Finding into death of Gregory Allen Floyd

IN THE CORONERS COURT Court Reference: COR 2017 1924

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008

Findings of: CAITLIN ENGLISH, DEPUTY STATE CORONER

Deceased: GREGORY ALLEN FLOYD

Date of birth: 5 September 1973

Date of death: 25 April 2017

Cause of death: I(a) Gunshot wound to the head

Place of death: 9 Belle Avenue, Wangaratta, Victoria

CONTENTS

BACKGROUND ...cssccsssssescccssssessrcccesssnesenescessnsecnenennnnscssesesencnessreqeertonscessressessaeuteausesenseseetesetsssaseseses 4 Family Violence ...cccscsescsssssssssssccssssessasscnsncsncsssssscasasstsssasasasssseassesoucarseassnanesessnconesssacossspsnssssesssnes 10 Family violence -Coercive controlling behaviour, emotional abuse and stalking sro 22 Family violence — Sexual coercive BEHAVIOUP ssscsresessrrccrserersriiseatenrsessentenenereneassenenenneneess 14

Mr Floyd’s mental health treatment .cccscsersernerssersreccrenssneescsereeceasrsceasesersenseaseenssrsnssesnessseessens IS RECOMMENDATION PURSUANT TO SECTION 72(2) OF THE ACT ....csssssesssssseessneneeee 16 FINDINGS AND CONCLUSION uu... cssscssssssssssesesssssensesrenssesnsssssntsererseseneonscasseusrensenuecersssennsnensanee 17

INTRODUCTION

Gregory Allen Floyd was born in Wangaratta on 5 September 1973 and was 43 years-old at the time of his death. Mr Floyd commenced a relationship with Ms Ora Holt! in late 2005 and they are survived by their four children born between August 2007 and December 2012.?

Mr Floyd grew up in Wangaratta and completed both primary and secondary studies in the local arca.? Mr Floyd was a car enthusiast and worked in the Wangaratta Kmart until his

death.4

Mr Floyd died on 25 April 2017 from a gunshot wound to the head. He shot himself after he shot Ms Holt, killing her.

THE PURPOSE OF A CORONIAL INVESTIGATION

Mr Floyd’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 also 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

1 See also Finding into death with inquest of Ora Holt COR 2017 1923

? Coronial Brief, Statement of Mark Johns dated 7 June 2017, 170.

3 Coronial Brief, Statement of Christopher Calvene dated 9 May 2017, 257.

4 Coronial Brief, Statement of Joanne McGrath dated 26 April 2017, 282.

5 Section 4 Coroners Aet 2008.

§ Section 89(4) Coroners Act 2008.

7 See Preamble and section 67, Coroners Act 2008.

® Keown v Khan (1999) 1 VR 69.

Section 69(1) Coroners Act 2008.

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.

All coronial findings must be made based on proof of relevant facts on the balance of probabilities.!! In determining these matters, | 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.

CORONIAL INVESTIGATION

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 Mr

‘Floyd.

I -also obtained a psychiatric report for Mr Floyd which was prepared by Dr Manjula

O’ Connor.

As Mr Floyd’s actions were responsible for death of his partner, Ora Holt, the circumstances of her death were reviewed by the Coroners Prevention Unit, particularly the Family Violence 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. This review is

also relevant to Mr Floyd’s death.

1 Section 67(1)(c) Coroners Act 2008.

"| Re State Coroner; ex parte Minister for Health (2009) 261 ALR 152.

2 (1938) 60 CLR 336.

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

15. On 29 April 2017, a member of the Forensic Services Department (Victoria Police) took fingerprint impressions from the deceased which identified him to be Gregory Floyd, born 5 September 1973.

16. 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

17. On 26 April 2017, Dr Sarah Parsons, a Forensic Pathologist practising at the Victorian Institute of Forensic Medicine, conducted an autopsy upon the deceased’s body. Dr Parsons provided a written report, dated 8 June 2017, which concluded that Mr Floyd died from a gunshot injury to the head.

