Deceased
Abigail Louise Cooke-Mitchell
Demographics
42y, female
Coroner
State Coroner Judge John Cain
Date of death
2015-01-24
Finding date
2021-09-27
Cause of death
Traumatic right subdural haematoma
AI-generated summary
A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment occurred when her partner called a home doctor service at 5.14pm reporting a major head injury with swollen face and severe headache, but the service failed to triage appropriately as an emergency requiring ambulance attendance. Instead, a doctor was assigned 3 hours later. The ambulance was only called at 9.36pm after the home doctor advised it was necessary. The patient was airlifted to hospital but had unsurvivable injuries. The systemic failures identified include inadequate telephone triage protocols by the home doctor service (missing symptoms of head injury requiring 000 activation), lack of scripted information about delays, and compounding delays from doctor workload and travel distance. While earlier ambulance attendance may not have altered outcome, the case demonstrates critical failings in emergency medical telephone triage that should trigger immediate specialist assessment.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT Court Reference: COR 2015 0363
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: Abigail Louise Cooke-Mitchell Date of birth: 23 February 1972 Date of death: 24 January 2015 Cause of death: 1(a) Traumatic right subdural haematoma Place of death: Alfred Hospital, Victoria Catchwords: family violence
Mrs Abigail Louise Cooke-Mitchell was 42 years old and living with her partner, Mr Kevin Mitchell at the time of her death. Mrs Cooke-Mitchell had one child from a former relationship, a son born in 1991.
Mrs Cooke-Mitchell was born in Melbourne and was raised by her mother in Moorabbin until they moved to Carrum Downs in 1988. Mrs Cooke-Mitchell attended secondary school until Year 10 and left to commence work as an apprentice carpenter.
Mrs Cooke-Mitchell found employment with the Melbourne Theatre Company building sets and props and around 1990, she met Richard Nyogar. Mrs Cooke-Mitchell gave birth to their son in 1991. Shortly after giving birth, Mrs Cooke-Mitchell became addicted to heroin.
Mrs Cooke-Mitchell was prescribed methadone and other medications to treat her heroin addiction, but this was unsuccessful, and she also started to abuse alcohol around this period.
Mrs Cooke-Mitchell’s drug and alcohol use created friction in her relationship with Mr Nyogar and they separated in approximately 1993. They had ongoing parental care disputes with respect of their son.
Mrs Cooke-Mitchell and Mr Mitchell started a relationship in approximately 2007. Mrs CookeMitchell was financially dependent on Mr Mitchell and Mr Mitchell supported her use of drugs and alcohol by procuring these items for her throughout their relationship.
Mrs Cooke-Mitchell and Mr Mitchell were residing in Mr Mitchell’s parents’ home in Marina Avenue, McCrae until the fatal incident.
Mrs Cooke-Mitchell’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.
The Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mrs Cooke-Mitchell’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of Mrs CookeMitchell, including evidence contained in the coronial brief and further evidence obtained under my direction. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities. 1
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
The available evidence suggests that Mrs Cooke-Mitchell sustained a significant head injury on 22 January 2015 within a three hour time window between midday,2 when she was reported to have been found on the ground sometime after a fall,3 and 3pm when according to Mr Mitchell she had another fall. Following the second fall, Mrs Cooke-Mitchell was put to bed by Mr Mitchell who then left the home.
Mr Mitchell was a sub-contracting builder and over years had worked on a number of properties for Ms Janice Wurlod and her husband. According to Ms Wurlod, she had known Mr Mitchell and Mrs Cooke-Mitchell for approximately seven to eight years but had not seen Mrs CookeMitchell for three years.
1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. 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 as to those matters taking into account the consequences of such findings or comments.
2 Coronial Brief, Statement provided by Alfred Health dated 10 November 2015, 394-396 3 Ibid
On 22 January 2015 between 4pm and 5pm Mr Mitchell attended the home of Ms Wurlod’s daughter, for whom he had recently worked on an extension and kitchen renovation.4
Mr Mitchell’s visit appeared to be unexpected and the purpose was to request payment for the recent building work. Whilst he was there, Mr Mitchell asked Ms Wurlod if she knew of any doctors who would conduct a home visit. Mr Mitchell explained that he was at home earlier and had found Ms Cooke-Mitchell ‘in a terrible state’ where her head appeared swollen and bruised from a fall.5 Ms Wurlod advised Mr Mitchell to call an ambulance, but he said ‘she would refuse to go with them.’ Mr Mitchell stayed for approximately 5-10 minutes, then said he was going to call a doctor.6
At approximately 5.14pm that same day, Mr Mitchell contacted the National Home Doctor Service (NHDS).7 He informed the operator that: “I got home today and my wife has had a fall and um, I need to get someone to check her over, but she won’t let me call an ambulance but her face is all swollen up and she has a massive headache. She is one of these people that won’t go when you supposed to go.
