Finding into death of Alicia Maree Little

IN THE CORONERS COURT COR 2017 006543 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the Death of Alicia Maree Little 1 December 2022 Delivered On: Coroners Court of Victoria, 65 Kavanagh Street, Delivered At: Southbank Hearing Dates: 1 December 2022 Findings of: Judge John Cain, State Coroner Counsel Assisting the Coroner Nicholas Ngai, Family Violence Senior Solicitor Keywords: Family violence; intimate partner; dangerous driving causing death

INTRODUCTION

1. On 28 December 2017, Alicia Maree Little was struck by a motor vehicle driven by her former intimate partner, Charles Evans, causing her death. The incident occurred on the property where Ms Little and Mr Evans resided in Kyneton, Victoria. Ms Little was 41 years old at the time of her death.

2. Ms Little had four children. They were not residing with her at the time of her death. Prior to her relationship with Mr Evans, Ms Little had been in several relationships in which she was a victim of family violence.

3. Prior to his relationship with Ms Little, Mr Evans was married and had three children. Mr Evans’ ex-wife and two of his children have stated that he perpetrated extensive family violence against his ex-wife, including physical and verbal abuse, controlling behaviour and stalking. Mr Evans also had a criminal history, having previously been convicted of common assault.

4. Ms Little and Mr Evans both grew up in families involved in the carnival industry and met in approximately 2013 whilst working at the Melbourne show. They commenced a relationship and initially resided in a caravan together at Diggers Rest, Sunbury, before moving the caravan to Gisborne in September 2016, then Kyneton in early 2017. In September 2017, the couple moved into a rental property in Lavenders Lane, Kyneton.

5. Evidence provided to the court suggests that Mr Evans perpetrated family violence towards Ms Little throughout their relationship and that Ms Little was in the process of separating from him when the fatal incident occurred.

THE CORONIAL INVESTIGATION

6. Ms Little’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.

7. Section 52(1) of the Act provides that a coroner may hold an inquest into any death that the coroner is investigating. This discretion must be exercised in a manner consistent with the preamble and purposes of the Act.

8. It was apparent, upon reviewing the coronial brief of evidence, that the events leading up to the fatal incident gave rise to community concern about issues of public health and safety.

Consequently, I determined that these issues warranted further investigation to: a) Ascertain what services were provided to Ms Little and Mr Evans in the lead up to the fatal incident; and b) Learn from the death of Ms Little to potentially reduce the risk of such an event occurring again and to ensure that key services are better able to support individuals receiving support in circumstances suggesting family violence or a history of family violence.

9. 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.

10. 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.

11. Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Ms Little’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.

12. This finding draws on the totality of the coronial investigation into the death of Alicia Maree Little including evidence contained in the coronial brief. 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

13. In the days preceding her death, Ms Little told family members and friends that she had separated from Mr Evans, and that she had commenced packing her belongings to leave their shared residence.

14. On 28 December 2017, Ms Little continued to pack her belongings. In the afternoon, Mr Evans was heard verbally abusing Ms Little during a phone call between Ms Little and her mother, Lee Little. Between 2.39pm and 3.44pm, Ms Little sent a series of text messages to a family friend stating that Mr Evans had alcohol and substance abuse issues, was controlling, and would not let her go to work. She also stated that she was separating from him.

15. At 3.23pm Lee called 1800 RESPECT2 for advice and support. 1800 RESPECT provided information to her about the support services available to Ms Little and suggested that Lee ask Ms Little to go to a local police station if possible.

16. At 3.41pm Ms Little contacted emergency services and stated that she was having a ‘domestic’3 with Mr Evans and wanted him removed from the property. Ms Little reported that Mr Evans was intoxicated and had assaulted and verbally abused her. The phone line repeatedly cut out during this call, and Ms Little said that this was happening because Mr 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 1800 RESPECT is a national family violence counselling service with a 24-hour help line.

3 Coronial brief, Appendix B – 000 Call Transcript (28 December 2017), 1.

Evans had run over her phone with a car, but that she was not physically hurt, and he did not have any weapons.

17. At some point after this, Mr Evans took Ms Little’s mobile phone and went to the rear of the property where his Toyota Hilux was parked. Mr Evans then commenced driving out of the property, driving at approximately 12 to 16 kilometres per hour. Whilst passing between a fence and a large concrete water tank, Mr Evans struck Ms Little with his vehicle.

18. The available evidence suggests that Ms Little was standing near the water tank facing towards Mr Evans vehicle when she was struck. Mr Evans did not stop to assist Ms Little and drove away from the property with Ms Little’s phone in his vehicle.

19. At 3.57pm police arrived at Ms Little’s residence and found Ms Little lying next to the water tank, seriously injured. An ambulance arrived at 4.11pm, and despite attempts at resuscitation, Ms Little was pronounced deceased at the scene at 4.46pm.

20. Mr Evans pleaded guilty to dangerous driving causing death and failing to render assistance after a motor vehicle accident. On 20 September 2019, in the Supreme Court of Victoria, Mr Evans was sentenced to four years imprisonment with a non-parole period of two years and six months.4 Identity of the deceased

21. On 30 December 2017, Alicia Maree Little, born 6 November 1976, was visually identified by her mother, Lee Little.

22. Identity is not in dispute and requires no further investigation.

Medical cause of death

23. Forensic Pathologist, Dr Paul Bedford from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on 29 December 2017 and provided a written report of his findings dated 8 March 2018.