18. A full toxicological analysis was negative for common drugs or poisons.

19. Iaccept the cause of death proposed by Dr Parsons.

BACKGROUND

20. Prior to his relationship commencing with Ms Holt, Mr Floyd had been married previously to Ms Karen Deckert whom he met in 1994 and married in June 2004.% Due to issues of suspected infidelity and conflict arising from these issues, Ms Deckert separated from Mr Floyd around September 2005. Mr Floyd and Ms Holt’s relationship commenced shortly after Mr Floyd separated from Ms Deckert.

21. In mid-2016, Ms Holt had a hysterectomy. Following this procedure, Ms Holt had

complications which required follow up" and she was prescribed codeine to manage pain.!°

22, In the nine months preceding their deaths, Mr Floyd began commenting to friends and family members that he believed that Ms Holt was having affairs with multiple people.!® Mr Floyd

‘also began to tell friends, family and service providers that he believed that Ms Holt was

133 Coronial Brief, Statement of Karen Deckert dated 13 July 2017, 271-272.

“4 Coronial Brief, Statement of Dr SG Maroney dated 19 June 2017, 302-303; Medical Records of Ora Holt provided by Ely Street Clinic; Medical Records of Ora Holt provided by Dr Amelia Bock.

13 Coronial Brief, Statement of Dr SG Maroney dated 19 June 2017, 302-303; Medical Records of Ora Holt provided by Ely Street Clinic; Medical Records of Ora Holt provided by Dr Amelia Bock.

16 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.

abusing prescription codeine, that she was planning to leave him and that she was gathering evidence to ‘set him up.!? He also began to be suspicious of the parentage of two of his children, eventually seeking advice about parentage testing.'* Mr Floyd confronted Ms Holt repeatedly about these allegations, and Ms Holt persistently denied all of them.”

In the weeks prior to the fatal incident, Mr Floyd sought treatment via general medical practitioners at the Ely Street Clinic and a social worker at Hume Psychology and Counselling Services. He had seen various GPs at Ely Street Clinic over several years. He was referred to Hume Psychology and Counselling Services by his employer (Kmart) through their Employee

Assistance Program after voicing concerns about his relationship to his manager.

On 27 February 2017, Mr Floyd booked into see a GP for anxiety related to his relationship with Ms Holt. This was the first documented occasion that Mr Floyd discussed mental health or rclationship concerns with a GP at Ely Street Clinic. Mr Floyd was concerned that Ms Holt

was misusing her prescribed codeine.7°

Mr Floyd had his first session with a social worker on 16 March 2017. A background history was taken, and the social worker recommended that Ms Holt attend the sessions as well.

However, Mr Floyd declined stating that Ms Holt would likely not engage. Mr Floyd reported a belief that Ms [Jolt might be having an affair but stated that he “needs to make 99% sure”?!

Mr Floyd further reported a belief that the affair may have been going on for some time, but he had been making excuses for the sake of their children. He stated that if he found Ms Holt to be having an affair, he would have no choice but to leave the relationship and

acknowledged the sadness that this would cause him.”

On 24 March 2017, Mr Floyd saw a GP to discuss concerns about his relationship and resulting anxiety. He requested a paternity test as he felt that his two youngest children may not be his biological children. His GP advised that Ms Holt’s consent was required and if a paternity test were to progress, a plan should be developed to prepare Mr Floyd for potential negative results, The GP discussed the potential adverse effects that this may have on Mr Floyd’s relationship with Ms Holt and the children. Mr Floyd decided not to progress with

the paternity test.

1 Coronial Brief, Statement of Neville Floyd dated 9 June 2017, 246; Statement of Justin Schultz dated 7 June 2017, 252-254.

'8 Coronial Brief, Statement of Dr PJ Keenan dated 8 June 2017, 308.

'9 Coronial Brief, Exhibit 18; Exhibit 39, 956-957, 959-963.