Trouble, she is having trouble walking and stuff need to get someone to come and check her out, worst case scenario will get an ambulance, but she reckons she doesn’t need one but I reckon needs someone to check her face out, this is about the third time she has fallen over in the last week. On medication called bupe or something like that. Call taker: We will organise a doctor for Abigail and give you a call when the doctor is on the way.8
He then said that his wife had a fall whilst he was away, I understood that this meant he was not home when the fall happened. I did not know where he was when I was talking to him. Then I asked the symptoms of his wife and he said that his wife had a fall, she has a swollen face, I asked if anyone had witnessed the fall and he said he didn’t know as he was not there. I asked him if there was anything else and he said that his wife had a bruised eye. I did not ask him if she was conscious. I said that due to this situation he 4 Coronial Brief, Statement of Janice Wurlod dated 5 March 2015, 273 5 Ibid 6 Ibid 7 Coronial Brief, Statement of Dr Hieu Tang dated 2 February 2015, 318 8 Coronial Brief, National Home Doctor Service call transcript, 5121-5138 9 Coronial Brief, Statement of Dr Hieu Tang dated 2 February 2015, 318
needed to call an ambulance as I thought that she may have a head injury. He said that his wife did not listen to him and that his wife needed to see the doctor to get the advice from the doctor. He was insistent about me, the doctor coming. I said that in this situation he needed to ring the ambulance as I was far away and had other patients to attend to first. He said, no no, his wife needed to see the doctor and I said if I go there, I would still refer her to the hospital, so please ring the ambulance as I explained I had 2 patients on my list to see before I get there. I did not tell him a time I would get there as I did not know how long the patients would be. I told him to ring the ambulance straight away.10
At 9.36pm the same day, Mr Mitchell contacted emergency services and an ambulance was dispatched to Mrs Cooke-Mitchell’s home address on Marina Avenue, McCrae, arriving at approximately 9.42pm.11 Ambulance paramedics who attended the residence noted that Mrs Cooke-Mitchell was unresponsive and had swelling from significant left facial injuries and a swollen left eye.12 Mr Mitchell reported that Mrs Cooke-Mitchell also had bruising on her buttocks from a fall the previous week.
Mrs Cooke-Mitchell was airlifted to the Alfred Hospital where she was assessed as having an un-survivable brain injury. She was subsequently taken off life support and passed away on 24 January 2015.13 Identity of the deceased
Upon reviewing the available evidence, Coroner Rosemary Carlin completed a Form 8 Determination by Coroner of Identity of Deceased dated 26 January 2015, concluding that the identity of the deceased was Abigail Louise Cooke-Mitchell born 23 February 1972.
Medical cause of death
10 Ibid, 319 11 Coronial Brief, Statement of Amanda Green, 328-329; Statement of Claire Emma McDonald dated 3 April 2015, 331-335 12 Ibid 13 Coronial Brief, Statement of Professor David Tuxen dated 10 November 2015, 395-396
(a) The postmortem examination revealed evidence of an acute right subdural haematoma with associated mass effect on the brain. A thin subdural membrane was indicative of organised past subdural haemorrhage;
(b) Bruises were evident over the face, arms, legs, back and left buttock. No evidence of fractures. There is no precise method of determining the age of soft tissue injuries such as bruises.
(c) A subdural haematoma is where blood collects in the space surrounding the brain, usually from bleeding due to trauma to the head. This may lead to headache, confusion and eventual loss of consciousness and death when there is compression of essential centres in the brain; and
(d) There was a neuropathology report completed by Dr Linda Iles which documented that dating of subdural haematomas is difficult and only approximate aging is possible. In this case, there was evidence of substantial acuate subdural haemorrhage consistent with an acute event, i.e. less than 48 hours old.
Toxicological analysis of post-mortem blood samples identified the presence of morphine, diazepam, and metabolites of nordiazepam and temazepam, midazolam, mirtazapine, and ibuprofen. None of these detected substances were at levels that suggest a connection to the mechanism of death in this case.
There was a significant level of alcohol detected in ante mortem blood at a level of 0.21 g/100mL. This may cause depression of the central nervous system with effects on cognition but was not a fatal amount.
Dr Young provided an opinion that the medical cause of death was ‘1(a) Traumatic right subdural haematoma’.
FURTHER INVESTIGATIONS AND CPU REVIEW Family violence investigation
As Mrs Cooke-Mitchell’s death occurred in circumstances of recent family violence, I requested that the Coroners’ Prevention Unit (CPU) 14 examine the circumstances of Mrs Cooke-Mitchell’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).15 I also requested medical specialists from the CPU’s Health and Medical Team review the service services provided by the NHDS in the lead up to Mrs Cooke-Mitchell’s death.
The available evidence suggests that Mrs Cooke-Mitchell and Mr Mitchell’s relationship was tumultuous and characterised by numerous family violence incidents primarily perpetrated by Mr Mitchell.
Mrs Cooke-Mitchell’s relationship with Mr Mitchell met the definition of ‘spouse under the Family Violence Protection Act 2008 (Vic) (the FVPA).16 The family violence perpetrated by Mr Mitchell towards Mrs Cooke-Mitchell in the lead up to the fatal incident met the definition of ‘family violence’ in the FVPA.
An in-depth family violence investigation was conducted in this case and I requested materials from several key service providers that had contact with Mrs Cooke-Mitchell and Mr Mitchell prior to Mrs Cooke-Mitchell’s death.
History of police contact with Mrs Cooke-Mitchell and Mr Mitchell
15 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community.