4 R v Evans [2019] VSC 606, 13[68].

24. The post-mortem examination revealed severe blunt force trauma injuries to Ms Little’s back and pelvis; internal injuries to the lungs and the liver; fractures of multiple posterior ribs, scapulae, and the pelvis. Ms Little’s death was determined to have resulted from severe effects on the lungs as well as blood loss into the peritoneum from lacerations to the liver.

25. Toxicological analysis of post-mortem samples identified the presence of cannabis and alcohol in Ms Little’s system.

26. Dr Bedford provided an opinion that the medical cause of death was 1(a) Multiple Injuries.

FURTHER INVESTIGATIONS PRECEDING THE INQUEST AND CPU REVIEW

27. The unexpected, unnatural, and violent death of a person is a devastating event. Violence perpetrated by an intimate partner is particularly shocking, given that all persons have a right to safety, respect, and trust in their most intimate relationships.

28. The relationship between Ms Little and Mr Evans met the definition of ‘family member’ as described by the Family Violence Protection Act 2008 (Vic) (FVPA).5 Moreover, Mr Evan’s actions towards Ms Little during their relationship, including his actions on the day of Ms Little’s death, constituted ‘family violence’.6

29. In light of Ms Little’s death occurring under circumstances of family violence, I requested that the Coroners’ Prevention Unit (CPU)7 examine the circumstances of her death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).8 Family violence in the relationship between Ms Little and Mr Evans

30. Evidence available to the court suggests that Mr Evans perpetrated family violence against Ms Little throughout their relationship, commencing approximately six months after their 5 Family Violence Protection Act 2008 (Vic), s 8.

6 Family Violence Protection Act 2008 (Vic), s 5.

7 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 8 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

relationship started. Ms Little reported to friends that Mr Evans was physically abusive and family members of Ms Little stated that Mr Evans was physically and emotionally abusive and threatening towards Ms Little and her children. One of Ms Little’s children described Mr Evans as belittling, controlling and manipulative.

31. In approximately May 2014, Mr Evans was allegedly driving a vehicle erratically whilst substance affected and asked one of Ms Little’s children, who was a passenger in the vehicle, ‘do you want to die?’9 When they arrived at their residence, Mr Evans allegedly put his hands around the child’s neck until Ms Little intervened to remove him.

32. At 4.50pm on 24 December 2014, Ms Little called emergency services and stated that Mr Evans had thrown her to the ground. The call ended before further information could be gathered by the operator. Police arrived at Ms Little’s residence at 5.50pm but could not locate Ms Little or Mr Evans on the premises. They called Ms Little’s phone number and left a message asking for her to call them, however Ms Little did not return their call and no further action was taken by police.

33. In a subsequent statement to police in 2015, Ms Little alleged that on 24 December 2014, Mr Evans had tackled her to the ground and held her arm behind her back, forcing her into the gravel and causing grazing to her face and arm. She also stated he was verbally abusive and when she told him that she had contacted police he reportedly responded, ‘you’d better **** not have’,10 before leaving the property. Although Ms Little heard police arrive on this occasion, she stated she was too scared to approach them due to fear of retaliation from Mr Evans.

34. At 3.49pm on 7 May 2015, Mr Evans called emergency services and said that he was restraining Ms Little to protect himself. Ms Little could be heard in the background of the call repeatedly telling Mr Evans to get off her, to get off her chest as she could not breathe, and twice telling Mr Evans to let go of her throat. Mr Evans denied touching Ms Little’s throat during the call stating, ‘I’m just sitting on her, mate’,11 to the operator.

9 Victoria Police, Summary of FVIO application dated 22 December 2020, 1.

10 Coronial brief, Appendix L – Statement of A Little (11 May 2015), 4.

11 Coronial brief, Appendix E – Transcript of 000 call (7 May 2015), 7.

35. Police arrived at approximately 4.20pm. Ms Little was observed to have a bruised right eye and reported that she and Mr Evans had been arguing, that Mr Evans had tried to grab her, that she had fought back by biting him, and that she ended up on the ground with Mr Evans on top of her. Mr Evans reported that he had restrained Ms Little after she attacked him and bit him, showing police bite marks on his torso, and a wound on his right thumb consistent with a bite mark.

36. Police assessed that Ms Little was the respondent in this matter and that Mr Evans was the Affected Family Member (AFM), and Ms Little was arrested.

37. Ms Little reported that she had sore ribs and an ambulance was called to convey her to Sunshine Hospital. Ms Little told attending paramedics that Mr Evans had pinned her to the ground and used his hands, elbows, knees and body to ‘repeatedly impact and apply pressure to keep her on the ground as she fought to get free’.12 Ms Little was noted to be taking shallow breaths as a result of sharp pain in her left rib, and to have bruising to her left cheek bone, to her left and right eyes, and to have an abrasion to her right eyebrow. Ms Little was noted as visibly distressed and complaining of a headache.

38. Ms Little’s medical examination at Sunshine Hospital also noted these injuries, as well as tenderness in her upper left abdomen, a tender left cheek, and multiple bruises to both forearms and upper arms. Hospital staff also suspected Ms Little had a displaced rib fracture.

