Deceased
Ora Holt
Demographics
39y, female
Coroner
Deputy State Coroner Caitlin English
Date of death
2017-04-25
Finding date
2020-06-05
Cause of death
gunshot wound to the head
AI-generated summary
Ora Holt, aged 39, was shot and killed by her partner Gregory Floyd on 25 April 2017 in Wangaratta, Victoria. Floyd exhibited escalating coercive, controlling and abusive behaviour throughout late 2016 and early 2017, including unfounded accusations of infidelity and drug use, stalking, financial abuse, and surveillance. Psychiatric evaluation concluded Floyd likely suffered from Delusional Disorder—a serious mental illness characterised by fixed false beliefs despite contrary evidence. While Floyd engaged with GP services, counselling and police in the weeks before the killing, his rational presentation and plausible false narrative (infidelity, drug use) meant the severity of risk was not recognised. The coroner found no missed prevention opportunities by service providers, but recommended GPs develop better index of suspicion tools for identifying family violence perpetrators, as delusions about infidelity can be diagnostically subtle and difficult to detect.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: COR 2017 1923
Form 37 Rule 63(1)
Section 67 of the Coroners Act 2008
Findings of:
Deceased:
Delivered on:
Delivered at:
Hearing date:
Counsel assisting the Coroner:
Catchwords:
5 June 2020
Coroners Court of Victoria, 65 Kavanagh Street, Southbank
21 August 2019
Nicholas Ngai, Family Violence Senior Solicitor
Suspected homicide, no person charged with an
indictable offence in respect of a reportable death,
mandatory inquest
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Ora Holt was aged 39 years and lived in Wangaratta with Gregory Floyd and their four children.
Ms Holt died on 25 April 2017 when she was shot in the head by Mr Floyd. After shooting Ms Holt, Mr Floyd then shot himself. !
On 21 August 2019, an inquest was held into Ms Holt’s death. Evidence was heard from the coroner’s investigator, Detective Leading Senior Constable Adrian Woodcock. Following his evidence, I adjourned the inquest in order to obtain a posthumous psychiatric evaluation of
Mr Floyd prior to concluding my investigation.
done, and complete my Finding.
as the death occurred in Victoria and was violent, unexpected and not from natural causes?.
oceurred.*
placed in custody or care, or the identity of the deceased is unknown.
| See also Finding into death with inquest of Gregory Floyd COR 2017 1924.
3 Section 89(4) Coroners Act 2008.
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, 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 investigation findings and by the making of comments
and recommendations.
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 in support.
Sources of evidence
Detective Leading Senior Constable Adrian Woodcock was the coroner’s investigator. He prepared a coronial brief which includes statements from witnesses, friends and family members, health professionals, police officers and the forensic pathologist who examined
Ms Holt.
As aforementioned, I also obtained a psychiatric report for Mr Floyd which was prepared by Dr Manjula O’Conner.
As Ms Holt’s death occurred as a result of her partner Mr Floyd’s violence, the circumstances
of her death were reviewed by the Coroners Prevention Unit, particularly the Family Violence
Keown v Khan (1999) 1 VR 69.
® Section 69 (1).
7 Section 67(1)(c).
® Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152.
Systemic Review Unit (FVSRU). The FVSRU review provided advice about whether there
were any systems failures by service providers in relation to Ms Holt’s death.
Identity of the Deceased pursuant to section 67(1)(a) of the Act
The identity of the deceased is Ora Holt born 1 January 1978.
Identity is not in dispute and requires no further investigation.
Medical cause of death pursuant to section 67(1)(b) of the Act
On 27 April 2017, Dr Sarah Parsons, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy. Dr Parsons provided a written report, dated 25 August 2017, which concluded that Ms Holt died from a single gunshot wound to the head.
Toxicological analysis of post-mortem specimens taken identified the presence of codeine and morphine.
Ms Holt was middle daughter to Helen and Dave Holt, with sisters Comfort and Brenna. She grew up in Ocean Grove and Bright and completed her schooling in the local area.!° After Year 12, Ms Holt decided against further study and worked at the Commonwealth Bank in Bright. She later moved to Wangaratta for work towards the end of 2001.!!
In late 2005, Ms Holt and Gregory Floyd commenced a relationship. Mr Floyd had recently separated from his wife, Karen Deckert.
with the children.
'© Coronial Brief, Statement of Helen Holt dated 5 June 2017, 151.