16 Section 8(1)(a) of the Family Violence Protection Act 2008 17 Ibid 105.
She also disclosed an incident where Mr Mitchell had braked suddenly in the car causing an injury to her neck.19
In her subsequent engagement with Safe Steps Mrs Cooke-Mitchell disclosed more extensive family violence perpetrated by Mr Mitchell, including physical and sexual abuse.20 A risk assessment completed by Safe Steps noted Mr Mitchell had access to weapons, had harmed/threatened to harm Mrs Cooke-Mitchell, had tried to choke her, threatened to kill her, sexually assaulted her, stalked her, harmed or threatened to harm animals, attempted or threatened suicide, and exhibited jealous and controlling behaviour towards her.21
On 30 April 2012 Mrs Cooke-Mitchell applied for and obtained a Family Violence Intervention Order (FVIO) to protect her from Mr Mitchell, and the couple separated for approximately nine months.22
Between April 2012 and August 2013, Mr Mitchell enrolled in a men’s program in Rosebud and participated in 34 of 46 group sessions. A case worker from the program maintained contact with Mrs Cooke-Mitchell during this time, and their notes indicated that Mr Mitchell’s ability to support Mrs Cooke-Mitchell ‘did not develop while he was in the program’23 and his ‘use of abusive behaviours towards [Mrs Cooke-Mitchell] continued whilst he attended the group.’24
In approximately July 2013, Mrs Cooke-Mitchell relapsed into opiate and alcohol abuse. At the time she told her treating General Practitioner (GP) that her relapse was due to her relationship with Mr Mitchell, who she reported was ‘passive aggressive.’25 Mrs Cooke-Mitchell was prescribed Suboxone treatment, which she continued on a fairly regular basis up until the date of her death.26 18 Coronial brief, Statement of A Haines, 75.
19 Coronial brief, Statement of S Brown, 79, Statement of A Gillespie, 179, 183.
20 Ibid.
21 Ibid.
22 Coronial brief, Certified extract of family violence intervention order dated 30 April 2012, 5975-5976.
23 Coronial brief, Statement of G Johns, 188.
24 Ibid.
25 Coronial brief, Statement of M Kozminsky, 219.
26 Ibid 219-220.
On 11 April 2014 Mrs Cooke-Mitchell made a further report of family violence to Victoria Police in Rosebud. On this occasion she disclosed that Mr Mitchell had perpetrated verbal abuse and controlling behaviour against her for the past seven years. She stated that she wanted to leave Mr Mitchell but was worried that he would assault her or kill her if she did. She also stated that she felt isolated and that Mr Mitchell was deliberately refusing to take her for her driver’s license test because he wanted to control her. She alleged that he would not allow her to work and that she was financially dependent on him, having to ask for permission to purchase food and essentials.27 Police issued a Family Violence Safety Notice (FVSN) to protect Mrs Cooke-Mitchell28 and the matter was listed for a mention hearing at the Frankston Magistrates’ Court on 14 April 2014. Neither Mr Mitchell nor Mrs Cooke-Mitchell attended the hearing and an interim FVIO was granted in their absence, which included a condition that prohibited Mr Mitchell from residing at the marital property in McCrae.29
On 16 April 2014, Mrs Cooke-Mitchell contacted the Salvation Army Crisis Service (SACS) for housing assistance, stating that she wanted to get away from Mr Mitchell and was scared that he would find her. She reported that he had sexually assaulted her the day prior by forcing her to have sex against her will.30
On 17 April 2014, Mrs Cooke-Mitchell contacted her GP asking for her Suboxone prescription to be moved to a new pharmacy. She told her GP that she was leaving Mr Mitchell and that he had been emotionally abusing her, preventing her from getting her license, and supplying her with alcohol to encourage her relapse into alcohol abuse.31
On 18 April 2014, Mrs Cooke-Mitchell attended the St Kilda Police Station and reported that Mr Mitchell had been persistently breaching the FVIO. She stated that Mr Mitchell had been repeatedly calling and texting her and she was worried that he knew where she was. She also reported that he was living at the marital property in McCrae despite the FVIO prohibiting him doing so.32
Over the following days Mrs Cooke-Mitchell contacted several support services, including Safe Steps and Homeground, seeking their assistance to leave her relationship with Mr Mitchell.33 27 Coronial brief, Statement of S Brown, 78-80, Statement of B Long 81-84; Victoria Police LEAP records, 34-35.
28 Coronial brief, Statement of B Long, 83.
29 Coronial brief, Statement of S Brown, 78-80, Statement of B Long 81-84; Victoria Police LEAP records, 34-35.
30 Coronial brief, Salvation Army Crisis Service Case Notes, 155.
31 Coronial brief, Statement of M Kozminsky, 220-221.
32 Coronial brief, Statement of D Beaman, 86-87.
33 Coronial brief, Salvation Army Crisis Service case notes, 153-55, 164-168, Homeground case file records, 173-78, Statement of A Gillespie, 179-180, Safe Steps SHIP records, 182-185.
In late April 2014 Mrs Cooke-Mitchell relocated to Cairns in Queensland.34 On 4 May 2014 Mr Mitchell flew to Cairns after Mrs Cooke-Mitchell purportedly requested money and clothing from him.35
On 5 May 2014 a family violence incident occurred in Cairns. Mr Mitchell alleged that during this incident Mrs Cooke-Mitchell punched him to the left eye.36 Mr Mitchell also described an incident the following day where Mrs Cooke-Mitchell was purportedly upset that he would not give her any more money and as a result would not let him leave the hotel room. A physical altercation occurred during which Mr Mitchell stated Mrs Cooke-Mitchell put her hands around his neck, bit him on the shoulder and punched him in the head.37
On 7 May 2014 Mrs Cooke-Mitchell moved into a family violence refuge in Cairns.38
The following day Mrs Cooke-Mitchell called Queensland Police to request that they assist her to safely remove her belongings from her former accommodation. When they attended that accommodation with Mrs Cooke-Mitchell, Queensland Police noted that Mr Mitchell had injuries to his face and conveyed him to the police station for interview.39 Mrs Cooke-Mitchell disclosed to police that Mr Mitchell had sexually assaulted her but declined to provide specific details. Queensland Police records from their interview of Mr Mitchell indicated that they believed he exhibited ‘crocodile tears whilst speaking to police,’40 and ‘his answers, mannerisms and body language suggested he may be trying to avoid any blame.’41
At some point in May 2014, Mr Mitchell returned to Melbourne. On 31 May 2014, he was interviewed by Victoria Police in relation to the breaches of the FVIO Mrs Cooke-Mitchell had reported on 18 April 2014.42
In June 2014, Mrs Cooke-Mitchell returned to reside at the marital property in McCrae. On 16 June 2014 she failed to attend a court hearing in relation to the FVIO with Mr Mitchell and the matter was struck out. On the same day Mrs Cooke-Mitchell’s mother assisted her with buying 34 Coronial brief, Statement of J Cooke, 105.
