Deceased
Mr A
Demographics
37y, male
Coroner
Coroner John Olle
Date of death
2017-09-29
Finding date
2022-05-23
Cause of death
Stab wound to the left kidney
AI-generated summary
A 37-year-old man was fatally stabbed by his de facto partner during a family violence incident. He had a documented history of perpetrating family violence including threats, stalking, choking, and repeated breaches of Family Violence Intervention Orders. Clinical lessons include: GPs should provide family violence referrals even without physical violence when patients report psychological distress and anxiety; Victoria Police risk assessments for FVIO variations were deficient and failed to consider full violence history; Corrections Victoria did not monitor prisoners' phone calls for FVIO breaches such as indirect contact through third parties; and Child Protection failed to communicate case closure to other agencies, preventing coordinated risk reassessment upon the perpetrator's release. Critical system failures included delayed service of interim FVIOs on incarcerated respondents and lack of protocols for prison monitoring of family violence–related contact breaches.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
IN THE CORONERS COURT COR 2017 004986 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner John Olle Deceased: Mr A Date of birth: 02 July 1980 Date of death: 29 September 2017 Cause of death: 1(a) STAB WOUND TO THE LEFT KIDNEY Place of death: Mernda, Victoria Catchwords: Intimate partner homicide; family violence
On 29 September 2017, Mr A was 37 years old when he was fatally assaulted by his then partner, Ms B in the context of a family violence incident. At the time of his death, Mr A lived with Ms B and their three young children Mernda, Victoria.
Mr A was born in Carlton, Victoria and grew up with his younger brother in South Morang.
At the time of his death, Mr A was unemployed but had previously been employed in the construction industry and more recently as a truck driver.
Mr A’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.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr A’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 Mr A’s death 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
On the evening of 29 September 2017, Mr A and Ms B were involved in a dispute in the kitchen of their residence in Mernda, Victoria.2 The dispute occurred in both the kitchen and dining room of their residence and was witnessed in parts by Ms B’s daughter, Child 3.3
Shortly before 5:00pm, the dispute escalated and Ms B, armed with a kitchen knife, chased Mr A around the kitchen island bench.4 Ms B inflicted two wounds to Mr A’s left arm and hand before stabbing him in the lower left area of the back.
Ms B contacted emergency services at 5:01pm and police members arrived first on scene at 5:10pm.5 Ambulance paramedics arrived shortly after the police and took control of the resuscitation attempts on Mr A. Unfortunately, Mr A was pronounced deceased at the scene at 6:03pm.6
Identity of the deceased
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, VARE interview of Child 3 dated 29 September 2017, 63-65 3 Ibid 4 Ibid 5 Coronial Brief, Exhibit 4 – 000 Call recording 6 Coronial Brief, Statement of James Abbott dated 13 November 2017, 163
Medical cause of death
Forensic Pathologist Dr Joanne Glengarry from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on 30 September 2017 and provided a written report of her findings dated 28 November 2017.
The post-mortem examination revealed the following: a) A knife wound to the left back causing injury to the left kidney. The wound tract was directed from back to front and left to right. It was approximately 15 to 20 cm in length; b) The stab wound perforated the left kidney, associated with a large amount of haemorrhage in the perinephric fat and incision of the left renal artery and renal vein.
1500 mL of blood was found within the abdominal cavity; c) There were two other incised wounds of the left forearm and left hand; and d) There was no significant natural disease detected that contributed to the death.
Toxicological analysis of post-mortem samples did not identify the presence of any alcohol or any commons drugs or poisons.
Dr Glengarry provided an opinion that the medical cause of death was 1 (a) STAB WOUND TO THE LEFT KIDNEY.
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.