20 Coronial Brief, Statement of medical witness dated 19 June 2017, 303.

21 Coronial Brief, Exhibit 35, 858.

2 Thid.

On 30 March 2017, Mr Floyd saw his social worker and he discussed his relationship difficulties.* Mr, Floyd stated that he knew that he had to end the relationship but was concerned about the impact that this would have on his children. Mr Floyd also discussed his concern that Ms Holt was abusing codeine and had accessed a prescription from Dr Moroney

in Mr Floyd’s name.”*

April 2017

On 6 April 2017, Mr Floyd saw his GP to request a sexually transmitted disease screen and investigations into his recent weight loss.?> The investigations into his weight loss returned with no significant physical abnormalities detected. Results for the STD screen were not present on the medical record and the pathology request was found in Mr Floyd’s work locker

after his death, indicating that he did not complete the STD screen.

On 10 April 2017, Mr Floyd attended with his GP for the final time. He requested a drug screen due to a belief that he may have inadvertently been given illicit substances. Negative

results were returned for all substances that were tested for.*

Also on 10 April 2017, Mr Floyd made contact with a local family law firm regarding his relationship and access to his children. The following day he attended an appointment with a family lawyer, where he 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 advice about their home and spousal maintenance, advised not to allow Ms Holt to take the children interstate*’, advised to consider his preferred custody arrangements should the relationship

end, and advised to inform his lawyer when Ms Holt moved out of the house.”®

On 20 April 2017, Mr Floyd saw his social worker for the final time. He presented as slightly more distressed than previous sessions and reported this to be due to being sad about his relationship.” Ms Holt had initially planned. to attend the appointment but changed her mind at the last minute. Mr Floyd was disappointed about this and feared that she had given up on their relationship. He reflected on whether his accusations of Ms Holt having an affair

constituted emotional abuse. Mr Floyd denied thoughts to harm himself or others. He denied

33 Coronial Brief, Exhibit 35, 858.

% Tid.

33 Coronial Brief, Statement of medical witness dated 8 June 2017, 308-309.

6 Tid, 309.

7 Coronial Brief, Exhibit 28, 803-807

8 Thid, 797-798.

8 Coronial Brief, Exhibit 35, 859.

would agree that he is not a violent person.”” .

having harmed Ms Holt or their children in the past and stated that his friends and ex-wife

On 20 April 2017, Ms Holt attended Wangaratta West Prumary School and gave her friend, Ms Pool an envelope asking her to put.it in a safe place. Ms Holt became visibly upset during this interaction and told her friend that she and Mr Floyd had been fighting and he would not think to look for the envelope there. Ms Holt also disclosed to her friend that she had been having relationship troubles with Mr Floyd and that he had been falsely accusing her of

having affairs.

On 22 April 2017, Ms Holt disclosed io a friend, Fiona Ormond, thal she was having relationship issues and that Mr Floyd had been accusing her of having affairs and abusing the codeine she was prescribed. Ms Holt also reportedly said 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 also reported being concerned that Mr Floyd

was monitoring her phone.*!

On 24 April 2017, Ms Holt and Ms Ormond had a further conversation and Ms Holt asked Ms Ormond to tell their mutual friend, Rachelle Maher, what had been happening between her and Mr Floyd. Ms Holt wanted Ms Maher’s advice as Ms Maher was a police officer.

Together, Ms Holt and Ms Ormond formed a plan for Ms Maher to have a children’s birthday party the following day so that Ms Holt could attend and speak with Ms Maher there.

Ms Ormond stated that ‘looking 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 Wangaratta West 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 ... [ believe that whatever [Ms Hoit] has told police/DHS it has to be really really bad for there [sic] involvement and not want to speak to me. Positive friends and family involved so must be

massive.’*4

3° Thid.

31 Coronial Brief, Statement of Fiona Ormond dated 26 April 2017, 185.

32 Thid 186.

33 Thid 187.

4 Coronial Brief, Exhibit 18, 730.

Al.