35 Ibid 106; Coronial brief, Queensland Police Services records, 193, Statement of J Mitchell, 238.
36 Coronial brief, Queensland Police Services records, 193.
37 Ibid.
38 Ibid 191; Coronial brief, Centrelink records, 6665.
39 Coronial brief, Queensland Police Services records, 193.
40 Ibid 5.
41 Ibid.
42 Coronial brief, Statement of D Beaman, 87; Exhibit 89 - Transcript of Victoria Police interview with Kevin Mitchell dated 31 May 2014, 6607-6634.
a security camera and lights, after Mrs Cooke-Mitchell stated that Mr Mitchell kept coming around to the house at night.43
It appears that at some point after this, Mrs Cooke-Mitchell recommenced her relationship with Mr Mitchell.44 From approximately mid-June Mr Mitchell commenced regularly purchasing alcohol and illicit substances, which appear to have been for Mrs Cooke-Mitchell.45
On 4 July 2014, Mr Mitchell attended Victoria Police station in Rosebud and reported that Mrs Cooke-Mitchell had assaulted him and that such assaults were a regular occurrence. Police applied for a FVSN to protect Mr Mitchell, and Mrs Cooke-Mitchell was arrested, interviewed and served with the FVSN on 5 July 2014.46 During her interview Mrs Cooke-Mitchell disclosed in the she had been in an abusive relationship with Mr Mitchell for years but did not wish to provide further details.47 Mrs Cooke-Mitchell told her mother that Mr Mitchell had inflicted the injuries upon himself and blamed her for them.48 Other parties noted witnessing bruises on Mr Mitchell’s face in the year prior to Mrs Cooke-Mitchell’s death. When queried about these injuries, he claimed they were caused by Mrs Cooke-Mitchell.49
On 5 July 2014, Mrs Cooke-Mitchell disclosed to her GP that Mr Mitchell was financially and emotionally abusive but denied any physical violence had occurred. She described an incident where Mr Mitchell had yelled and screamed at her on the morning of her driver’s license test, as a result of which she was unable to concentrate and failed the test. The GP discussed family violence with Mrs Cooke-Mitchell at length and provided her with printed information about family violence and support services and advised her to keep it where Mr Mitchell would not see it.50 43 Coronial brief, Statement of J Cooke, 106.
44 Coronial brief, Statement of M Kozminsky, 222.
45 Coronial brief, Statement of E Mitchell, 227, Exhibits 64-68, 5948-5953.
46 Coronial brief, Statement of E Chala 89-91, Application for a Family Violence Safety Notice, 4726, Transcript of interview with Abigail Cooke-Mitchell dated 5 July 2014, 6589-6606; Victoria Police LEAP records, 23; Victoria Police L17 records, 5.
47 Coronial brief, Statement of K Larsen, 94-95, Exhibit 87 - Transcript of Victoria Police interview with Abigail Cooke-Mitchell dated 5 July 2014, 6589-6606.
48 Coronial brief, Statement of J Cooke, 110.
49 Coronial brief, Statement of M D’Alterio, 256, Statement of J Wurlod, 274.
50 Coronial brief, Statement of M Kozminsky, 222, Exhibit 46 – Genesis Medical Centre medical records relating to Abigail Cooke Mitchell, 5199-5200.
On 7 July 2014, a FVIO was granted to protect Mr Mitchell from Mrs Cooke-Mitchell. It contained conditions which prevented Mrs Cooke-Mitchell from committing family violence against Mr Mitchell but did not prevent them from living or communicating with each other.51
From around 28 July 2014 onwards Mr Mitchell began purchasing alcohol almost daily.52
On 29 July 2014, Mr Mitchell signed a statement of no complaint with respect to Mrs CookeMitchell in relation to the family violence incident between the couple on 4 July 2014. Despite this, in August 2014 a summons was issued for Mrs Cooke-Mitchell to attend court in relation to this charge.53
During the following months Mrs Cooke-Mitchell booked but failed to attend multiple driving test appointments at VicRoads. She also failed to attend scheduled appointments with Centrelink, and as a result her payments were stopped. Text messages sent around this time between Mrs Cooke-Mitchell and Mr Mitchell indicate Mrs Cooke-Mitchell felt isolated and did not have access to basics and groceries or the means to obtain them herself.54
On 2 September 2014, Mrs Cooke-Mitchell told her GP she had recommenced abusing alcohol and that Mr Mitchell had not taken her to a job interview, which led to the cancellation of her Centrelink payments, increased her financial dependence upon him, and prevented her from leaving him. The GP strongly encouraged Mrs Cooke-Mitchell to get legal advice.55
On 23 September 2014, Mr Mitchell was served with a charge and summons for breaching the FVIO Mrs Cooke-Mitchell held against him in relation to the events in April 2014.56
Diary entries recorded in Mrs Cooke-Mitchell’s phone in October and November 2014 detail ongoing family violence perpetrated by Mr Mitchell against Mrs Cooke-Mitchell during this period, including instances of verbal abuse, physical abuse, denial of access to money, denial of transport to medical appointments, and failures to take her to scheduled driving tests.57 51 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 596; Intervention Order dated 7 July 2014, 4727.
