 5 — Palms Motel CCTV logs, 190

38 Coronial Brief, Statement of Vasko Stojcevski dated 23 November 2014, 114

44,

of friction between George and his parents, as, on occasion, tradesmen were required to assist to turn the gas back on. George had turned the gas off about twenty times since ceasing to

take his anti-psychotic medication in approximately August 2013.”

The next morning, Sunday 23 November 2014, Mr Pedevski was woken by his wife at about 8.00am. He took his medication and ate his breakfast. At about 10.30am, he went to the rear yard to hang washing on the clothesline, while his wife remained in the kitchen preparing

food.*°

Mr Pedevski met George in the rear yard. They had a heated conversation regarding the hot water system and Mrs Pedevska heard her husband tell their son, ‘Don’t touch the hot water

system. If you don’t switch it [back] on, I'll go to police.

While Mr Pedevski began to hang out the washing, George removed a hammer from a plastic bag. He then struck his father repeatedly to the head and face with the hammer. Mr Pedevski tried to protect himself, which resulted in defensive injuries to his hands. During the struggle, Mr Pedevski fell to the ground with his walking frame falling on top of him. George then

fled, leaving the hammer behind.”

After preparing food and a period of rest on the couch, Mrs Pedevska became concerned that her husband had not come back inside. She went outside and found him in the rear yard. She

saw flies over his face and the hammer nearby.

At approximately 1.30pm, Mrs Pedevska contacted emergency services for assistance and Ambulance paramedics arrived at 1.39pm. Ambulance paramedics used an electrocardiogram (ECG) monitor which confirmed that Mr Pedevski was deceased. Ambulance paramedics did

not attempt resuscitation due to the ECG result and observations of the onset of rigor mortis.4

39 Coronial Brief, Statement of Danica Pedevska dated 10 December 2014, 95

°° ibid, 97

4! Coronial Brief, Statement of Danica Pedevska dated 23 November 2014, 91

2 Psychiatric report of Dr Lester A. Walton dated 27 July 2015, 2

8 Coronial Brief, Statement of Danica Pedevska dated 23 November 2014, 91

44 Coronial Brief, Statement of Benjamin Bretherton dated 23 November 2014, 129

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

Family violence and mental health

The unexpected, unnatural and violent death of a person is a devastating event. It is important to recognise that violence perpetrated by a family member is particularly shocking, given the

family unit is expected to be a place of trust, safety and protection.

The relationship between Mr Pedevski and George fell within the definition of family member under the Family Violence Protection Act 2008. There was also a history of family

violence prior to the fatal incident and the fatal incident itself constituted family violence.*®

Whilst George’s violent behaviour towards his parents occurred due to a disordered mental state, Carers Victoria note that in the context of the relationship between care givers and those that they care for, ‘regardless of the insight a person may have about their use of violence, the impacts on people living with it can mirror those of other family violence survivors. Risk can be just as heightened and repercussions on health and wellbeing equally significant to people

experiencing deliberate and coercive violence. et

I also note that elder abuse is a form of family violence and can be physical, sexual, emotional, psychological or economic in nature. Ihave also considered the findings and recommendations of the Royal Commission into Family Violence (the Royal Commission) which was established on 22 February 2015. The Royal Commission findings note that “while women are over-represented as victims in prevalence data, the proportion of older men who experience family violence is higher than for younger men. Older people can also be at particular risk of economic or financial abuse. The perpetrator is often the victim’s son or

daughter.”

In light of Mr Pedevski’s death occurring during an incident of family violence, I requested that the Coroners’ Prevention Unit (CPU) examine the circumstances of Mr Pedevski’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD)* and

to review George’s mental health treatment.

45 Family Violence Protection Act 2008, section 8(1)(c) 46 Family Violence Protection Act 2008, section 5(1)(a)(i) 47 Victoria, Royal Commission into Family Violence, Volume V: Report and recommendations (2016), 67

48 Ibid ® 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 deaths

VSREVD provides assistance to Victorian Coroners to examine the circumstances in which family violence occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together

$2.

An in-depth family violence and mental health investigation and was conducted by the CPU in this matter and I requested materials from several key service providers that had proximate

contact with George and Mr Pedevski prior to his death.