39. Police served Ms Little with a Family Violence Safety Notice (FVSN) in protection of Mr Evans whilst she was at the hospital. Police decided to interview Ms Little at a later date as she had been given morphine.

40. Whilst Ms Little was in hospital, Mr Evans attended Sunbury Police Station and made a statement. He stated that Ms Little had pushed him and accused him of speaking to other women on the internet. He said that he had grabbed her wrist to stop her, and that they had fallen to the ground. Mr Evans alleged that he had gotten on top of Ms Little and that she had fought to get him off of her, biting him on the hand and his body. Mr Evans stated, ‘I 12 Coronial brief, Statement of B Nunan, 83.

wasn’t scared or angry when [Ms Little] attacked me I was just worried for her because I think she should be on some type of medication.’13

41. Following this incident, Ms Little stayed with her mother, Lee, for approximately six to eight weeks.

42. On 11 May 2015, Ms Little made a formal statement at Bendigo Police Station about the incident that had occurred on 7 May 2015. In this statement, Ms Little detailed controlling behaviour perpetrated by Mr Evans, reporting that he would not let her go anywhere by herself and would look through her phone and delete phone numbers and pictures. Ms Little stated that on 7 May 2015, Mr Evans had verbally abused her, had begun swearing and spitting at her when she had fallen over backwards, and that he had gotten on top of her. Ms Little stated that during the incident she was in pain and in fear for her life and lost consciousness twice. Ms Little also stated that Mr Evans had put his hands around her throat and said, ‘you deserve to die’,14 describing the incident as, ‘more than scary or terrifying’.15 Ms Little admitted to biting Mr Evans on the thumb in an attempt to get away. Ms Little also advised police about the incident that had occurred on 24 December 2014, and indicated that she had planned to relocate as she no longer felt safe in Diggers Rest. As a result of this statement, police commenced a criminal investigation regarding charges against Mr Evans for recklessly causing injury and unlawful assault.

43. On 11 May 2015, a Family Violence Intervention Order (FVIO), applied for by police, was issued by the Broadmeadows Magistrates Court in protection of Mr Evans. The 12-month FVIO prohibited Ms Little from perpetrating family violence against Mr Evans or damaging his property.

44. On the same day, Ms Little made her own application for a FVIO to protect herself and her two eldest children from Mr Evans. Court documents from this date noted that Ms Little had ‘clear bruising to the left side of her face’16 on this day. A 12-month FVIO was issued in 13 Coronial brief, Appendix F – Statement of C Evans (7 May 2015), 5.

14 Coronial brief, Appendix L – Statement of A Little (11 May 2015), 2.

15 Ibid 3.

16 Bendigo Magistrates Court, records relating to FVIO proceedings between Ms Little and Mr Evans, 14.

protection of Ms Evans and her children on 19 May 2015, which prohibited Mr Evans from having contact with Ms Little or her children.

45. On 12 May 2015, Ms Little attended Tristar Medical Group, Kangaroo Flat, seeking medical attention for chest pain. During this appointment, Ms Little provided an account of the events on 7 May 2015, which were consistent with her police statement. The GP noted that Ms Little’s injuries included bruising to her face, limbs, and abdomen.

46. Ms Little continued to have ongoing chest pain and an X-ray conducted on 22 May 2015 revealed that she had a fractured rib.

47. On 14 July 2015, Ms Little was interviewed by police in relation to the incident on 7 May

48. During this interview, Ms Little maintained that Mr Evans had assaulted her, and that she had bitten him in self-defence. She was released pending summons. A Family Violence Liaison Officer (FVLO) reviewed this case after 20 July 2015 and directed that a brief of evidence be prepared. Police obtained Ms Little’s GP records on 22 July 2015.

49. At some point after this, Ms Little reconciled with Mr Evans, telling her mother, Lee, that she believed he had changed.

50. On 27 August 2015, Ms Little was charged with intentionally causing injury, recklessly causing injury and unlawful assault in relation to the incident on 7 May 2015.

51. On 12 November 2015, a police member from Broadmeadows Prosecutions advised the arresting officer that Ms Little had likely been acting in self-defence on 7 May 2015.

Following this discussion, the arresting officer spoke to Ms Little and Mr Evans, who both advised they did not want the other charged with any criminal offences and in early January 2016 they each signed statements of no complaint. As a result, the charges against Ms Little were withdrawn, and the allegations she made against Mr Evans were not progressed further.

51. On 19 April 2016, Ms Little called Lee and told her that Mr Evans ‘was belting her again’.17 Lee stated that during this call she heard Ms Little yelling at Mr Evans to get off her and to stop hitting her, and Mr Evans screaming at and verbally abusing Ms Little and her 17-year17 Coronial brief, Statement of L Little, 36.

old son. Lee also stated that she heard Mr Evans telling Ms Little’s son that he was better off dead. Ms Little later told a friend and family violence support service that Mr Evans had assaulted her and attempted to choke her son during this incident. Ms Little’s son also stated that Mr Evans had hooked a van, that Ms Little and her son were in, to his truck and had driven at speed, nearly causing the van to flip over.