52 Coronial brief, Exhibits 64-68, 5948-5953.
53 Victoria Police LEAP records, 2.
54 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 1199-1200.
55 Coronial brief, Statement of M Kozminsky 219, 222; Exhibit 46 - Genesis Medical Centre medical records relating to Abigail Cooke-Mitchell, 5198.
56 Victoria Police LEAP records, 57.
57 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 589-591.
Evidence from Mrs Cooke-Mitchell’s phone suggests that on 16 November 2014 Mrs CookeMitchell lost a tooth as a result of a physical assault by Mr Mitchell.58 In a conversation with a counsellor on 18 November 2014, Mr Mitchell noted that Mrs Cooke-Mitchell had chipped her tooth after he pushed her and she knocked her teeth on a bottle.59
Images on Mrs Cooke-Mitchell’s phone taken on 22 November 2014 indicate a hole in the wall at her home.60 When later asked about this hole by Victoria Police, Mr Mitchell stated that Mrs Cooke-Mitchell had ‘come at him’ when she was drunk and he had deflected her, causing her to fall into the wall with her buttocks.61
On 24 November 2014, Mrs Cooke-Mitchell disclosed ongoing family violence to her drug and alcohol counsellor and stated that she was intending to separate from Mr Mitchell.62 She also told friends, family, and Mr Mitchell, that she was planning to separate from him.63
At around this time Mr Mitchell began telling people that Mrs Cooke-Mitchell was unwell and having difficulty walking and climbing the stairs at their home.64 On 6 December 2014 Mr Mitchell hired a disability shower stool, purportedly for Mrs Cooke-Mitchell.65
Several text messages sent between 7 and 11 December 2014 between Mr Mitchell and Mrs Cooke-Mitchell suggest that Mrs Cooke-Mitchell repeatedly asked Mr Mitchell to take her to a medical practitioner but Mr Mitchell did not do so.66
On 12 December 2014, Mrs Cooke-Mitchell attended her GP and reported that Mr Mitchell had thrown her causing an injury to her buttock. The GP observed the injury and took photographs.
He also referred Mrs Cooke-Mitchell for an x-ray as he was concerned she may have a pelvic fracture, but Mrs Cooke-Mitchell declined the referral, stating she did not want her husband to know she had shown the GP her injury.67
59 Coronial brief, Exhibit 52 - New View Psychology medical records relating to Kevin Mitchell, 5593.
60 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 4210-4211.
61 Coronial brief, Exhibit 65 - Transcript of Victoria Police interview with Kevin Mitchell dated 10 November 2014, 6398.
62 Coronial brief, Exhibit 50 - Peninsula Health medical records relating to Abigail Cooke-Mitchell, 5386.
63 Coronial brief, Statement of J Cooke, 112.
64 Coronial brief, Statement of J Mitchell, 241, Statement of M D’Alterio, 256-257.
65 Coronial brief, Statement of R Barry, 28.
66 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 506-507, 510, 513-15, 510, 1225.
67 Coronial brief, Statement of M Kozminsky, 219.
68 Coronial brief, Exhibit 25 - Phone records of Abigail Cooke-Mitchell, 4214-4220.
from instances where Mrs Cooke-Mitchell had become violent whilst intoxicated and he had grabbed her by the hair and pushed her away. He stated this occurred one to two times per week in the lead up to her death.69
When queried by the pharmacist as to why she was obtaining an additional dosage, when she should have had enough medication at home to last her a few more days, Mrs Cooke-Mitchell stated that her husband sometimes took her medication from her.70
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death: National Home Doctor Service
The available evidence suggests that there were two events on 22 January 2015, one at midday and another at approximately 3pm in the setting of historical subdural brain bleeds. The circumstances and time of the final fatal head trauma on 22 January 2015 remains unknown.
Mr Mitchell’s decision making led to significant delays in Ms Cooke-Mitchell accessing timely specialist medical assessment and treatment. These delays were compounded by the NHDS triage system where Mr Mitchell was not advised to call 000 for an ambulance when he first requested a doctor and reported Mrs Cooke-Mitchell’s symptoms. At the time of the initial call at approximately 5.14pm, Mr Mitchell described an ‘unwitnessed’ fall and symptoms of a significant head injury, ‘she’s got a massive headache… she’s having trouble walking and stuff… I need to get someone to check her out.’71
These symptoms warranted an immediate call to emergency services and ambulance attendance. Instead the NHDS operator continued with setting up a visit by a doctor who was not assigned until three hours after the first 5.14pm call.
69 Coronial brief, Exhibit 85 - Transcript of Victoria Police interview with Kevin Mitchell dated 10 November 2014, 6398.
70 Coronial brief, Statement of M Caplan, 201.
During the 5.14pm call, there was no scripted ending by the NHDS call taker to inform Mr Mitchell of a surge in demand and estimated arrival time.72 A current high demand for doctor resources at the time of an initial telephone conversation may prompt the caller to seek alternative medical assistance. Delays in transfer and treatment were compounded by the allocated doctor’s workload and travel distance.