Mr Floyd also wrote about being concerned about losing Ms Holt and the children, his job, his friends and family, and of ‘possible jail time if what she has set me up for is bad enough.* The available evidence however 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 same day, Mr I'loyd attended the Wangaratta Police Station and spoke to a senior constable. He detailed his belief that Ms Holt was having an affair, was taking drugs and was setting him up. However, Mr Floyd also advised police that he had been lying to his colleagues and friends about being investigated by Child Protection 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.26

The police officer whom Mr Floyd spoke with felt that this interaction with Mr Floyd was only to seek general advice about relationships and Family Violence Intervention Orders.

During this discussion, the police officer 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.>”

Later that day Ms Holt spoke with Ms Pool about her relationship problems. Ms Pool suggested that 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.7#

The following morning, on 25 April 2017, Ms Ormond had a conversation with several of Ms Holt’s close friends and they resolved to come up with a plan to assist Ms Holt when she attended the children’s party at Ms Maher’s house that afternoon.® One of Ms Holt’s friend stated that she was planning to take Ms Holt to the police or the Centre Against Violence.°

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

On 25 April 2017 around midday just before 12.30 pm, Ms Holt was preparing the children to get ready to attend a birthday party for the child of one of Ms Holt’s close friends.’ Mr Floyd

35 Ibid 724.

36 Coronial Brief, Statement of police member dated DATE, 324,

37 thid 325.

38 Coronial Brief, Statement of Tania Pool dated 9 June 2017, 219.

3° Coronial Brief, Statement of Fiona Ormond dated 26 April 2017, 188.

“0 Coronial Brief, Statement of Ruth Mulligan dated 26 April 2017, 204.

*! Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017.

44,

45,

had his hunting rifle out on the kitchen table ready to go hunting as he was not attending the birthday party.

An altercation occurred between Ms Holt and Mr Floyd in the laundry room located in the rear of the residence. 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 back yard.

The available evidence suggests that Ms Holt then fled with the children out of the house and they headed towards the neighbouring property belonging to ‘Tanya and Luke Chilcott whilst Mr Floyd pursued them with his hunting rifle.#

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. Before Mr and Mrs Chilcott managed to flee the house to escape, they heard three gunshots."?7 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 personnel in a bedroom at the Chilcott’s property, both with gunshot wounds to the head."® The evidence supports a finding that after shooting and killing Ms Holt, Mr Floyd killed himself with the

same firearm.

® Coronial Brief, Exhibit 32 — Vidco interview of AF dated 6 June 2017.

8 Coronial Brief, Exhibit 32 — Video interview of AF dated 6 June 2017.

“4 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.

4 Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 79; Statement of Tanya Chilcott dated 25 April 2017, 84.

46 Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 79.

*’ Coronial Brief, Statement of Luke Chilcott dated 25 April 2017, 79; Statement of Emma Johnson dated 27 April 2017, 113.

48 Coronial Brief, Statement of Pauline Terri Williams dated 9 June 2017, 355.

COMMENTS PURSUANT TO SECTION 67(3) OF THE ACT

Finding of suicide

48. Suicide is defined by the World Health Organisation as ‘un act deliberately initiated and performed by a person in the full knowledge or expectation of its fatal outcome’. A finding of suicide can impact upon the memory of the deceased person and can reverberate throughout a family for generations, Such a finding should only be made on compelling

evidence, not indirect inferences or speculation.

49. In considering whether Mr Floyd’s death was due to suicide, I note that there was no evidence of a third party’s involvement in his death and that. there was substantial evidence that the

fatal gunshot wound was self-inflicted.

50. On the available evidence, I am satisfied that the factors identified within the background, and which culminated in the homicide of Ms Holt, led to Mr Floyd determining to end his own

life.

Family Violence

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

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

52. For the purposes of the Family Violence Protection Act 2008 (the Act), the relationship between Mr Floyd and Ms Holt clearly fell within the definition of ‘family member*® under that Act.