"| Coronial Brief, Statement of Comfort Johns dated 5 June 2017, 164.
Mr Floyd worked as a storeman at Kmart and Ms Holt worked at home looking after the children.
Mr Floyd was a recreational hunter and owned a .308 calibre Weatherby bolt action rifle and a
.22 calibre Stirling bolt action rifle,
n mid-2016 Ms Holt had a hysterectomy, which had complications requiring follow up. She
was prescribed codeine for pain management.
In late 2016, Mr Floyd began commenting to his friends and family members that he believed that Ms Holt was having affairs with multiple people,’ that she was abusing prescription
codeine, and that she was planning to leave him and gathering evidence to ‘set him up.’
Mr Floyd also began to voice suspicions about the parentage of two of his children, eventually seeking advice about parentage testing.!4 Mr Floyd confronted Ms Holt a number of times about these allegations, which Ms Holt persistently denied.'>
Mr Floyd sought treatment from the GPs at the Ely Street Clinic. On 27 February 2017, Mr Floyd saw a GP for anxiety related to his relationship with Ms Holt. This was the first documented occasion that Mr Floyd discussed mental health or relationship concerns with a GP at Ely Street Clinic. Mr Floyd was also concerned that Ms Holt was misusing her
prescribed codeine.!°
His employer, Kmart referred him to Hume Psychology and Counselling Services through
their Employee Assistance Program after he told his manager about his relationship concerns.
Mr Floyd had his first session with a social worker on 16 March 2017. The social worker recommended that Ms Holt also attend the sessions, however Mr Floyd stated that Ms Holt was unlikely to engage.
During March 2017 Mr Floyd contacted Sergeant Damien Loiterton via telephone five or six times. Mr Floyd disclosed his concerns about Ms Holt and told Sergeant Loiterton (whom he knew from school) that he was seeing a psychologist and a family lawyer. Sergeant Loiterton
® Coronial Brief, Statement of Roslyn McKenna dated 1 May 2017, 214; Statement of Neville Floyd dated 9 June
2017, 226-227; Statement of Jeremey Johnston dated 29 April 2017, 106; Statement of Justin Schultz dated 7 June 2017, 252-254.
© Coronial Brief, Statement of Neville Floyd dated 9 June 2017, 246; Statement of Justin Schultz dated 7 June 2017, 252-254,
'5 Coronial Brief, Exhibit 18; Exhibit 39, 956-957, 959-963.
'6 Coronial Brief, Statement of medical witness dated 19 June 2017, 303
referred Mr Floyd to the Wangaratta Police Family Violence Unit and arranged for Senior Constable Phil Barnden to fellow up with Mr Floyd.
On 24 March 2017, Mr Floyd saw a GP to discuss his relationship issues and his anxiety.!7 He
requested a paternity test however after discussion, he decided not to pursue it.!®
On 30 March 2017, Mr Floyd saw his social worker and again discussed his relationship
issues,!” stating Ms Holt was abusing codeine and had accessed a prescription from
Dr Moroney in Mr Floyd’s name.”°
April 2017
Bs
On 10 April 2017, Mr Floyd attended his GP requesting a drug screen, reporting he may have
been given illicit substances. The results were negative.?!
On 11 April 2017, Mr Floyd attended an appointment with a family lawyer and discussed his concerns that Ms Holt was using drugs, had hacked his phone to monitor his conversations and was having an affair. He was provided with legal advice about separation and child
custody.”
On 20 April 2017, Mr Floyd saw his social worker to discuss relationship issues. He denied
having thoughts to harm himself or others.
On 20 April 2017, Ms Holt gave her friend, Tania Pool (who worked at the children’s primary school) an envelope (containing notes, a letter and money) asking her to put it in a safe place.
The envelope was subsequently revealed to contain money and a series of diary notes written by Ms Holt in which she described her fear of Mr Floyd, and contained comments such as *... he is scaring me so much I don’t know what to do ...’% Ms Holt disclosed to Ms Pool she was having relationship troubles with Mr Floyd and that he had been falsely accusing her of having affairs. At the same time, the Assistant Principal, Kristy Keenan saw Ms Holt was distressed and took her into her office for some privacy. Ms Holt disclosed some of her
relationship difficulties to Ms Keenan.
'S Coronial Brief, Exhibit 35, 858.