52. Following this incident, a family member observed Ms Little to have black eyes, a swollen lip and a wound on the bridge of her nose. Ms Little’s son was observed with bruising around the throat and under his arm pits. This incident was not reported to police however Ms Little left the relationship after it occurred and lived with her mother for several weeks.

53. On 20 April 2016, Ms Little attended her GP and was noted to have multiple bruises on her body, a blackened and swollen right eye, and a swollen left finger. Ms Little told the GP that Mr Evans had inflicted these injuries on her the night before, and that he had also assaulted her son. The following day an X-ray showed that Ms Little had a fractured finger. The GP referred Ms Little for counselling for anxiety and Post Traumatic Stress Disorder (PTSD), noting her recent separation and exposure to family violence, and her experiences of flashbacks and nightmares.

54. On 20 April 2016, Ms Little attended the Wangaratta Centre Against Violence (CAV), after contacting the service for assistance on 6 April 2016. CAV completed a family violence risk assessment and noted several significant risk factors in relation to the family violence perpetrated by Mr Evans, including; the use of a weapon in the last incident, access to weapons, history of choking, threats to kill, perpetration of harm to Ms Little’s children, stalking, sexual assault, preventing Ms Little from seeing family and friends, escalation of violence and obsession and control. CAV also noted that Ms Little had previously fought back against Mr Evans, had subsequently been seen as the perpetrator by police and that, as a result, she did not have ‘much faith in the system or police’.18 Ms Little reported that her fear level was ten out of ten and she was assessed as requiring immediate protection. CAV 18 Centre Against Violence, records relating to A Little, 31.

completed a safety plan with Ms Little and provided her with psychoeducation on family violence.

55. In the weeks following, Ms Little disclosed to her GP that Mr Evans continued to psychologically abuse her in text messages and advised CAV that she was being ‘emotionally pulled’19 to return to her relationship with him.

56. Ms Little attended several appointments with CAV for support during this time, until her file was closed on 9 September 2016 after CAV were unable to contact her.

57. At some point after 11 September 2016, Ms Little returned to live with Mr Evans again, and they moved their caravan from Diggers Rest to Gisborne, where they stayed for six to eight months.

58. In late 2016, Ms Little disclosed to a friend that Mr Evans had recently assaulted her. As a result of this assault, Ms Little left Mr Evans and stayed with her friend for a week. She also began the process of applying for a new FVIO but then changed her mind and returned to live with Mr Evans after he apologised to her.

59. On 8 December 2016, Ms Little attended her GP and reported that her mood had been deteriorating in recent months. Ms Little reported that Mr Evans was supportive and did not disclose any family violence at this time. Ms Little’s GP referred her to a private psychiatrist and a private psychologist.

60. Ms Little attended eight sessions with a private psychologist between 10 January 2017 and 6 June 2017. During her first appointment, Ms Little disclosed that there had been a history of family violence perpetrated by Mr Evans against her that this had resulted in black eyes and broken ribs. Ms Little did not make any further disclosures of family violence in subsequent sessions.

19 Coronial brief, Statement of C Grogan, 109; Centre Against Violence, records relating to A Little, 13-14.

61. In approximately April or May 2017, Ms Little and Mr Evans moved their caravan to Kyneton, and in September 2017 they moved into a rented property at 7 Lavenders Lane, Kyneton.

62. In the months and weeks leading up to the fatal incident, Ms Little told friends and family that Mr Evans was physically, emotionally, psychologically, and verbally abusive towards her. Ms Little alleged that there had been physical abuse, which had included Mr Evans hitting and forcefully grabbing and holding her. Ms Little also played a recording to one friend of Mr Evans being verbally abusive towards her, and others witnessed or were told about Mr Evans use of controlling, obsessive and jealous behaviours. For example, Ms Little’s friends witnessed or were told that Mr Evans was keeping Ms Little under his surveillance, checking her phone to see who she was speaking to, and accusing her of cheating on him.

63. On 3 December 2017, Ms Little told her GP at Neal Street Medical Centre about the history of family violence perpetrated against her by Mr Evans, and said she wanted to leave the relationship but had too much going on. The GP discussed family violence and generalist family services with Ms Little.

64. In mid-December 2017, Mr Evans asked Lee for her blessing to marry Ms Little. Lee said no and believed at this time that Ms Little ‘felt empowered to walk away from her relationship’20 with Mr Evans.

65. On 26 December 2017, Ms Little sent a text message to Lee indicating that she planned to leave Mr Evans and that he was being verbally abusive towards her.

66. On 27 December 2017, during a phone call with Ms Little, Lee heard Mr Evans verbally abusing Ms Little while she was packing her things to leave. Ms Little reportedly declined an offer for her mother and brothers to come and assist her.

67. Over the next day, Ms Little continued packing her belongings and told family and friends that she was separating from Mr Evans.

20 Coronial brief, Statement of L Little, 39.

THE INQUEST

68. Pursuant to section 52(2) of the Act, it is mandatory for a coroner to hold an inquest if the death occurred in Victoria and a coroner suspects the death was as a result of homicide and no person or persons have been charged with an indictable offence in respect of the death.

69. Section 52(1) of the Act provides that a coroner may hold an inquest into any death that the coroner is investigating. This discretion must be exercised in a manner consistent with the preamble and purposes of the Act.