For the purposes of the Family Violence Protection Act 2008, the relationship between Mr A and Ms B was one that fell within the definition of ‘de facto partner’7 under that Act. Moreover, Ms A’s actions in fatally assaulting Mr A constitutes ‘family violence’.8 7 Family Violence Protection Act 2008, section 9 8 Family Violence Protection Act 2008, section 8(1)(a)
In light of Mr A’s death occurring under circumstances of family violence, I requested that the Coroners’ Prevention Unit (CPU)9 examine the circumstances of his death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).10 History of family violence between Mr A and Ms B
The available evidence suggests that there was a significant history of family violence perpetrated by Mr A towards Ms B throughout their relationship. This included behaviour that was physically, emotionally, and psychologically abusive, threatening, and coercive, and caused Ms B to fear for her safety. Many of the incidents of family violence were witnessed by Ms B’ children. Ms B reported that throughout their relationship Mr A had threatened suicide to manipulate her and that he would ‘constantly revert from being nice and loving to abusive and controlling.’11 Such conduct falls within the definition of family violence under the Family Violence Protection Act 2008 (Vic).12
This family violence resulted in Ms B and Mr A engaging with a variety of services including Victoria Police, the then Department of Health and Human Services – Child Protection (Child Protection),13 Berry Street, and Corrections Victoria prior to Mr A’s death.
Between 20 November 2014 and 27 February 2017 there were 13 incidents of family violence reported to Victoria Police.
The first incident of family violence reported to police between Mr A and Ms B was on 20 November 2014. On this occasion, a witness contacted police after they saw Mr A and Ms B having a verbal argument outside of a medical centre. When police attended, Ms B denied any family violence or threats.14 Based on this information, the police made referrals for Ms B and Mr A to support services but took no further action on this occasion.15
Although she did not tell this to attending police at the time, Ms B later disclosed that immediately prior to this incident Mr A had driven very fast on the way to the medical centre 9 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 10 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 11 Form 32 material, combined redacted materials, 204.
12 s 5.
13 Now known as the Department of Families, Fairness and Housing.
14 Form 32 material, additional statements, statement of S Boyce; Berry Street, records relating to Ms B.
15 Form 32 material, additional statements, statement of S Boyce.
and had threatened to kill her. She stated that she minimised the incident as much as she could to the police as she was worried about Child Protection intervention.16 Child Protection had previously been involved with Ms B’ daughter, Child 3, due to family violence between Ms B and Child 3’s father.
Mr A’s cousin, Ms C, alleged that during a family trip on or around 23 January 2015, she had witnessed Ms B ‘constantly putting [Mr A] down, yelling and screaming at him in the hotel room and in public.’17 This was denied by Ms B. Ms C stated that the couple often argued about Mr A disciplining Child 3.18
Ms C also stated that in approximately mid-2015 Mr A had a fractured arm, and Ms B purportedly told her that she had broken Mr A’s arm during an argument by hitting him with a coffee cup.19 This was also denied by Ms B.
In September 2015 a neighbour called Victoria Police after overhearing yelling and banging from Mr A and Ms B’ residence. When police attended, Ms B did not disclose any family violence, stating that there had been a verbal argument and that she did not require police assistance. Mr A was not present or spoken to by police on this occasion. The police returned a few days later to conduct a welfare check on Ms B and she indicated that there had been no further incidents since the previous report and that she was not interested in accessing support services at that time.20
On 30 December 2015 a neighbour contacted police to report another family violence incident at Mr A and Ms B’ residence. Notes from this incident indicate that Ms B reported that Mr A had been accusing her of having an affair and had locked himself in the bathroom with Ms B’ phone. Ms B then allegedly forced her way into the bathroom and tried to retrieve her phone, sustaining scratches to her forearms. Mr A tried to leave the property with the phone and Ms B reached into his car to retrieve it as he was driving away, leading to a neighbour intervening to pull her away from the moving vehicle.21 16 Defence documents, psychiatric report of Professor Quadrio, 26.