20 Thid.
21 Tbid, 309.
2 Coronial Brief, Exhibit 28, 803-807.
3 Coronial Brief, Exhibit 16, 670.
Al.
44,
On 22 April 2017, Ms Holt disclosed to another friend, Fiona Ormond, Mr Floyd was accusing her of having affairs and that she was abusing her prescribed codeine. Ms Holt also told Ms Ormond that Mr Floyd had informed her that he had people watching the house and that he had proof that she had previously brought men to their house when he was not at
home. Ms Holt was also concerned Mr Floyd was monitoring her phone.”*
On 24 April 2017, Ms Holt and Ms Ormond discussed telling their mutual friend, Rachelle Maher, a police officer, what was happening between Ms Holt and Mr Floyd. Together, they formed a plan for Ms Holt to speak to Ms Maher at her child’s birthday party the following day. Ms Ormond stated that ‘/ooking back now it was as if she was looking for a way to speak
to [Ms Maher] without raising any suspicion with [Mr Floyd].’*°
Ms Holt also told Ms Ormond that she had left some money and a letter with Ms Pool at the
primary school, ‘just in case she needed it; in case he did something.’*®
Mr Floyd’s last diary entry is dated 24 April 2017. In this entry he wrote that it was the ‘toughest day so far and have realised the enormity [sic] of this whole thing ... I believe that whatever [Ms Holt] has told police/DHS it has ta be reaily really bad for there [sic] involvement and not want to speak to me. Positive friends and family involved so must be
massive.’?7
The evidence confirms that Ms Holt had not approached any authorities to lodge a complaint,
and there was no basis for Mr Floyd’s concerns.
On the afternoon of 24 April 2017, following a call from Senior Constable Barnden, Mr Floyd attended the Wangaratta Police Station and spoke to Senior Constable Barnden in the Family Violence Unit. He detailed his belief that Ms Holt was having an affair, was taking drugs and was setting him up. However, Mr Floyd also advised Senior Constable Barnden that he had been lying to his colleagues and friends about his relationship issues, including that he was being investigated by DHHS, when he was aware that this was untrue. Mr Floyd was reported to have said that he had lied to make his story more appealing and get sympathy from others.
Senior Constable Barnden reported that Mr Floyd stated ‘... J might be over complicating the
small things.?78
4 Coronial Brief, Statement of Fiona Ormond dated 26 April 2017, 185.
25 Thid 186.
26 Thid 187.
27 Coronial Brief, Exhibit 18, 730.
8 Coronial Brief, Statement of Senior Constable Barnden dated 25 April 2017, 324.
Senior Constable Barnden reported the interaction with Mr Floyd was about general advice regarding relationships and Family Violence Intervention Orders. Senior Constable Barnden did not believe that Mr Floyd was at risk of harming himself or his family. As a result, no further action was taken by police following this meeting.*” Senior Constable Barnden stated: ‘I did not consider Greg to be a recidivist family violence offender and was pleased that he
had recognised that he had some issues and was being proactive in his dealing with them.”*®
Later that day when Ms Holt spoke with Ms Pool, Ms Pool suggested Ms Holt go to the police about her concerns. However, Ms Holt stated that she could not go to the police as she had seen Mr Floyd there earlier and believed he had friends within the Wangaratta Police
Station.??
Circumstances in which the death occurred pursuant to section 67(1)(c) of the Act
49,
On 25 April 2017, Anzac Day, Ms Ormond spoke with several of Ms Holt’s close friends.
They resolved to assist Ms Holt when she attended the child’s birthday party at Ms Maher’s house that afternoon. They planned to take Ms Holt to the police or the Centre Against
Violence.**
At around midday just before 12.30 pm, Ms Holt was helping the children get ready to attend the birthday party.*? Mr Floyd had his hunting rifle out on the kitchen table ready to go hunting as he was not attending the birthday party.*4
An altercation occurred between Ms Holt and Mr Floyd in the laundry. One of the children who was present during the altercation witnessed Mr Floyd start to choke Ms Holt and Ms Holt shove Mr Floyd into the backyard.*5
The available evidence suggests that Ms Holt then fled with the children out of the house.
They ran to their neighbour’s house, Tanya and Luke Chilcott, whilst Mr Floyd pursued them with his hunting rifle.**
°° Coronial Brief, Statement of Senior Constable Barnden dated 25 April 2017, 326.
*| Coronial Brief, Statement of Tania Pool dated 9 June 2017, 219.