70. I considered it appropriate to use my discretion to hold a Summary Inquest on 1 December

71. However, I did not deem it necessary to hear from any witnesses as the concerns identified in the coronial investigation had been ventilated in substantive correspondence between the Court and interested parties.

COMMENTS

71. Pursuant to section 67(3) of the Act, I make the following comments connected with the death: Mental health treatment and family violence victim support

72. On 8 December 2016, Ms Little’s GP referred her to a private psychologist. The referral letter summarised various stressors faced by Ms Little, but noted that she had ‘good support with her partner’.21 Ms Little attended eight sessions with The private psychologist between 10 January 2017 and 6 June 2017.22 These sessions focussed primarily on anxiety management and Ms Little’s relationships with her children.23

73. During her first appointment Ms Little disclosed a history of family violence perpetrated by Mr Evans and the private psychologist noted that this had resulted in black eyes and broken ribs.24 In a statement provided to the Court, the private psychologist advised that she had asked Ms Little whether she had any current concerns about the relationship and Ms Little 21 Mental Health Service, Psychology records of A Little, 19.

22 Mental Health Service, Psychology appointment list of A Little, 1.

23 Ibid, 37.

24 Mental Health Service, Psychology records of A Little, 28.

had said she did not trust Mr Evans and believed that he had been unfaithful to her.25 The private psychologist also stated that Ms Little told her that she and Mr Evans would have ‘explosive verbal disagreements’, and that she believed her inability to regulate her emotions contributed to this issue.26

74. On 24 January 2017, the private psychologist spoke with Ms Little about not allowing Mr Evans’ behaviour to ‘impact her’.27 On 6 June 2017, Ms Little told the private psychologist that she did not trust Mr Evans,28 but that if an argument occurred she would be able to walk away.29

75. Although the relationship between Ms Little and Mr Evans was discussed, the private psychologist did not record any discussions about family violence following Ms Little’s first appointment. During these appointments, Ms Little had disclosed a history of physical abuse perpetrated by Mr Evans and detailed the injuries she had sustained from this assault.

Physical violence is an indicator of an increased risk of continued or an escalation in severity of violence.30 Failure to further assess the risk to Ms Little represents a missed opportunity to re-engage Ms Little with family violence support.

76. The discussion between Ms Little and her private psychologist regarding whether to allow Mr Evan’s behaviour to ‘impact her’ further highlights the lack of insight into the power imbalance in relationships affected by family violence and devalues Ms Little’s experience of violence. The available evidence indicates that there was a lack of safety planning and holding Mr Evan’s to account for his use of violence.

77. The available evidence suggests that Ms Little’s private psychologist met their obligations as a mental health practitioner under the policies and guidelines currently in place and in place at the time of this service contact. Whilst the response by Ms Little’s private psychologist to Ms Little’s experience of family violence was suboptimal, guidance for 25 Ibid, 35.

26 Ibid.

27 Ibid, 29.

28 Ibid, 32.

29 Ibid, 37.

30 Family Safety Victoria, MARAM Practice Guides: Foundation Knowledge Guide (2021), 33.

health professionals on family violence risk assessment was limited at the time of this service engagement.

78. The failure of mental health services to refer victims of family violence to specialised support services has been a repeated theme in recent findings handed down by the Court.31

79. These concerns were echoed in the findings of the 2017 Royal Commission into Family Violence (RCFV)32 which highlighted that health professionals often lack the knowledge or resources to appropriately or effectively respond to family violence.

80. To address this, the RCFV considered that family violence should form part of the critical working knowledge of health professionals, rather than being an optional addition to their studies and ongoing professional development. Recommendation 102 of the RCFV specifically recommended that a family violence learning agenda form part of undergraduate and graduate training for general practitioners and mental health professionals (including psychologists and psychiatrists).33

81. In response to this recommendation, the Office of the Chief Psychiatrist, the Royal Australasian and New Zealand College of Psychiatrists, the Royal Australian College of General Practitioners and the Australian Psychological Society issued a joint statement in June 2019, committing to promoting a learning agenda on family violence as a priority for each organisation and to exert any influence possible on undergraduate and graduate University training.34

82. In 2018, the Victorian Government introduced a new Family Violence Risk Assessment and Risk Management Framework, the Multi-Agency Risk Assessment and Management Framework (MARAM). The MARAM supports practitioners in assessing, monitoring, and managing family violence risk35 and prescribes certain organisations and professionals with responsibilities in identifying and responding to family violence. The responsibilities 31 COR 2018/3266, COR 2017/4175, COR 2017/6328, 2019/1858 and 2018/3733 32 Royal Commission into Family Violence Final Report (March 2016) 33 Ibid, Volume 4, Chapter 19, 55 34 Exhibit 75, Statement from the Office of the Chief Psychiatrist entitled, ‘Commitment to a family violence learning agenda,’ dated June 2019.

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

applicable to staff in framework organisations can differ according to the responsibilities of their roles. Generally, all framework organisations must ‘demonstrate an evidence-based, shared understanding of family violence risk and impact’36 which ‘promotes an effective, integrated service response to family violence.’ 37 This includes an understanding of the spectrum of family violence types, family violence risk factors and the complexity of experiences across the community.38

83. As of 19 April 2021, public health services, including psychologists operating in a public health settings, were prescribed to comply with the obligations set out under the MARAM.