17 Coronial brief, statement of A Bailey, 99.
18 Ibid.
19 Ibid.
20 Form 32 material, additional statements: statement of K Edgar, statement of P Halls, statement of N Milner.
21 Form 32 material, combined redacted material, LEDR Mk2 Summary Report, 492-493; additional statements, statement of J Mansfield; Department of Health and Human Services, child protection records relating to L Kolders, 11-12; No to Violence/Men’s Referral Service, records relating to Alexandros Alexandrou 1, 6.
Ms B reported that Mr A had become increasingly jealous and controlling and had isolated her from family and friends. She also reported that he had become increasingly aggressive towards her daughter, Child 3, and had flicked cigarette lighters at her. Police applied for a Family Violence Safety Notice (FVSN) to protect Ms B and her children. This FVSN excluded Mr A from the property. Police members submitted referrals to support services for Ms B and Mr A.22
An interim Family Violence Intervention Order (FVIO) was issued on 29 February 2016 and served on Mr A by police on 20 March 2016. This order prohibited Mr A from committing family violence against Ms B, Child 3, and Child 1, but allowed him to continue to reside and communicate with them.23
On 26 March 2016, Ms B contacted police to report a further family violence incident. On this occasion, she reported that Mr A had accused her of having an affair, called her names and had repeatedly tried to look at her phone. She reported that he had also sprayed her with household cleaner, verbally abused Child 3, and told Child 3 that Ms B was having sex with other men whilst Child 3 was at school.24 Police commenced a criminal investigation for contravention of the FVIO and for unlawful assault in relation to this incident.25
On 29 March 2016, Child Protection conducted a home visit at Ms B’ residence. On this occasion Ms B confirmed that Mr A had perpetrated family violence against her but denied that any physical abuse had occurred. Child 3 was also interviewed by Child Protection and disclosed that she was afraid of Mr A.26
On 10 April 2016, a support worker from Berry Street conducted a home visit to Ms B with Victoria Police. On this occasion Ms B appeared tearful and reported that Mr A had left earlier that day after an argument. She indicated that no physical violence had occurred, but he had been verbally abusive. The police sighted the children, who appeared to be happy, and discussed the supports that were available to Ms B. Ms B advised that she wanted to meet the Berry Street 22 Form 32 material, combined redacted material, LEDR Mk2 Summary Report, 492-493; additional statements, statement of J Mansfield; Department of Health and Human Services, child protection records relating to Child 3, 1112; No to Violence/Men’s Referral Service, records relating to Alexandros Alexandrou 1, 6.
23 Form 32 material, combined redacted material, police brief of evidence re FVIO contravention, 83-84; additional statements, statement of J Mansfield.
24 Form 32 material, combined redacted material, police brief of evidence re FVIO contravention, 65-86; additional statements, statement of C Baillieu, statement of R Westgarth; Department of Health and Human Services, child protection records relating to Child 3, 83.
25 Form 32 material, additional statements, statement of C Baillieu, 1.
26 Department of Health and Human Services, child protection records relating to Child 3, 83-84.
worker to discuss her options without the police present and said she would contact Berry Street to arrange a time for this.27
Ms B declined an offer by police to vary the FVIO to exclude Mr A from the property and to prevent him from contacting her. She indicated that she was not fearful or concerned for her safety but was happy to engage with Berry Street for support. The attending police members completed a family violence report and submitted referrals for support.28
Berry Street subsequently contacted Ms B and arranged an appointment with her on 17 April 2016.29 Ms B later cancelled this appointment and advised them she would contact them later to reschedule it.30
On 18 April 2016, Mr A was arrested and interviewed in relation to criminal offences arising from the family violence incident on 26 March 2016.31
On 19 April 2016, a final FVIO was issued at Heidelberg Magistrates’ Court which prohibited Mr A from having contact or residing with Ms B and her children. Mr A was not present at the hearing.32
On 29 April 2016, Ms B’ neighbours called police after hearing a female yelling for help and for someone to call the police. Police attended and spoke to Ms B, who stated that Mr A had attended her home and again accused her of having an affair. A verbal argument had occurred, during which Mr A had hit her repeatedly and grabbed her by her arm, throat, and face. He had also purportedly held her up against a wall with his hands around her neck. This assault had caused visible injuries to Ms B, including red marks on her neck, and bruising to her eye and left arm. At the time of this assault, Ms B was pregnant with Child 2, and both Child 3 and Child 1 were present in the home.33 27 Berry Street, records relating to Ms B, 29.