® Coronial Brief, Statement of Ruth Mulligan dated 26 April 2017, 204.
® Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017.
Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017.
Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017.
*© Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017; Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 78; Statement of Tanya Chilcott dated 25 April 2017, 83.
53:
Mrs Chilcott let Ms Holt and her children into their house and locked Mr Floyd outside.
Mr Floyd broke a window near the loungeroom and gained entry to the house.*” Mr Chilcott attempted to stop Mr Floyd, telling him to put the gun down and Mr Floyd said words to the effect of, ‘she’s fucking set me up.** Mr Floyd continued to move towards the back of the
house.
As Mr Floyd moved towards the back of the house, Mr and Mrs Chilcott fled the house with their own children and Ms Holt’s children also fled the house. Daeja Floyd heard her dad yelling, ‘What did you set me up for?’ *° As they fled the house Mr and Mrs Chilcott heard three gunshots.“ Mr and Mrs Chilcott, their children and Ms Holt’s children all sought refuge
at another neighbour’s residence nearby until the Police arrived with emergency services.
Ms Holt and Mr Floyd were later discovered deceased by emergency services in a bedroom at
the Chilcott’s house, both with gunshot wounds to the head.*!
The circumstances of Ms Holt’s death detail a sequence of events that can be described as truly terrifying. Ms Holt and the four children fled from the family house, from where they were preparing to go to a birthday party, to escape from Mr Floyd who was wielding a shotgun and who then pursued them to the neighbours’ house.
The neighbours, the Chilcotts, with their own small children, enabled Ms Holt and her four children to take refuge. Mr Chilcott attempted to fend off Mr Floyd who broke into their house through a window and pointed his gun at him. The Chilcotts are to be commended for
their selfless assistance to Ms Holt and her children in the most traumatic of circumstances.
The Chilcotts, with all the children, then took refuge in Marlene Park’s home, a local resident.
Although Mrs Park did not know them, she welcomed them into her home when they presented at her front door in great fear and seeking safety.
I commend both the Chilcott’s and Mrs Marlene Park for their bravery.
My investigation into Ms Holt’s death was directed to public health and safety matters and focused on the issue of preventing family violence deaths. The findings of the 2016 Royal
37 Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 79; Statement of Tanya Chilcott dated 25 April 2017, 84.
38 Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 79.
38 Coronial Brief 50.
*' Coronial Brief, Statement of Pauline Terri Williams dated 9 June 2017, 355.
Commission into Family Violence confirmed that family violence should be understood as a broad concept, not merely as physical violence. Threats, coercion, attempts to control or
manipulate, as well as emotional abuse, all constitute forms of family violence.
period leading up to her death.
opportunities were missed.
COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT Family Violence — Risk frameworks and factors
expected to be a place of trust, safety and protection.
Mr Floyd’s actions by killing Ms Holt and causing her death constitutes ‘family violence.”
part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).*
Common Risk Assessment Framework (CRAF), details a number of evidence based risk
factors which have been found to impact on the likelihood and severity of family violence.*®
” Family Violence Protection Act 2008, section 9(1)(b).
8 Family Violence Protection Act 2008, section 5(1)(a)(i).
“ 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.
*© Department of Health and Human Services, Family Violence Risk Assessment and Risk Management Framework and Practice Guides 1-3 (2012), 2™ Edition.
7 Thid 48 Thid
These risk factors are divided into three categories: those which relate to the victim of family
violence, those which relate to the perpetrator, and those which relate to the relationship.*”
Whilst the evidence did not confirm any victim specific risk factors with respect to Ms Holt, there appears to have been five perpetrator specific risk factors relevant to Mr Floyd.
Specifically, he had access to weapons (firearms), engaged in: stalking behaviour, had been sexually coercive, exhibited obsessive and jealous behaviour, and exhibited controlling behaviour towards Ms Holt. All these factors meant that there was an increased risk of Ms Holt being killed or almost killed.”*
With respect to relationship specific risk factors, two specific risk factors appear to have been present in this case. Specifically, Mr Floyd perceived the relationship to be in the initial stages of separation, and there had been an escalation in the frequency and severity of family violence perpetrated by Mr Floyd. Both risk factors indicated an increased risk of Ms Holt being killed or almost killed.” The available evidence suggests that he may have suffered
from a delusional disorder which is discussed further below.