This reform, however, does not include private psychologists or other private mental health practitioners, like private counsellors or psychiatrists. As such, there is no mandatory family violence training currently in place for these professionals.

84. Other efforts by the Victorian Government to increase family violence knowledge among the mental health professionals have primarily been directed towards the public health sector, with these resources being less accessible or visible to those in private practice. Whilst professional bodies also offer family violence training to their members, the quality and uptake of this training is unclear and there does not appear to be any requirements for private mental health practitioners to undertake family violence training or professional development at present.

85. In a submission made by the Royal Australasian and New Zealand College of Psychiatrists (RANZP) to the Family Violence Reform Implementation Monitor in July 2020, it was noted that ‘there is still work remaining to educate mental health professionals and assist them to incorporate knowledge of coercive and controlling behaviours and unequal power relations into their clinical problem solving’.39 The RANZP further noted that ‘there is still a glaring gap in education and awareness of family violence amongst psychiatrists and mental health professionals more generally’40 and that ‘a recent study suggested there is 36 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018), 19.

37 Ibid.

38 Ibid.

39 Royal Australian and New Zealand College of Psychiatrists, Royal Australian and New Zealand College of Psychiatrists Submission (July 2020), https://www.fvrim.vic.gov.au/sites/default/files/202009/Submission%20%23089%20-%20Organisation~aland%20College%20of%20Psychiatrists_0.PDF, 3.

40 Ibid, 3.

limited time spent in specific skills training for management of domestic violence, with increased hours spent in domestic violence training significantly correlated with greater knowledge and preparedness to manage domestic violence.’41

86. In their submission to the House Standing Committee on Social Policy and Legal Affairs’ inquiry into family, domestic and sexual violence in October 2020, the Australian Psychological Society re-iterated this point and advised of their support for mandatory family violence training for psychologists, noting that ‘developing workforce expertise around domestic violence means that training should be mandatory and ongoing’42 for a range of professions including psychologists.

Victoria Police response to the family violence incident on 24 December 2014

87. I am satisfied that the response from police to the call made by Ms Little on 24 December 2014 was not contrary to the guidelines that were applicable at the time. Police attended the property, however no one appeared to be present. They attempted to contact Ms Little and were unsuccessful. Ms Little did not return their call and was not recorded in LEAP43 as residing at the address at that time. Without sufficient information to identify her as the complainant in the incident, police were unable to complete an L1744 on this occasion or record the incident in LEAP.

88. The relevant guidelines did not provide instruction or guidance for police members to follow up with AFMs if they were not present at an incident and could not be identified. I note that 41 Ibid.

42 Australian Psychological Society, Re: Inquiry into family, domestic and sexual violence submission 246 (October 2020), < https://psychology.org.au/getmedia/6657e51d-87a0-4247-ab4fda00bcabcc65/20aps_submission_family_domestic_sexual_violence.pdf>, 4.

43 LEAP is short for Law Enforcement Assistance Program which is an online database that is fully relational and stores information about all crimes bought to the notice of police as well as family incidents and missing persons.

It also includes details on locations and persons involved.

44 L17 is a reference to the Victorian Police Risk Assessment and Risk Management Report ‘L17’ and is the mechanism by which Police who attend family violence incidents can make referrals to community agencies and/or reports to Child Protection. The Portal provides an electronic means for Victoria Police to make referrals and reports and in December 2016 it ended the practice of sending and receiving faxes. It is a web-based Siebel application that is used by Child Protection staff, The Orange Doors and services funded by the Department of Fairness, Families and Housing to deliver family violence support. The Portal receives a referral incident from police, identifies which services should receive the referral and sends the referral/report to the service.

since this time, the Victoria Police Manual – Family Violence (VPM Family Violence) has been updated and now states that police should ‘follow up with AFMs if not present at the incident to complete the [VP Form L17]’.45 Victoria Police response to the family violence incident on 7 May 2015

89. The Victoria Police Code of Practice for the Investigation of Family Violence (Code of Practice)46 applicable at the time of the incident on 7 May 2015 stated that police responding to a family violence incident must identify the primary aggressor and, where physical violence has occurred, assess if it is likely that someone has been acting in self-defence.47

90. The Code of Practice lists five indicators that police may consider when identifying the primary aggressor, including respective injuries, the likelihood or capacity of each party to inflict future injury, whether either party has defensive injuries, which party is more fearful, and patterns of coercion, intimidation and/or violence by either party. The Code of Practice also provides that when it was unclear who the primary aggressor was, the AFM should be determined ‘on the basis of which party appears to be most fearful and in most need of protection’.48

91. The available information suggests that Mr Evans was the primary aggressor in the relationship and this incident. The injuries to both Ms Little and Mr Evans suggested that Ms Little was acting in self-defence. Ms Little also reported a similar incident which had occurred previously and detailed a history of controlling behaviour, intimidation and violence perpetrated against her by Mr Evans. In addition, Ms Little expressed a high level of fear with respect to Mr Evans, stating that she thought she was going to die during the incident, whereas Mr Evans expressly stated that he was not scared.

92. I note that the full breadth of this information was not available to police when they first attended the incident, and that information regarding the history of family violence in the 45 Victoria Police, Victoria Police Manual – Family Violence (20 July 2022) 9.

46 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3rd Edition V2, 8.