I invited the NHDS to provide a response to concerns raised in this case and they provided statements from:
(a) Dr Umberto Russo, Chief Medical Officer of 24-7 Healthcare, of which NHDS is a wholly owned subsidiary; and
(b) Ms Rebecca Lombardo, Coaching and Quality Team Lead of the NHDS.
Dr Russo confirmed that the NHDS triage policy in 2015 indicates that ‘head injury’ and ‘loss of consciousness’ required the operator to advise the caller that the call was an emergency and 000 needed to be contacted. Dr Russo concedes that upon review of the transcript that several concerning symptoms were reported by Mr Mitchell and that these symptoms should have prompted the NHDS operator to advise Mr Mitchell to call emergency services.73 He also concedes that the lengthy delay between the receipt of the call and the actual dispatch of the booking was unacceptable and that would not have occurred today as the medical practitioner receiving the booking performs an important second line triage role.74
Dr Russo confirms that if the call from Mr Mitchell on 22 January 2015 was made today, he would have been advised at the first instance to contact emergency services. The symptoms of ‘massive headache’ would have triggered the NHDS operator to advise him to call 000 pursuant to new policies. The symptoms of ‘fall’ and ‘face swollen’ would also now prompt an NHDS operator to ask if there was a blackout or vomiting or drowsiness, as not only are current NHDS operators trained to enquire for more details about any reported symptom, but their Connect program system that is utilised by operators prompts such questions.
Dr Russo also confirms that the delay between receipt of Mr Mitchell’s call and allocation of the case to a doctor would also not occur today as changes to procedure ensures that there is now a streamlined process for allocation to occur within 15 minutes of receipt of the initial 72 A coronial recommendation directed to ESTA 000 in the November 2018 Asthma Thunderstorm Findings. www.coronerscourt.vic.gov.au.
73 Statement of Dr Umberto Russo dated 8 June 2021, 2 74 Ibid
call.75 The allocated doctor will perform a secondary triage to ensure that emergency calls are diverted to 000.
The statement of Ms Lambardo confirms that the current training regime for phone operators employed by the NHDS. These include improvements to the triage system that ensure that if the operator is not clear about the symptoms or conditions of a patient, they are advised to tell the caller to contact emergency services.76
Ms Lambardo also confirms that if ‘unwitnessed fall’ is selected as part of the triage performed by NHDS operators, they will be prompted to record further information and then the call should be triaged to inform the caller to contact 000.77
The concerns raised by the coronial investigation into services provided by NHDS to Mr Mitchell and Mrs Cooke-Mitchell identified significant missed opportunities to intervene in the circumstances of Mrs Cooke-Mitchell’s death. The medical examination of Mrs CookeMitchell revealed that the cause of death from a subdural haematoma was likely less than 48 hours in age from the date of the neuropathological exam conducted on 24 January 2015.78 There was also evidence of previous subdural bleeding from historical head injuries a few weeks old. Whether an earlier attendance of an ambulance to transport Mrs Cooke-Mitchell to hospital would have altered the outcome in this case is speculative as the exact time of the fatal head injury remains unknown.
Salvation Army – Family violence outreach program
They can be referred by a range of services including a general practitioner, a maternal and child health nurse, or a teacher or counsellor at their child’s school or by another specialist service such as housing, Integrated Family Services, or drug and alcohol or mental health services. These services provide an important role in identifying risks and supporting vulnerable women and children experiencing family violence.
no response. They sent a text message on 2 May 2014 suggesting Mrs Cooke-Mitchell nominate an appropriate time to speak with them. Mrs Cooke-Mitchell responded, stating ‘Not sure if you’re still able to help… im [sic] in cairns [sic]. Later this afternoon would be a good time.
.[sic] thank you.’79 The service responded ‘Thank you for your reply. As you are in Cairns we are unable to offer support.’80
The referral form provided to the Family Violence Outreach Program by Homeground indicated Mrs Cooke-Mitchell faced significant family violence risk from Mr Mitchell, and noted the presence of several risk factors that could indicate Mrs Cooke-Mitchell was at an increased risk of being killed or seriously injured.81
The text message from Mrs Cooke-Mitchell indicated that she was receptive to their assistance and did not indicate whether Mrs Cooke-Mitchell was in Cairns permanently, or whether she had appropriate safety and support measures in place.
I note that whilst it may not have been appropriate for the Family Violence Outreach Program to provide ongoing assistance to Mrs Cooke-Mitchell whilst she was living interstate, the Family Violence Outreach Program worker should have contacted Mrs Cooke-Mitchell to confirm her living arrangements, conduct a risk assessment and ensure she was linked in with appropriate supports before ceasing their contact with her.
I note that whilst this service contact evidences a lack of appropriate risk assessment and follow up referrals, these shortcomings are likely to have been addressed by subsequent reforms to the family violence service system, following the Royal Commission into Family Violence82. In 2020, the most recent iteration of the Code of Practice for Specialist Family Violence Services83 developed by Domestic Violence Victoria was introduced and notes that the ‘safety of victimsurvivors is the cornerstone principle of specialist family violence services and is prioritised at all times.’84
All services that come into contact with family violence victims should be equipped to identify, assess and manage risk, and to ensure that victims are supported. Following recommendations made by the Royal Commission into Family Violence, the Multi Agency Risk Assessment and 79 Coronial Brief, St Kilda Crisis Service records relating to Abigail Cooke-Mitchell, 152.