CRAF has recently been replaced by the Family Violence Multi-Agency Risk Assessment and Management Framework (MARAM). There are several additional risk factors included within MARAM applicable in this case. Specifically, the MARAM considers a victim’s selfassessed level of risk, the perpetrator’s use of family violence in prior relationships and the presence of emotional abuse in assessing for the risk posed to a victim.*! Ms Holt selfassessed that she was at a high level of risk as evident in notes she wrote and gave to Ms Pool in the envelope prior to her death, and in conversations with friends. Additionally, a statement from Mr Floyd’s ex-wife, Ms Deckert, confirms that he had a history of perpetrating family violence in this prior relationship, specifically stalking, emotional abuse and controlling behaviour.? The letters, notes and diary excerpts left by Mr Floyd indicate he was
emotionally abusive towards Ms Holt during their relationship.
The perception by a perpetrator that a relationship was in the imminent stages of separation is also identified within the MARAM as a risk factor which can indicate the risk of family
violence escalating in a very short timeframe.** Although there was no evidentiary basis for
27-28.
7 Tbid
27-30.
Coronial Brief, Statement of Karen Deckert dated 14 July 2017, 271-274.
Family Safety Victoria, above n 76, 27.
Mr Floyd’s belief that Ms Holt was going to leave him, these beliefs held by Mr Floyd potentially increased the level of risk posed to Ms Holt prior to the fatal incident. The period immediately prior to or after separation is recognised as a heightened period of risk for intimate partners as ‘the perpetrator may perceive a loss of control over her and may become
more unpredictable’.**
Family violence — Coercive controlling behaviour, emotional abuse, stalking and sexual
coercion
74,
Evidence in the coronial brief suggests that Mr Floyd was jealous, controlling, financially
abusive and sexually coercive towards Ms Holt during their relationship.
None of Mr Floyd’s beliefs with respect to Ms Holt’s behaviour were substantiated. There was no involvement by Victoria Police and Child Protection.** Despite Mr Floyd telling people Ms Holt was abusing prescription codeine, her GP stated Ms Holt ‘showed no
evidence of abusing this drug [codeine]. *°
Mr Floyd also appears to have engaged in surveillance of Ms Holt. Mr Floyd had told several people about his beliefs in relation to Ms Holt’s fidelity towards him.*’ Mr Floyd’s notes also indicate that he had examined Ms Holt’s phone™, was monitoring the battery use on Ms Holt’s laptop to ascertain how much she was using it,°° noting her bank withdrawals and
keeping her used tissues for drug testing.
Despite these risks, as the coronial investigator’s summary notes, no one who knew Mr Floyd or was involved in a professional capacity with him foresaw that his actions were escalating to a point where he was becoming homicidal and suicidal and capable of placing Ms Holt and their children and members of the community in danger. Ms Holt did not disclose her concerns or fears about Mr Floyd to any professional person, such as a GP, counsellor or
police member.
Department of Health and Human Services, ‘Family Violence: Risk Assessment and Risk Management Framework and Practice Guides 1-3—Edition 2’ (April 2012), 19.
Coronial Brief, Statement of A Woodcock, 458. Email from Detective Romina McEwan dated 10 January 2019.
*° Coronial Brief, Statement of Dr SG Maroney dated 19 June 2017, 302.
*? Coronial Brief, Statement of Justin Floyd dated 8 June 2017, 246; Statement of Christopher Calvene dated 9 May 2017, 259-261.
*® Coronial Brief, Statement of Fiona Ormond dated 26 April 2017,184; Statement of Brendan Wyatt dated 26 April 2017, 278; Exhibit 18, 712-713, 723.
3° Corenial Brief, Exhibit 18, 718.
Coronial Brief, Exhibit 18, 718-723.
Mr Floyd was likely to have been suffering from a potential undiagnosed mental health
condition at period leading up to the fatal incident and this issue is explored further below.
Review of services contact
Pls
As part of its review, the FSRFVD reviewed the contact Mr Floyd and Ms Holt had with service providers to ascertain whether there were any prevention opportunities. This means, were any indicators or red flags missed by any agency which could have alerted authorities to
the risk of Mr Floyd’s ultimate behaviour.
The review included examining Mr Floyd’s interactions with Victoria Police, the Firearms Licensing Process by which Mr Floyd was able to apply to be deemed a non prohibited person and have his firearms licence and firearms re-instated, Mr Floyd’s contact with the Ely street clinic, Hume Psychology Services, Nevi Lenne Gross Barristers and Solicitors, and his
employer, Kmart Wangaratta.