53. Considering Ms Holt’s death occurred under circumstances of family violence, I requested that the Coroners’ Prevention Unit (CPU)*! examine the circumstances of Ms Holt’s death as

part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).7

54. The Family Violence Risk Assessment and Risk Management Framework, known as the

Common Risk Assessment Framework, details a number of evidence based risk factors which

“World Health Organisation, The World Health Report 2001, awailable online at: https://www.who.int/whr/2001/chapter2/en/index6.html, 37.

*9 Section 9(1)(b), Family Violence Protection Act 2008.

51 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 VSREVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community.

have been found to impact on the likelihood and severity of family violence.** 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.**

The available evidence did not confirm any victim specific risk factors with respect to Ms Holt. However, with respect to perpetrator specific risk factors, there appear to have been five such risk factors with respect to Mr Floyd. Specifically, he had access to weapons (firearms), engaged in stalking behaviour, had been sexually coercive, exhibited obscssive 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 relationship 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 factor's indicated an increased risk of Ms Holt being killed or almost killed.5® The available evidence suggests that he may have

suffered from a delusional disorder which is discussed further below.

It is noted that the CRAF has recently been replaced by the #amily Violence Multi-Agency Risk Assessment and Management Framework.*’ There are several additional risk factors included within MARAM which were not included in the CRAF that were applicable in this case. Specifically, the MARAM considers a victim’s self-assessed 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 self-asscssed that she was at a high level of risk as evident in notes she wrote to herself prior to her death and in conversations with friends. Additionally, a statement from Mr Floyd’s ex-wife, Ms Deckert, suggests that he had a history of perpetrating family violence in this prior relationship, specifically stalking,

emotional abuse and controlling behaviour.*?

3 Department of Health and Human Services, Family Violence Risk Assessment and Risk Management Framework and Practice Guides 7-3 (2012), 2™ Edition.

• Thid 30.

45 Thid 27-28.

56 Ibid.

5? Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018).

%8 bid 27-30.

39 Coronial Brief, Statement of Karcn Deckert dated 14 July 2017, 271-274.

i

The perception by a perpetrator that a relationship was in the imminent stages of separation is also identified within the MARAM as an additional risk factor which can indicate the risk of

family violence escalating in a very short timeframe.

There was no evidentiary basis for Mr Floyd’s beliefs regarding separation and a potential family law dispute, which may also have included Department of Health and Human Services — Child Protection (Child Protection) or police involvement. However, 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’.

Although none of these additional risk factors are highlighted within the new MARAM as indicating an increased risk of lethal violence, the inclusion of emotional abuse as a distinct risk factor within the MARAM highlights the importance of considering non-physical forms

of family violence as a risk factor for future violence.

Family violence —Coercive controlling behaviour, emotional abuse and stalking

63,

Evidence in the coronial brief suggests that Mr Floyd was jealous, controlling, and financially abusive towards Ms Holt during their relationship. One of Ms Holt’s family members stated that Mr Floyd was controlling of the finances in the relationship, and Ms Holt ‘always had to ask if she could have money to do things.’ She also described Mr Floyd as a ‘jealous

person? ®

Another family member of Ms Holt stated that Mr Floyd would not allow Ms Jiolt to have Facebook in case her ex-partners contacted her. Ms Holt’s family observed that Mr Floyd did

not want her to look after her appearance in case other men looked at her.*

Ms Holt’s friends described Mr Floyd as controlling, stating that he would not allow Ms Holt to get her hair styled or go out with friends on the weekends or to attend concerts, and that

when she did go out, Mr Floyd would text her constantly.

6° Family Safety Victoria, above n 76, 27.

51 Department of Health and Human Services, ‘Family Violence: Risk Assessment and Risk Management Framework and Practice Guides !-3—Edition 2’ (April 2012), 19

® Coronial Brief, Witness statement dated 5 June 2017, 166

8 Thid 167.

4 Coronial Brief, Witness statement dated 27 July 2017, 177.

® Coronial Brief, Witness statement dated 9 June 2017, 220.