80 Ibid.
81 Ibid159.
82 Royal Commission into Family Violence Final Report (March 2016), Volume 2, Chapter 8, 1 83 Domestic Violence Victoria, Code of practice: Principles and standards for specialist family violence services for victim survivors (2020, 2nd ed).
84 Ibid 36.
Management (MARAM) framework was introduced in September 2018, which identifies family violence screening and risk assessment as a key responsibility of family violence support services and provides clear and practical guidance to such services about conducting such assessments when first making contact with a client.85 I confirm that several of the Salvation Army’s programs including the Family Violence Outreach Program are services required to align with MARAM and ensure that staff are trained appropriately to screen for family violence risk and provide access to support services or referrals.
Victoria Police FVIO Contravention action
On 18 April 2014, Mrs Cooke-Mitchell reported to police that Mr Mitchell had repeatedly breached the FVIO in place to protect her.86 Mrs Cooke-Mitchell presented as fearful and was concerned that Mr Mitchell had discovered where she was staying. Police examined her phone and discovered numerous calls and messages from Mr Mitchell in contravention of the FVIO.87 A VP Form L1788 was completed, referrals were submitted for Mrs Cooke-Mitchell and Mr Mitchell and a criminal investigation was commenced.89
On 31 May 2014, Mr Mitchell was interviewed with respect to breaching the FVIO and made admissions to having been served with the FVIO and having breached it.90
The record of Mr Mitchell’s interview for the FVIO breaches was received on 16 June 2014 by the police informant and a brief was compiled. However, the charge and summons for this contravention was not issued and sent to Mr Mitchell until 21 September 2014.91
Whilst the initial actions of Victoria Police responding to the reported breaches of the FVIO appear to have been appropriate, it is concerning that Mr Mitchell was not charged in respect to contravening the FVIO until approximately five months after the contraventions occurred, 85 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018).
86 Coronial brief, Statement of D Beaman.
87 Ibid 86; Victoria Police LEAP records, 29.
88 An L17 refers to the Victoria Police Risk Assessment and Management Report that Victoria Police are required to complete after they have attended a family incident. The report is completed when family incidents, interfamilialrelated sexual offences, and child abuse are reported to police. The report includes information on the incident itself, the affected family member and other party (OTH), hazards/risk factors present at the time of the incident and any actions taken by Victoria Police following the incident including referrals for support.
89 Victoria Police LEAP records, 29.
90 Coronial brief, Statement of D Beaman, 87, Exhibit 89 – Transcript of Victoria Police interview of Kevin Mitchell dated 31 May 2014.
91 Coronial brief, Statement of D Beaman, 88; Victoria Police LEAP records, 48.
despite him admitting to having committed the offences. This was a significant missed opportunity to hold Mr Mitchell accountable for his behaviour and reinforce that contraventions of the FVIO would result in criminal charges.
Family violence investigation – a ‘trauma informed’ approach
On 4 July 2014, Mr Mitchell reported to Victoria Police that Mrs Cooke-Mitchell had punched him in the face whilst he was driving. He stated that she was substance affected by heroin and alcohol at the time. He further stated that when they returned to their property in McCrae, Mrs Cooke-Mitchell reportedly fell out of the car and that Mr Mitchell left her on the ground whilst he took their dogs for a walk. When he returned he reportedly tried to assist Mrs CookeMitchell to go inside and she slapped him in the head with an open hand. Mr Mitchell advised that he then left her on the stairs and attended the local police station to report the assault.
During his engagement with police on 4 July 2014, Mr Mitchell reported that Mrs CookeMitchell had been violent in the past but that this was the first time he had reported it to the police. He also stated that he had previously had black eyes as a result of her assaults which he had tried to hide from others.95
Victoria Police took photographs of Mr Mitchell’s injuries, issued a FVSN to protect him, made formal referrals for both parties, and commenced a criminal investigation in relation to potential assault charges.96 92 Finding in the investigation into the death of Joy Rowley dated 21 July 2019 (2011 3947) 23.
93 Ibid.
94 Ibid.
95 Coronial Brief, Statement of E Chala, 89-91; Application for a Family Violence Safety Notice, 4726.
96 Coronial brief, Family Violence Intervention Order dated 7 July 2014, 4727, Application for a Family Violence Safety Notice, 4726; Victoria Police LEAP records, 23.
On 7 July 2014 a FVIO was issued in protection of Mr Mitchell which prohibited Mrs CookeMitchell from committing family violence against him but did not prohibit them from living together or having contact with each other.97
Mrs Cooke-Mitchell was interviewed by Victoria Police on the same evening, and was described by one of the interviewing officers as ‘difficult to engage throughout the entire interview.’98 It was noted she was ‘inconsolable and erratic and implied domestic violence was a frequent feature of her relationship with [Mr Mitchell]’99 but, ‘despite being given numerous opportunities to discuss these allegations further [Mrs Cooke-Mitchell] declined to co-operate and was dismissive of our offer to discuss her circumstances further or accept referrals.’100
The transcript from Mrs Cooke-Mitchell’s interview with police indicates that she alleged that Mr Mitchell was abusive, had engaged in conduct that day which he knew had ‘gone too far’101 and had contacted Victoria Police because he wanted to make a report before Mrs CookeMitchell did.102 However, when questioned further by police about this, Mrs Cooke-Mitchell declined to identify any injuries or disclose specifics as to what Mr Mitchell had done or the violence that he had perpetrated against her.103
In the absence of further, more specific, disclosures from Mrs Cooke-Mitchell, the actions of Victoria Police in response to Mr Mitchell’s complaint could be argued to be appropriate based on the Code of Practice for the Investigation of Family Violence104 that was in place at the time.