47 Ibid.

48 Ibid 8, 23.

relationship, and the full extent of Ms Little’s injuries, was not obtained until a later date.

Police’s initial assessment was based on the information available to them at the time.

93. Relevant police guidelines at the time did not address the issue of misidentification of the primary aggressor or provide instruction or guidance for members to revoke a FVIO application when a misidentification occurred. This meant that when further information was brought to the attention of police after the incident, Mr Evans was subjected to a criminal investigation, however Ms Little remained categorised as a respondent in the L17 and LEAP records.

94. The misidentification of Ms Little as the primary aggressor on this occasion appears to have had a negative impact on Ms Little, who subsequently expressed to CAV that she had lost faith in police and the system after this incident. From this time, up until the day of the fatal incident, Ms Little did not report any further family violence incidents to police, despite disclosing ongoing family violence perpetration by Mr Evans to friends and family during that time.

95. Research into the issue of misidentification of primary aggressors suggests that misidentification is often driven by racialized, classed and gendered stereotypes of ideal victims, and women in general, as being submissive to authority, downtrodden, passive, and dependent.49 Women who have complex needs and/or histories of trauma may not fit these stereotypes and may appear erratic and be hostile or aggressive towards police. This in turn may influence police decision-making in favour of the perpetrator, who may in contrast appear calm and rational given their relative control over the situation and because they are not fearful or traumatized.50 Further, victims who appear to have misused substances on police arrival, potentially influenced by reasons related to their experiences of trauma, are 49 Women’s Legal Service Victoria, “Officer she’s psychotic and I need protection”: Police misidentification of the ‘primary aggressor’ in family violence incidents in Victoria (Policy Paper 1, July 2018) 3; Heather Nancarrow et al Accurately identifying the “person most in need of protection” in Domestic and Family Violence Law (Research Report Issue 23, ANROWS, November 2020) 11, 26; No To Violence, Predominant aggressor identification and Victim Misidentification (Discussion Paper, November 2019) 12; Family Safety Victoria, MARAM Practice Guides: Foundation Knowledge Guide: Guidance for professionals working with child or adult victim survivors, and adults using family violence (2021) 112.

50 Women’s Legal Service Victoria (n 24) 3; Family Violence Reform Implementation Monitor, State of Victoria, Monitoring Victoria’s Family Violence Reforms: Accurate identification of the predominant aggressor (Report, December 2021) 18.

less likely to fit stereotypes of ideal victimhood and may be at increased risk of misidentification as the primary aggressor.51

96. It is possible that the police identification of Ms Little as the primary aggressor on 7 May 2015 may have been influenced by Ms Little’s non-conformity with ideal victim stereotypes.

Ms Little was not passive during the family violence incident, having reportedly engaged in violent resistance by biting Mr Evans. Police also suspected that Ms Little was alcohol affected on their arrival.

97. Misidentification can have significant impacts on victim-survivor’s access to safety and can negatively impact other areas of the law that they may be engaged in such as child protection and family law.

98. There may also have been a lack of understanding by attending members about trauma presentations of victims of family violence. Ms Little reportedly struggled to provide her version events and was described as appearing ‘distant and distracted’, and ‘not making much sense’.52 The officer who made these comments recorded that Ms Little may have been substance affected but did not document whether they considered the possibility that Ms Little’s presentation may also have been affected or distorted by injury, fear and/or trauma.53

99. There is no doubt that police officers face extremely challenging situations when they attend family violence incidents, and the predominant aggressor will not always be plainly obvious.

The RCFV identified concerns about the misidentification of women as primary aggressors by police. In response to this, the RCFV recommended that Victoria Police improve the guidance provided to their members in relation to primary aggressors and develop procedures for amending LEAP when they become aware that a person is not the primary aggressor.

100. Since this time, the VPM Family Violence has been amended to include a more thorough definition of the term primary aggressor and now includes further indicators police can 51 Women’s Legal Service Victoria (n 24), 3; No To Violence (n 24) 6; Family Violence Reform Implementation Monitor (n 25) 12.

52 Coronial brief, Statement of H Perkins, 75.

53 Women’s Legal Service Victoria (n 24) 3.

consider when identifying the primary aggressor. It also encourages police to be alert to the possibility of attempts at manipulation and systems abuse by primary aggressors, and of primary aggressors appearing calm in relation to victims who may present as agitated or violent.

101. As noted above, the RCFV recommendations led to the introduction of a new family violence risk assessment tool, the MARAM and the Family Violence Information Sharing Scheme (FVISS)54 and Child Information Sharing Scheme (CISS)55. These provide greater guidance around family violence risk assessment and allow for greater sharing of information to improve the breadth of information available to services when conducting risk assessments.

This can assist services in identifying the primary aggressor in a relationship. Victoria Police are a prescribed agency who can share information under both the FVISS and CISS. They have also introduced a new L17 risk assessment tool, informed by the MARAM, to improve their family violence risk assessment.

102. Following the RCFV, Victoria Police have undertaken significant work to improve the way they respond to family violence. This has included establishing the Family Violence Response Model. Victoria Police has also implemented extensive changes to training, policy and guidance to better educate members on the complexities of family violence dynamics and the presentation of victim/survivors who are trauma affected. These improvements mean that police members and FVLOs are now significantly more resourced to deal with the complexities of family violence.