65,

In diary notes contained within the coronial brief, Mr Floyd indicated that he believed Ms Holt had gone to the police about him and that someone from Child Protection had spoken

to their children at school.

None of Mr Floyd’s beliefs with respect to Ms Holt were substantiated within the materials

‘provided in the coronial brief, or in the enquiries made with Victoria Police and Child

Protection.’ Ms Holt’s general practitioner also noted in his statement to the Court that Ms Holt ‘showed no evidence of abusing this drug {codeine}. 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.

Ms Holt’s notes to Mr Floyd also suggest that Mr Floyd was controlling, and Ms Holt was in fear of him. Ms Holt wrote ‘you want all the control in our relationship I have no say in anything’® and ‘Im [sic] scared everytime [sic] you come home cause [sic] I dont [sic] know

what mood your [sic] in?”

On 20 April 2017, Ms Holt also appears to have made a series of diary notes which were included in an envelope provided to staff at the Wangaratta Primary School for safe keeping.

The diary notes reiterate Ms Holt’s fear of Mr Floyd, and contain comments such as ‘he is searing me so much I don’t know what to do,” ‘he’s been accusing me of affairs for months now but its [sic] got so bad and scarey [sicj.’” A note dated 20 April stated, ‘He says “You know how much I love you dont [sic] you?” I say yes cause Im [sic] so scared and it seems he

is skeeming [sic] something about me and Im [sic] scared.”

The available evidence also suggests that Mr Floyd did appear to have some knowledge that his behaviour was abusive. In his own notes, he mentions the fact that the letters he had written to Ms Holt had gone missing and although he could not recall what he had written in them, he stated ‘I hope they are not viewed as some sort of emotional violence if that is what [Ms Holt] is up to.” Later, in an entry dated 21 April 2017, Mr Floyd wrote ‘J guess reading back I have been emotionally abusing [Ms Holt] and have said some terrible things?”

% Corunial Brief, Statement of P Barden, 325; Exhibit 18; Exhibit 28, 799-800.

® 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.

© Thid.

® Thid.

7 Coronial Brief, Exhibit 16, 670.

® Ibid 671.

® Thid 672.

™ Yhid 713.

® Thid 730.

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.”

Both the CRAF and the MARAM identify stalking as a risk factor which can indicate an increased risk of a victim being killed or almost killed.° This is supported by research which has found ‘a sirong association between stalking and subsequent lethal/near lethal abuse.’' This research also noted that in 15 per cent of the cases of femicide and attempted femicide that they examined, there was ‘prior stalking but no prior domestic violence’® and that ‘49% of the attempted or actual homicide victims who were not physically abused were stalked.® This highlights how important it is to recognise the serious risk of deadly harm presented by

stalking behaviours alone.**

Family violence — Sexual coercive behaviour

72,

The definition of family violence in the FVPA includes behaviour that is ‘sexually abusive.’®

Material in the coronial brief suggests that Mr Floyd engaged in sexually coercive behaviour towards Ms Holt.

In a series of letters and notes written by Mr Floyd to Ms Holt, Mr Floyd said he was unhappy with their relationship and accused her of cheating on him.** It is unclear when these documents were written as they are undated. They were discovered by Ms Holt’s family

members after the fatal incident and were provided to the coronial investigator.

Mr Floyd also wrote other letters to Ms Holt that appear to be more directly controlling and

threatening.

% 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.

® Coronial Brief, Exhibit 18, 718.

® Coronial Brief, Exhibit 18, 718-723.

*0 Department of Health and IIuman Services, above n 70, 27.

81 Judith McFarlane, Jacquelyn C Campbell and Kathy Watson, ‘Intimate. Partner Stalking and Femicide: Urgent Implications for Women’s Safety’ (2002) 20(1-2) Behavioural Sciences and the Law 64-65.

82 [bid 65.