On this occasion, Mr Mitchell presented with visible injuries and reported being fearful of Mrs Cooke-Mitchell. It is also arguable, however, that Victoria Police could have interrogated Mr Mitchell further about his history of perpetrating family violence against Mrs Cooke-Mitchell.
98 Coronial brief, Statement of K Larsen, 94.
99 Ibid.
100 Coronial brief, Statement of K Larsen, 94, Exhibit 87 - Transcript of Victoria Police interview of Abigail CookeMitchell dated 5 July 2014, 6599.
101 Ibid.
102 Ibid.
103 Ibid 6589-6606.
104 Victoria Police, Code of Practice for the Investigation of Family Violence (June 2014) 3rd ed, vol 2.
disclosure and understanding difficult presentations as ‘an adaptive response to challenging life experiences.’105
The available evidence indicates that Mrs Cooke-Mitchell was arrested in the late evening, held in a cell for several hours and interviewed at 4.20am the following morning.106 Given her experience of being a family violence victim in the past, this most likely exacerbated her existing trauma. This did not create a safe space for disclosures, she appeared to be quite distressed by this treatment, noting ‘you just left me locked up in a cell when he’s done all this to me,’107 ‘it’s wrong to put the victim in a cell’108 and ‘I can’t believe you are putting me through all of this.’109
Had Victoria Police reviewed historical LEAP records, they would have been aware of Mrs Cooke-Mitchell’s history of mental illness and experiences of family violence. They would have also been informed that there was an ongoing investigation in relation to Mr Mitchell contravening a FVIO that had been in place to protect Mrs Mitchell arising from the events of April 2014. Despite the availability of this information, Victoria Police appear to make no reference to, or acknowledgement of, this history in their interview with either party. It is unclear whether this was because they did not review the LEAP records, or they chose not to refer to them.
Research conducted by ANROWS notes that a ‘failure to recognise trauma, and misunderstanding trauma-related behaviours, can contribute to inappropriate and unhelpful responses to those seeking help.’110 Further, this research notes that negative interactions ‘could seriously damage women’s trust and self-confidence’111 and such responses can ‘magnify the effects of trauma and reduce the likelihood of future help-seeking.’112
Mrs Cooke-Mitchell’s engagement with police on 7 July 2014 appears to have impacted upon her willingness to engage with Victoria Police subsequently. After this incident Mrs CookeMitchell ‘said the police were on her side when she told them her story and this changed when [Mr Mitchell] went and saw them.’113 As evident in the Police records, Mrs Cooke-Mitchell 105 Family Safety Victoria, Foundation Knowledge Guide (2020) 34.
106Coronial brief, Exhibit 87 - Transcript of Victoria Police interview with Abigail Cooke-Mitchell dated 5 July 2014, 6589.
107 Ibid.
108 Ibid 6600.
109 Ibid 6605.
110 Salter et al, ‘A deep wound under my heard: Constructions of complex trauma and implications for women’s wellbeing and safety from violence’ ANROWS Research Report (Issue 12, 2020), 113.
111 Ibid.
112 Ibid.
113 Coronial brief, Statement of J Cooke, 110.
made no further reports of family violence to Victoria Police after this interaction, despite continuing to diarise and document her experiences privately.
I confirm that this issue has been addressed by the subsequent implementation of the MARAM, which Victoria Police are now required to follow. The MARAM aims to ensure that services responding to family violence in Victoria have a shared understanding of family violence and requires prescribed services to adopt a ‘trauma-informed approach that recognises how different experiences of trauma in adults and children, might affect a person’s presentation, needs and ability to engage with services.’114
I further note that Victoria Police have made several changes to their family violence response in 2019 and beyond. A new Family Violence Report VP Form L17 has been developed, which explicitly requires police to check the parties LEAP history of family violence, and measures have been put in place to encourage accurate and thorough completion of these reports.115
In response to concerns raised by this coronial investigation, Victoria Police confirm that if a similar incident occurred today, police members would be required and expected to take a different approach utilising the new Family Violence Report L17. For instance, members would be required to proactively support the victim of family violence to make a statement or take other protective measures, making appropriate referral pathways, applying for an FVIO on the victim's behalf and/or compiling a brief of evidence even where there is an unwilling complainant.116
(a) the identity of the deceased was Abigail Louise Cooke-Mitchell, born 23 February 1972;
(b) the death occurred on 24 January 2015 at the Alfred Hospital, Victoria from 1(a) Traumatic right subdural haematoma; and
(c) the death occurred in the circumstances described above.
114 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018) 20.
115 Victoria Police Practice Guide - Family Violence Roles and Responsibilities, 3-4, 11-12.
116 Victoria Police response dated 7 May 2021, 4
Having considered all the available evidence, I am satisfied that no further investigation is required in this case.
I convey my sincere condolences to Mrs Cooke-Mitchell’s family for their loss.
Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Mr Kevin Mitchell, Senior Next of Kin Colonel Winsome Merrett, Chief Secretary, Salvation Army Australia Dr Umberto Russo, Chief Medical Officer, National Home Doctor Service Mr Benjamin Liu, CEO, National Home Doctor Service Ms Lauren Callaway, Assistant Commissioner, Family Violence Command, Victoria Police Ms Linsey Walker, Victorian Government Solicitor’s Office Detective Senior Constable Dustin Sheppard, Coroner’s Investigator Signature: ______________________________________ Judge John Cain
STATE CORONER Date: 27 September 2021 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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