28 Form 32 material, additional statements, statement of J Moloney; Department of Health and Human Services, child protection records relating to Child 3, 84.
29 Berry Street, records relating to Ms B, 25-26.
30 Ibid 24.
31 Form 32 material, combined redacted material, custody records, 58; Department of Health and Human Services, child protection records relating to Child 3, 12, 84.
32 Form 32 material, combined redacted material, Certified extract of FVIO, 222-224.
33 Form 32 material, combined redacted material, statement of S Kolders, 118-120, police brief of evidence re FVIO contravention, 504-527, LEDR Mk2 Summary Report, 608-612; additional statements, statement of J McKenna;
When police attended on this occasion, Mr A had already left the residence. They commenced a criminal investigation for unlawful assault and breach of the FVIO, took photographs of Ms B’ injuries, and submitted a whereabouts request for Mr A.34
For several weeks leading up to 3 May 2016, Mr A reportedly drove around Ms B’ home on up to ten separate occasions, performing repeated laps of her block, playing loud music, beeping his horn and yelling out Ms B’ name.35 On 3 May 2016, Mr A again drove near Ms B’ address, engaging in similar behaviour. He then approached her door and banged on it repeatedly, demanding that she return her engagement ring to him. Ms B left the property with her children to take Child 3 to school, and Mr A followed her in his vehicle. After dropping Child 3 off at school Ms B drove straight to the Mill Park Police Station to report the incident.36
Later the same day Mr A attended Child 3’s school, where Ms B was waiting in her car to pick Child 3 up, and began to verbally abuse Ms B. He again demanded that she return the engagement ring he had given her. Two other parents intervened at this incident. One asked Mr A to leave and recorded video footage of his behaviour whilst the other checked on Ms B and contacted the police. Mr A left shortly afterwards.37
On 4 May 2016, Ms B made a formal statement at Mill Park Police station about the above incidents.38 Workers from both Berry Street and Child Protection also attended the police station on this day to speak with Ms B.39 Child Protection advised Ms B that she needed to go into refuge or find alternate accommodation until Mr A was successfully arrested by police. Ms B indicated that she did not wish to go into refuge with her children and instead arranged to stay with her parents.40
On 9 May 2016, Mr A was arrested and interviewed at the Mill Park Police Station and charged with intentionally causing injury, recklessly causing injury, contravening a FVIO (indictable), contravening FVIO (summary) and unlawful assault.41 He was also served with the final FVIO Department of Health and Human Services, child protection records relating to L Kolders, 12, 84; Psychiatric Report of Professor Quadrio, 28.
34 Form 32 material, additional statements, statement of J McKenna, 1.
35 Form 32 material, combined redacted material, police brief of evidence re FVIO contravention, 95-129; LEDR Mk2 Summary Report, 627-631; LEAP incident report, 650-654.
36 Form 32 material, combined redacted material, police brief of evidence re FVIO contravention, 95-129; LEDR Mk2 Summary Report, 627-631; LEAP incident report, 650-654.