3 Tid 66.

hid.

55 Section 5, Family Violence Protection Act 2008 (Vic).

86 Coronial Brief, Exhibit 13.

75,

Mr Floyd’s sexually coercive behaviour appears to have occurred alongside his other controlling and stalking behaviour. This is consistent with research which identifies that intimate partner sexual violence ‘generally occurs in the context of other forms of violence and was often part of a larger pattern of coercive control in a relationship.*’ Research also suggests that.victims of intimate partner sexual violence are ‘less likely to seek help than

victims of other forms of [family violence j.°**

Mr Floyd’s mental heaith treatment

76,

After reviewing the available evidence I requested an expert report from a mental health specialist, Dr Manjula O’Connor,®’ to examine the circumstances of Ms Holt’s and

Mr Floyd’s deaths and 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’s review indicates that Mr Floyd may have experienced a Delusional Disorder in the proximate period leading up to the fatal incident. Dr O’Connor’s assessment was made at the symptombased level which included reviewing medical records, firsthand clinician and service

statements and statements of family and friends.°°

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 one month of delusions but no other psychotic symptoms. Delusions are essentially false beliefs based on an incorrect inference about the external reality that

persists despite evidence to the contrary.

In the case of Mr Floyd, 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, The

overwhelming available evidence confirms that there was no basis for holding these beliefs.

Dr O’Connor further 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

®7 Australia’s National Research Organisation for Women’s Safety, above n 151, 2.

88 Thid.

8 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.

5° Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 7-10

5! The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) (2013).

% Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 10.

% Tbid, 10-11.

82,

Victoria Police. Service providers appeared to accept the validity of his reports of Ms Holt’s behaviours without any attempts to verify the accusations beyond checking with a neighbour

who Mr Floyd claimed was a drug dealer from whom Ms Holt obtained drugs.

Dr O’Connor’s report indicates that a red flag for services and clinicians is the presence of blame for psychological distress as reported by a client (especially a male based on increased likelihood of family violence perpetration) who attributes the actions of their intimate partner as the primary cause of their distress.°° Dr O’Connor outlines that in such circumstances, the emphasis for clinicians should be on confirming through assessment, empathetic exploration and collateral information, that a patient’s violence-supporting thinking and narratives by the

client, are based on an objective reality.”

I confirm that establishing the safety of the client and their intimate partner/family member through basic comprehensive assessment and engagement should be a foundation response.

Dr O’Connor however confirms that maintaining rapport with a client while gathering information and understanding of perpetrator thinking while not triggering an exacerbation in

violent behaviour towards the victim, is a complex balance.”

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

required.

RECOMMENDATION PURSUANT TO SECTION 72(2) OF THE ACT

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. There is however, no expansion of what this would look like or 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, 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

% Coronial Brief, Statement of police member dated 26 April 2017, 314.

55 Expert mental health report provided by Dr Manjula O’Connor dated 5 November 2019, 11-13.

%6 Thid. :

7 Tid, 12-13.

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.

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 Gregory Allen Floyd, born 5 September 1973;

b) the death occurred on 25 April 2017 at 9 Belle Avenue, Wangaratta, Victoria, from a

gunshot wound to the head; and c) the death occurred in the circumstances described above.

I convey my sympathy to Mr Floyd’s family.

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

the internet.

I direct that a copy of this finding be provided to the following: a) Mrs Annette Winestone, senior next of kin;

b) Karen Deckert;

c) Ms Lauren McKenzie;

d) Ms Alison Maclean, Principal Strategic Advisor, Ovens Murray Integrated Family

Violence Committee

e) Detective Sergeant Glenn Grandy, Professional Standards Command, Victoria Police;

f) Superintendent Belinda Bates, Civil Litigation Unit, Victoria Police; and

g) Detective Senior Constable Adrian Woodcock, Victoria Police, Coroner’s Investigator.

Signature:

CAITLIN ENGLISH DEPUTY STATE CORONER Date: 5 June 2020