The review did not identify any missed opportunities for prevention. The review found that appropriate referrals were made by Sergeant Loiterton and the information provided to Senior Constable Barnden was insufficient to consider that a formal report of family violence had been received by police which would have triggered compulsory police action under the Victoria Police Code of Practice for the Investigation of Family Violence.*! There were no missed opportunities for intervention or prevention with respect to Mr Floyd being declared a nonprohibited person under the Firearms Act 1996 (Vic) and the subsequent re-instatement of
his firearms in 2015.
Based on the information provided by GP’s at the Ely Street Medical Clinic, it appears that they were aware of relationship difficulties between Mr Floyd and Ms Holt, however there does not appear to have been any indication that family violence was occurring in the relationship. No missed opportunities for intervention or prevention were identified with
respect to this service.
Mr Floyd’s employer appropriately referred him to the Employee Assistance Program after he spoke to his managers in February and March 2017 about his relationship difficulties with Ms Holt. As a result of the referral, he attended three counselling sessions with Helen Sellar at
Hume Psychological Services in Beechworth in Marchand April 2017.
®! Victoria Police, Code of Practice for the Investigation of Family Violence (2017) 3" edition, Version 3.
The review found that Ms Sellar appeared to have conducted appropriate enquiries in relation to family violence with Mr Floyd. These inquiries did not lead to any concerns on Ms Sellar’s behalf with respect to Mr Floyd’s behaviour.
Ms Holt attended the Ely Street clinic on a number of occasions during 2017 in relation a physical ailment. She saw Dr Maroney at her last appointment in March but did not disclose any stress, mental health issues or relationship difficulties during her appointments. No
missed opportunities were identified for intervention or prevention.
Ms Holt attended Dr Amelia Bock, a specialist, during 2016 and 2017. There is no indication she disclosed any relationship or mental health difficulties during her consultations. No
missed opportunities for intervention or prevention were identified.
Ms Keenan from the primary school spoke to Ms Holt on 20 April 2017. Although Ms Holt spoke of relationship difficulties, Ms Keenan did not hold concerns for Ms Holt’s safety during the interaction. It appears to have been a brief interaction, interrupted by the school bell requiring Ms Keenan to attend to her duties. Any opportunity for intervention was limited and there was no time to explore the situation further. As such there were no missed
opportunities for intervention or prevention from this service contact.
I accept the advice from the FSRFVD that no prevention opportunities were identified from
either Mr Floyd or Ms Holt’s contact with the various service providers.
Mr Floyd’s mental health
I requested an expert report from a psychiatrist, Dr Manjula O’Connor,™ to examine
Mr Floyd’s behaviour in the lead up to the fatal incident.
Whilst there are limitations of a psychiatric diagnosis made post-mortem, Dr O’Connor diagnosed Mr Floyd as suffering from Delusional Disorder in the proximate period leading up to the fatal incident. Dr O’Connor’s assessment was made at the symptom-based level which included reviewing medical records, firsthand clinician and service statements and statements
of family and friends.
® Dr Manjula O’Connor is a specialist consultant psychiatrist and honorary senior fellow at the University of
Melbourne. She is also chair of the Australian Family Violence Psychiatry Network.
°3 Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 7-10.
Dr O’Connor references the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders“, which defines “Delusional Disorder” as an illness characterised by at least 1 month of delusions but no other psychotic symptoms. Delusions are false beliefs based on an incorrect inference about the external reality that persists despite
evidence to the contrary.
In Mr Floyd’s case, this was evident in his delusional belief that Ms Holt was having multiple affairs, reporting him to authorities and preparing to separate and leave him, taking the children with her. The overwhelming evidence supports the finding that there was no basis for him holding these beliefs.
Dr O’Connor confirms that individuals suffering from Delusional Disorder typically present as well-groomed and well-dressed without evidence of gross impairment.® Mr Floyd had presented as believable and engendered an empathetic response from clinicians and Victoria Police. The validity of his reports of Ms Holt’s extra marital affairs and drug use were accepted without any collateral information being sought to verify those reports, save for a Victoria Police member checking the LEAP record of a neighbour whom Mr Floyd claimed was supplying drugs to Ms Holt.*? Dr O’Connor noted Mr Floyd’s delusions were clearly plausible, as they were about real life situations, namely being deceived by his partner and that she was taking drugs. They were not delusions that indicated a loss of control over mind
or body, such as hearing voices, or aliens putting thoughts in his mind.