103. Victoria Police also established the Centre of Learning for Family Violence (Centre of Learning) in 2019 to support and enhance the family violence education of police members.

The Centre of Learning provides career long, targeted family violence education across all ranks within Victoria Police and is supported by a team of education specialists based at the 54 The FVISS supports effective assessment and management of family violence risk by agencies that work with family violence victims and alleged perpetrators. Under the scheme, information sharing entities can share information related to assessing or managing family violence risk.

55 The CISS supports certain professionals working with children and young people. The scheme makes it easier for these professionals to see the full picture of the child they work with, helping them to understand what they can share and how to protect a family’s privacy.

Victorian Police Academy. Family Violence Training Officers are also based within each of the 21 Victoria Police Divisions to strengthen education opportunities in workplaces.

104. In December 2021, the misidentification of primary aggressors in family violence incidents was examined by the Family Violence Reform Implementation Monitor (FVRIM) in their report Monitoring Victoria's family violence reforms: Accurate identification of the predominant aggressor56 (the Report).

105. In this Report the FVRIM noted that that misidentification of the primary aggressor continues to be a significant issue in Victoria, as does the lack of clarity about approaches to rectifying it when it does occur, indicating that these issues require urgent attention. In recommendations four to eight of the Report, the FVRIM recommended that Victoria Police:

(a) Re-examine and potentially redesign the Family Violence Report and associated processes and guidance to:

(i) support officers to identify the predominant aggressor before beginning the risk assessment, particularly in ambiguous situations (ii) clearly differentiate between the risk assessment (and referral) function for civil protection purposes, and any criminal incidents (particularly in cases where a victim has used force), and (iii) ensure alignment with Victoria Police policies and the Family Violence MultiAgency Risk Assessment and Management (MARAM) Framework.

(b) Trial a review process, involving the specialist family violence sector, for any Family Violence Report where a woman is identified as a respondent (and possibly for other targeted cohorts) before it is committed to Victoria Police's LEAP database.

56 Family Violence Reform Implementation Monitor (n 25).

(c) Urgently review how family violence records are captured in LEAP to ensure that where misidentification is found, the record can be amended so a person doesn't continue to be incorrectly listed as a respondent.

(d) Establish and communicate clear processes to guide police responses where there is new information that suggests misidentification has occurred, including:

(i) a contact point at Victoria Police that other agencies can use to raise misidentification (ii) an agreed process to make a determination that misidentification has occurred (iii) specific guidance for police on the actions they need to take once this determination has been made.

(e) Develop clear guidance for withdrawing family violence intervention order applications or criminal charges in cases of misidentification and give police prosecutors the authority to quickly facilitate this.57

106. Victoria Police advise that they are considering these recommendations and progressing work to refine their policy and practice regarding the identification of primary aggressors in family violence incidents. Family Violence Command are currently developing a program of works to respond to the recommendations, which includes reviewing policies and practices, improving training and development for members, and exploring ways to correct misidentification of primary aggressors when they occur in police databases. They have been consulting with a wide range of stakeholders to inform their responses and progress these works, including legal services and child protection and specialist family violence agencies.

When this work is finalised, both the consolidated VPM Family Violence and the Code of Practice will be updated to reflect these changes.

107. Family Violence Command has also established a Predominant Aggressor Project to review policy and processes to prevent, reduce and rectify instances of misidentification of the primary aggressor at family violence incidents. This includes exploring possible options for 57 Ibid 6.

improvement, such as the introduction of multi-agency case reviews, supervisor guidance and corrective actions.

108. I support the recommendations of the FVRIM and encourage Victoria Police to continue their work in this space.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:

1. With the aim of promoting public health, preventing deaths and supporting mental health practitioners to address family violence, I recommend that the National Federation Reform Council (NFRC) review the current registration standards required of registered psychologists. Measures should be considered to introduce family violence mandatory CPD for registered private psychologists and private psychiatrists to provide for an occupationspecific level of family violence understanding and referrals for further support where a patient/client is identified as experiencing or suspected to be experiencing family violence.

FINDINGS AND CONCLUSION

109. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Alicia Maree Little, born 6 November 1976; b) the death occurred on 28 December 2017 at 7 Lavenders Lane, Kyneton, Victoria, 3444, from multiple injuries; and c) the death occurred in the circumstances described above.

110. I convey my sincere condolences to Ms Little’s family for their loss.

111. Pursuant to section 73(1) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

112. I direct that a copy of this finding be provided to the following: Brian and Lee Little, Senior Next of Kin

Lauren Callaway, Assistant Commissioner Family Violence, Victoria Police Kate Davey, Victorian Government Solicitor’s Office Danielle Middleton, Transport Accident Commission Dr Neil Coventry, CEO, Office of the Chief Psychiatrist The Honourable Anthony Albanese MP, Chair, National Federation Reform Council Eleri Butler, CEO, Family Safety Victoria Mr Andrew Peters, CEO, Royal Australian and New Zealand College of Psychiatrists Dr Zena Burgess, CEO, Australian Psychology Society Helen Collins, Applicant Senior Constable Leigh Smyth, Coroner’s Investigator Signature: ___________________________________ Judge John Cain, State Coroner Date : 1 December 2022 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.