37 Ibid.
38 Form 32 material, combined redacted material, police brief of evidence re FVIO contravention, 118-120.
39 Berry Street, records relating to Stephanie Kolders, 22.
40 Ibid.
41 Form 32 material, combined redacted material, custody records, 58; additional statements, statement of A Cutajar, statement of J McKenna.
that had been issued on 19 April 2016.42 As a result of these charges Mr A was remanded in custody until 6 June 2016.43
After Mr A was remanded in custody, Ms B returned to her home. Ms B arranged for the locks to be changed, and Berry Street assisted her to obtain financial assistance so that she could move to a new rental property where Mr A would not be able to locate her.44
On 17 May 2016, a case coordination meeting was held between Victoria Police, Berry Street, Child Protection, Child First and the Northern Area Mental Health Services (NAMHS). During this meeting, information was shared about Ms B and Mr A, and support for the family was coordinated between these services. During this meeting, NAMHS noted that they had engaged with Mr A in April 2016 in relation to drug induced psychosis and morbid jealousy. NAMHS also noted that Mr A was known to always carry a knife. NAMHS further advised that they had made several attempts to get Mr A to attend their clinic for assessment after the initial referral, but that he was unwilling to participate and ultimately their referral was closed.45
On 6 June 2016, Mr A was released on bail, with an undertaking that he would comply with the FVIO and report to police twice a week.47
After his release Mr A contacted Ms B via phone to advise her that he was no longer in custody.
He sent her text messages and called her on numerous occasions in breach of the FVIO and his bail conditions. Ms B agreed to meet with him and allowed him to live with her again between 7 and 13 June 2016, later stating that she had ‘missed him while he was on remand’48 and that she had been ‘hoping that he had made some changes in himself while he was on remand.’49
43 Form 32 material, combined redacted material, custody records, 58; additional statements, statement of A Cutajar, statement of J McKenna.
44 Berry Street, records relating to Stephanie Kolders, 17-19.
45 Ibid 18-19.
46 Ibid 16.
47 Form 32 material, combined redacted material, custody records, 58, certified extract of application for bail, 244; additional statements, statement of M Hooke.
48 Form 32 material, combined redacted material, statement of S Kolders, 202.
49 Ibid.
the FVIO and his bail conditions.50 Ms B later stated that when they were leaving the hospital Mr A allegedly insulted Child 3, used inappropriate language in front of the children, and called Ms B a derogatory name.51 Immediately following this incident, Ms B drove Mr A to the Mill Park Police Station so that he could sign in as per his bail conditions. After they parked the car, Mr A removed Ms B keys from her so that she could not drive away whilst he went inside.
When he returned from the station, he returned her keys to her and she drove him to his home.52
After this incident Ms B stated to police that she ‘didn’t want anything more to do with [Mr A].’53 Ms B attempted to distance herself from him, but Mr A continued to harass her, and often drove by her home, beeping his horn and playing loud music. Throughout this period, Mr A reportedly demanded money, appliances, and her engagement ring.54
On 14 June 2016 Child Protection conducted a home visit with Ms B. During this visit Child 3 advised them that Mr A had been coming to the house regularly. When questioned about this, Ms B said she had no social supports, that she was worried about being a single mother to three young children, and that she could not guarantee that she would not call Mr A for support again.
Ms B also said that she would be open to recommencing her relationship with Mr A in the future if his behaviour changed.55
Child Protection held concerns that Ms B would bring the children into contact with Mr A, and they would be exposed to further family violence. They were also concerned that Mr A had failed to engage with Child Protection despite their repeated attempts to contact him. As a result, Child Protection issued a protection application by emergency care and the matter was heard at the Broadmeadows’ Children’s Court the following day, on 15 June 2016. The hearing was adjourned to a later date, and Ms B and Child Protection agreed to an undertaking under which the children would live with Ms B and she would not have contact with Mr A until the next hearing. Mr A was not present at the hearing.56
On 20 June 2016, Mr A and his brother attended Ms B’ home. On this occasion, they were reportedly verbally abusive towards her and demanded money. Mr A attended again the 50 Form 32 material, combined redacted material, police brief of evidence for FVIO contravention, 181-299; LEDR Mk2 Summary, 686; LEAP Incident Summary Report, 681-685.