Dr O’Connor noted delusional disorder is challenging to treat for various reasons, including patients’ frequent denial that they have any problem, rational presentation, difficulties in
developing a therapeutic alliance and social/interpersonal conflicts.
With respect to family violence, Dr O’Comnor noted, ‘This case highlights the difficulty of diagnosing perpetration of family violence when the perpetrator presents a rational story of being a victim as in this case. [Mr Floyd] aroused empathy in others because [he] was the
victim of infidelity and a drug using partner.’
Dr O’Connor noted the Kessler 10 (K10) a Psychological Distress Scale was not used by Mr Floyd’s general practitioners. She noted however that although Mr Floyd presented to his
“ The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) (2013).
6° Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 10.
6° Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 10-11.
© Coronial Brief, Statement of police member dated 26 April 2017, 314,
88 Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 11.
& Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 12.
94,
GP as distressed, given his ability to rationalise convincingly the reason for that distress, the
K10 would have been unlikely to have prompted a different response by the professionals.
Although there was a lack of exploration of the validity of Mr Floyd’s reports about Ms Holt, again, this was linked to his ability to present as rational and functional. This also went some way to explain the lack of action to seek collateral information to verify Mr Floyd’s reports about Ms Holt.
A delusional disorder is a serious mental illness that, as noted by Dr O’Connor, is difficult to diagnose and treat. The client does not usually fit the perception of someone with a serious mental illness/psychotic disorder because they are functioning, appear rational and are able to
explain why they feel the way they do and appear to be help-seeking and problem solving.
Most GPs would never see a patient with delusional disorder so the focus of this recommendation is on the index of suspicion for violence, so that GP’s may notice a trigger
that makes them think of potential family violence, for example, indications of surveillance.
The Royal Australian College of General Practice (RACGP) 2008 Abuse and violence, Working with our patients in general practice advises GPs about an index of suspicion on which to clinically assess the reports of a person who may or may not be a perpetrator of family violence. However, there are no examples of what a GP would include or exclude in making such a clinical judgement. There is also an assumption that all GP’s are equally knowledgeable and skilled in understanding the concept and application of an index of suspicion. An example of such a tool provided as part of the document is the Elder Abuse Suspicion Index (EASI), but there is no equivalent or comparable tool available for GPs
specific to family violence perpetrators.
I therefore recommend that the RACGP should review the currency of the 2008 Abuse and violence, Working with our patients in general practice guiding document and documents that reference it. After development of the above document, the RACGP should work with Primary Health Networks and local family violence hubs to provide awareness and education
for members.
The RACGP should also develop guidance and examples of an index of suspicion for general
practitioners who are working with potential perpetrators of family violence.
Having investigated Ms Holt’s death and having held an inquest in relation to her death on
21 August 2019, at Melbourne, I make the following findings, pursuant to section 67(1) of the Act:
(a) _ that the identity of the deceased was Ora Holt, born 1 January 1978;
(b) that Ms Holt died on 25 April 2017, at 7 Belle Avenue, Wangaratta, from a gunshot
wound to the head; and
(c) that the death occurred in the citconistances set out above.
I convey my sincerest sympathy to Ms Holt’s family and friends.
Pursuant to section 73(1) of the Act, I order that this Finding be published on the internet.
I direct that a copy of this finding be provided to the following:
(a) Mrs Helen Holt, Senior Next of Kin;
(b) Ms Karen Deckert;
(c) Mrs Trudi Floyd;
(d) Ms Marlene Park;
(e) Mrs Annette Winestone; (f)) Ms Lauren McKenzie;
(g) Mr and Mrs Luke and Tanya Chilcott;
(h) Mr and Mrs Henry and Naomi McKenzie;
Gi) Ms Alison Maclean, Principal Strategic Advisor, Ovens Murray Integrated Family
Violence Committee;
(j) Detective Senior Constable Adrian Woodcock, Coroner’s Investigator, Victoria Police;
(k) Detective Sergeant Glenn Grandy, Professional Standards Command, Victoria Police;
() Superintendent Belinda Bates, Civil Litigation Unit, Victoria Police; and
(m) Mr Grant Taylor, Victoria Police
Signature:
OELLED 2 CAITLIN ENGLISH DEPUTY STATE CORONER Date: 5 June 2020
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