The Royal Commission found that family violence is most commonly recognised in intimate partner relationships and that violence that occurs between other types of familial relationships, such as that between a parent and child, is regularly overlooked. This is also the case within the broader social service sector, who may not possess the experience or knowledge to identify elder abuse or violence outside of intimate partner relationships as family violence.>! The Royal Commission also found that the lack of understanding held by service providers in relation to elder abuse can ‘create missed opportunities to intervene and

provide support to victims’, such is the case in the death of Mr Pedevski.”

Aged care facilities and hospitals were identified by the Royal Commission as playing a critical role in the identification and response to elder abuse. The Royal Commission found that health professionals often fail to identify elder abuse given a lack of understanding of

what constitutes elder abuse and that it can present subtly.

On the available evidence, it is apparent that service providers engaged with George and Mr Pedevski did not recognise Mr Pedevski’s reports of abuse, threats, and intimidation as indicators of elder abuse and family violence. How those agencies failed to make proper enquiries, adequately assess risks and share relevant information concerning serious risk

factors, is a cause of real and substantial concern.

With respect to George’s discharge from Werribee Mercy on 18 June 2013, records from Werribee Mercy indicate that risk assessments were completed and safety plans were developed. However, upon examination of these documents it appears that these assessments were inadequate and that there was a lack of consideration of the risks highlighted by

George’s parents or strategies to manage their safety.*3

Notes relating to George’s use of violence and his risk to others suggest that George’s threatening behaviour was viewed as an individualised case management issue by staff and that the needs or experiences of his parents were not responded to. Records from Werribee

Mercy indicate that staff were focused solely on treating George, whilst failing to address the

this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community 51 Victoria, Royal Commission into Family Violence, Volume V: Report and recommendations, (2016), 67

» ibid

53 Medical records of George Pedevski provided by Werribee Mercy Hospital

effects of the behaviour and the resulting support needs of those who were being impacted by George’s violence. By categorising the violence in this way, the risk posed to George’s parents appears to have been minimised and may explain why mental health staff did not take adequate steps to manage the risk of family violence posed to Mr Pedevski and Mrs Pedevska

upon George’s discharge from Werribee Mercy.

In addition, I note that records from Western Health also evidence the minimisation of violence experienced by Mr Pedevski. Mr Pedevski’s designated social worker in Western Health appeared to have initially indicated a concern for the safety of Mr Pedevski, however, focus appears to have quickly shifted to concerns for the safety of staff members entering the home. In prioritising this focus, post-discharge services appear to have failed to respond to or contemplate the risk posed to Mr Pedevski and did not take steps to monitor the risk of harm

posed by George.*#

Western Health records further indicate that despite their staff being aware of the safety concerns surrounding George’s behaviour, a lack of information sharing also appears to have occurred between support agencies upon Mr Pedevski’s discharge from Western Health in January 2014. Western Aged Care Assessment Service (ACAS) were not directly informed about the risk posed by George until after their involvement with the family and when they were informed, the abusive behaviour towards Mr Pedevski was not mentioned by other

Western Health services.*

In correspondence sent to the Court dated 11 February 2019, Western Health states that ACAS had access to Mr Pedevski’s entire medical file and were informed about risk assessment findings.©° I have reviewed the medical file and note that whilst case notes do provide information regarding the risk posed to Mr Pedevski’s safety by George, the only risk assessment findings related to a ‘falls and mobility’ risk assessment. I further confirm that no personal safety risk assessment was conducted to assess the risks posed by George to Mr Pedevski and that the overall focus of Western Health services was the risks to their own staff

and not Mr Pedevski as a discharged patient.

I note that ACAS were the gateway service to Salvation Army being involved with the family to deliver a community care package. It is reasonable that the Salvation Army should have

been notified of risks posed by George including his propensity for violence so that they

54 Medical records of Risto Pedevski provided by Western Health 55 Medical Records of Risto Pedevski provided by Western Health 56 Western Health correspondence to the Coroners Court of Victoria dated 11 February 2019

could make an informed assessment of Mr Pedevski’s support needs. A review of the records provided to the Court, however, do not indicate that any such information was shared with

Salvation Army.

62. I further note that family violence specific safety planning and risk assessments do not appear to have been completed by any services involved with Mr Pedevski. The Victorian Government has two main guidelines used to guide practice in relation to elder abuse; With Respect to Age—2009:Victorian Government Practice Guidelines for Health Services and Community Agencies for the Prevention of Elder Abuse (Respect to Age Guidelines) and Elder Abuse Prevention and Reponses Guidelines for Action 2012—14 (Guidelines for Action).°” The Respect to Age Guidelines are relevant to workers who visit older person’s in

the home and are told of, or believe that, elder abuse is occurring.