51 Form 32 material, combined redacted material, statement of Ms B, 203.
52 Ibid.
53 Ibid.
54 Ibid.
55 Department of Health and Human Services, child protection records relating to Child 3, 504-506.
56 Ibid 498.
following day and was again verbally abusive. Ms B did not let Mr A inside on either occasion and filmed both incidents on her mobile phone from the balcony of her home.57
Ms B later reported that around this time Mr A became ‘more and more abusive’58 and on one occasion during a phone call ‘threatened to bash me and my door down.’59
Ms B reported that Mr A wanted her to vary the FVIO to allow him to reside with her and attend Sophia’s birth. Ms B spoke to Child Protection about this on 13 July 2016 and they advised her against varying the FVIO, indicating that they may consider removing her children from her if she varied the order to allow Mr A to have contact with them.60
On 14 July 2016, Mr A made an application to vary the FVIO. The presiding Magistrate stood the matter down so that the police could make enquiries with Ms B and Child Protection about the application. Child Protection advised the police that they would not support the variation61 and the application was struck out the following day.62
On the same day Senior Constable Mitchell Hooke of the Whittlesea Family Violence Team was allocated a Family Violence Priority Target Management Plan (PTMP) in relation to Mr A.63 PTMP’s are planned responses within Victoria Police for priority ‘Persons of Interest’ to ensure a targeted and coordinated approach is adopted by police members to prevent and disrupt recidivist and other high risk offending in the community.
On 22 July 2016, Mr A and his brother were arrested after they allegedly smashed a police car windscreen. Mr A was released on bail in relation to this incident on 23 July 2016. Victoria Police strongly opposed the granting of bail on this occasion, noting the history of family violence, Mr A’s stalking of Ms B, his repeated contravention of the FVIO and Ms B’ vulnerability due to her pregnancy.64 Mr A’s bail conditions required him to provide a $2,000 surety, comply with the FVIO, report daily to police, and comply with a curfew between 10.00pm and 6.00am.65 57 Form 32 material, combined redacted material, statement of Ms B, 203-204.
58 Ibid.
59 Ibid.
60 Department of Health and Human Services, child protection records relating to Child 3, 431.
61 Ibid 427.
62 Ibid 425.
63 Form 32 material, additional statements, statement of M Hooke, 1.
64 Form 32 material, combined redacted material, Victoria Police Remand Brief, 167-176 65 Form 32 material, combined redacted material, certified extract of criminal proceeding, 246.
On 24 July 2016, SC Hooke attended Ms B’ property with a worker from Berry Street. SC Hooke introduced himself to Ms B and explained that his role was to maintain oversight of any family violence between her and Mr A. SC Hooke requested that Ms B report any nonimmediate breaches of the FVIO directly to him and to contact ‘000’ for emergency incidents.66 Ms B indicated that she no longer wanted to amend the FVIO to allow her to see Mr A as he had been making no effort with Child Protection. She stated everything was going well and that she had her mother at home with her for support.67
On the same day SC Hooke also met with Mr A at his home and introduced himself and explained his role.68
On 26 July 2016, Ms B contacted SC Hooke and advised him that Mr A had breached the FVIO that morning by driving around her house in his car, beeping the horn and playing loud music for approximately 30 minutes. Ms B also reported that Mr A had been calling and texting her the day before. SC Hooke attended Ms B home to obtain a statement from her that morning, then attended Mr A’s residence that afternoon to arrest him for contravening the FVIO. Mr A refused to go with SC Hooke and locked himself in his home for approximately one hour before agreeing to leave the premises to be placed under arrest.69
Mr A was charged with numerous offences, specifically ‘Contravene Family Violence Intervention Order on four counts, Persistent Contravention of Intervention Order, Stalk Another Person, Contravene Condition of Bail, and Commit Indictable Offence Whilst on Bail on two counts’70 and was remanded in custody.
On 7 August 2016, Ms B gave birth to Child 2.71 Mr A was still in remand at this time and was not present at the birth.
Between 27 July 2016 and 15 September 2016, Ms B engaged with Berry Street, sought counselling support for Child 3, and advised Child Protection that she had no intention of reconciling with Mr A.72 On 19 September 2016, Child Protection withdrew their protection application after Ms B signed an undertaking that she and the children would have no contact 66 Form 32 material, additional statements, statement of M Hooke, 1.