63. The Respect to Age Guidelines stipulate that when elder abuse is detected, health workers must undertake an assessment to determine the service needs of the client. The Guidelines specifically note that if an assessment tool to screen for elder abuse is not available at the service, an assessment should be undertaken by ACAS.*® The Guidelines go on to discuss the need for professionals to develop a safety intervention, especially in instances where the

perpetrator resides in the home of the victim.*°

64. In constructing the safety plan, the Respect to Age Guidelines note that professionals should work with the older person and review the plan regularly.°° While ACAS had access to Mr Pedevski’s medical file, there is no indication that ACAS staff utilised a specialised screening tool in relation to risks to Mr Pedevski’s personal safety or that ACAS ever discussed Mr

Pedevski’s safety with him directly.°!

65. The provision of family violence specific support, including ongoing risk assessments and safety planning to Mr Pedevski may have helped to minimise the risk of ongoing or future violence. Monitoring George’s behaviour, his mental health, and taking steps to engage

George in support would not only have assisted Mr Pedevski and his wife to manage the risks

57 Victorian Government Department of Human Services, With Respect to Age—2009. Victorian Government Practice Guidelines for Health Services and Community Agencies for the Prevention of Elder Abuse (Melbourne, 2009); Victorian Government Department of Health, Elder Abuse Prevention and Reponses Guidelines for Action 2012—14 (Melbourne, 2019)

58 Victorian Government Department of Human Services, With Respect to ‘Age—2009: Victorian Government Practice Guidelines for Health Services and Community Agencies for the Prevention of Elder Abuse (Melbourne, 2009), 23

» ibid, 27

© ibid 7

61 Medical Records of Risto Pedevski provided by Western Health; Western Health correspondence to the Coroners Court of Victoria dated 11 February 2019

posed to them but may also have assisted George in re-engaging with mental health services

which could have greatly minimised his risk to others.

I acknowledge that the actions necessary to rectify the lapses in support provided to Mr Pedevski are being addressed by the extensive work currently being undertaken in the healthcare sector to develop the capacity of staff to prevent, identify and respond to family

violence and elder abuse.

In this regard, I note that the Royal Commission proposed the implementation of policies and procedures to support service providers in navigating ethical issues when working with older

people who were experiencing abuse.

I confirm that in 2017 the Victorian Government begun a trial of The Integrated Model of Care for Responding to Suspected Elder Abuse in response to findings from the Royal Commission. I endorse this model which aims to ‘strengthen elder abuse responses and support within Victorian health services 6 and is currently operating in five health services,

including Western Health. The program encompasses four key components;

a) Workforce training- the Victorian Government has employed the Bouverie Centre to train clinical staff and partners to identify and respond to suspected elder abuse.

b) Liaison Officer- the implementation of an elder abuse prevention and response Liaison Officer at each service who can be consulted by staff.

c) Counselling and mediation services- available to older people and their families and/or carers.

d) Local Prevention Network- to organise awareness raising events in the community.

I also endorse Recommendation 154 from the Royal Commission which proposes that the Victorian Government encourage the Commonwealth Government to specify that workers in the community service sector must have successfully completed certified training in identifying family violence and responding to it. This includes reviewing existing Community Services Training Packages to ensure that each course has a core, rather than elective, unit

that adequately covers all manifestations of family violence.

The Royal Commission further identified that the ‘mental health sector is currently ill-

equipped to identify and address family violence 6 and often fails to employ a system-

® Victoria, Royal Commission into Family Violence, Volume V: Report and recommendations, (2016), 67 8 Minister for Housing, “Tackling Elder Abuse in the Community”. 15 June 2017, available online at: https://www.premier. vic.gov.au/tackling-elder-abuse-in-the-community/

4 ibid

TA.

focused family violence analysis. In their report, the Royal Commission also noted that mental health services, including psychiatrists, are in a critical position to be able to respond to victims and perpetrators of family violence. Despite this, guidelines available for mental health workers treating victims and perpetrators of family violence are not binding and do not

make up a part of the accountability measures.

The Royal Commission also identified that psychiatrists are not provided with adequate training and resources to equip them to effectively identify, assess and respond to family violence. A lack of family violence education within medical and psychiatric training has also been identified as limiting the understanding and engagement of psychiatrists in supporting

families and patients with family violence related issues.

In Mr Pedevski’s case, a more comprehensive family violence risk assessment may have assisted in the establishment of ongoing family violence specific safety plans and coping strategies for George and provided support to Mr Pedevski and Mrs Pedevska in managing

George’s behaviour.

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 services.

Specifically, I endorse Recommendation three which provides that organisations should adopt minimum standards and core competencies in identifying family violence, conducting risk assessments and risk management practices 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. ®

65 Victoria, Royal Commission into Family Violence, Volume IV: Report and recommendations, (2016), 30 66 Victoria, Royal Commission into Family Violence, Volume IV: Report and recommendations, (2016), 51 61 Victoria, Royal Commission into Family Violence, Volume V: Report and recommendations, (2016), Recommendation 3

8 Victoria, Royal Commission into Family Violence, Volume IV: Report and recommendations, (2016), Recommendation 98

6 Victoria, Royal Commission into Family Violence, Volume IV: Report and recommendations, (2016), Recommendation 97

I also endorse Recommendation 102 which focuses on the training and development of psychiatrists and medical staff in responding to people with a mental illness who perpetrate

family violence.

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 services with education and training to identify family violence risks

and manage these risks appropriately.

I note that Mercy Health has established the position of Specialist Family Violence Advisor in

January 2019 and that this role is task with key priorities including”:

(a) Training with a focus on recognising, responding and referring people experiencing or

perpetrating family violence.

(b) Improving documentation to highlight clinical alerts relating to family violence and intervention orders and ensuring adequate information sharing as per the Family

Violence Information Sharing Scheme.

(c) Continuing active membership of the Western Risk Assessment and Management Panel

(RAMP).

(d) Encouraging practices that prioritise the safety of the victim survivor and hold the person

perpetrating family violence to account.

(ec) Support to clinicians managing patients who are victims or perpetrators of family

violence.

I further note that Mercy Health’s Mental Health Service continues to refine its management of high risk and complex patients. Mercy Health employ the use of a High Risk Panel consisting of senior clinicians chaired by the Forensic Clinic Specialist that meet monthly to review and provide input into management plans developed by clinicians to assist in the care

of high risk and complex patients.”!

J note that Western Health have also implemented improvements to strengthen their response and management of family violence and elder abuse. These initiatives include but are not

limited to:

7 Statement of Associate Professor Dean Stevenson dated 12 March 2019, 3

1 ibid

(a) Participation in the ‘Strengthening Hospital Responses to Family Violence’ pilot project.

(b) Establishment of the ‘Health Equity Committee’ with oversight and governance of vulnerable cohorts within the service, which include family violence and elder abuse

victims.

(c) Establishment of the Health Justice Partnership with Brimbank Melton Community Legal Centre, who are on-site to provide legal advice to patients and staff experiencing

family violence.

(d) Development and review of policies and procedures including Clinical Management of

Family Violence and Clinical Management of Elder Abuse.

(e) Training and Education that includes identifying and responding to family violence to be

delivered across the organisation for Managers, Senior Leaders and Clinicians.

(f) Elder Abuse specific training in partnership with the Bouverie Centre, delivered to staff

across the service.

(g) Participation in the Department of Health and Human Services Elder Abuse Integrated

Model Project which includes the recruitment of an Elder Abuse Liaison Officer.

I am satisfied, having considered all the available evidence, that no further investigation is

required.

FINDINGS AND CONCLUSION

Having investigated the death, without holding an inquest, I make the following findings

pursuant to section 67(1) of the Act: a) _ the identity of the deceased was Risto Pedevski, born 15 July 1935;

b) the death occurred on 23 November 2014 at 66 Fehon Street, Yarraville, Victoria, from

blunt force injuries to the head and neck; and c) the death occurred in the circumstances described above.

I convey my sincerest sympathy to Mr Pedevski’s family.

Pursuant to section 73(1) of the Coroners Act 2008, | order that this finding be published on the internet.

85. Idirect that a copy of this finding be provided to the following: a) Mr Luchi Pedevski, senior next of kin; b) Dr Paul Eleftheriou, Chief Medical Officer, Western Health; c) Ms Claudia Hirst, Deputy General Counsel, Mercy Health Australia; d) Dr Neil Coventry, Chief Psychiatrist, Office of the Chief Psychiatrist; and e) Detective Senior Constable Simon Quinnell, Victoria Police, Coroner’s Investigator.

Signature:

Aol EP

CAITLIN ENGLISH ACTING STATE CORONER

Date: /2 fly LOV7