67 Berry Street, records relating to Ms B, 9.
68 Form 32 material, additional statements, statement of M Hooke, 1.
69 Form 32 material, Form 32 material, combined redacted material, Victoria Police brief of evidence re FVIO contravention 181-30; Victoria Police LEAP incident summary and LEDR Mk2 Summary 702-707; Form 32 material, additional statements, statement of M Hooke, 3-4.
70 Form 32 material, additional statements, statement of M Hooke, 15.
71 Department of Health and Human Services, child protection records relating to Child 3, 397.
72 Ibid 366, 379, 383; Berry Street, records relating to Ms B, 5-8.
with Mr A, and that she would continue to engage with Berry Street and appropriate services.
This undertaking was to remain in force until 18 March 2017.73
On 5 October 2016, Child Protection met with Ms B and closed their case.74 They had no further involvement with Ms B or her children between this time and the fatal incident.
On 9 December 2016, Mr A was convicted of persistent contravention of a family violence order and committing an indictable offence whilst on bail and sentenced to 12 months imprisonment with a non-parole period of six months.75
On 13 February 2017, First Constable Jessica Moloney was assigned the Family Violence PTMP with respect to Mr A. On 22 February 2017 FC Moloney identified that the FVIO was due to expire on 28 February 2017. FC Moloney contacted Ms B via telephone, who advised FC Moloney that she was not in fear of Mr A and that she wanted him to be able to see his children. Ms B also noted that Mr A’s mother was ill with a brain tumour and that she wanted Mr A to be able to take the children to see her. Ms B advised FC Moloney that she would oppose any application to extend the FVIO. Despite this, Victoria Police subsequently applied to extend the FVIO.76
On 23 February 2017, Mr A was convicted of contravening a FVIO, unlawful assault, persistent contravention of a FVIO, committing an indictable offence whilst on bail and intentionally damaging property. He was sentenced to two months imprisonment to be served concurrently with his existing sentence.77
During his term of imprisonment, Mr A did not engage in any programs targeted towards his offending behaviour.78 He also continued to contravene the FVIO by seeking to have Ms B added to his list of permitted visitors, asking family members about Ms B and her children, and asking family members to pass messages and items on to her.79 These breaches of the FVIO protecting Ms B and her children were not reported to police.
73 Department of Health and Human Services, child protection records relating to Child 3, 379.
74 Ibid 354.
75 Form 32 material, combined redacted material, LEAP Criminal Record, 55.
76 Form 32 material, additional statements, J Moloney, 4.
77 Form 32 material, combined redacted material, LEAP Criminal Record, 55.
78 Corrections Victoria, records relating to Mr A, ‘IMF section 1-3’, 51-52.
79 Fulham Correctional Centre, recordings of phone calls made by Alexandros Alexandrou.
At some point prior to March 2017, Ms B and Mr A recommenced their relationship whilst he continued to serve his term of imprisonment.80
On 27 February 2017, the FVIO protecting Ms B and her children was extended on an interim basis and Child 2 was added to the order as an Affected Family Member (AFM).81 The conditions of the interim FVIO prohibited Mr A from contacting or communicating with Ms B or her children.82 On the same day, Victoria Police spoke with Ms B about the FVIO proceedings, and she indicated that she did not want the FVIO to prohibit Mr A from seeing her or the children.83
The interim FVIO does not appear to have been provided to Fulham Correctional Centre, where Mr A was serving his term of imprisonment, until at least 4 March 2017. As a result, Mr A was able to successfully add Ms B to his permitted visitors list and have telephone contact with her on 2 and 3 March 2017.84 Mr A was subsequently served with the extended FVIO and Ms B was removed from his approved visitors list.85
On 24 March 2017, Victoria Police applied to vary the FVIO in accordance with Ms B wishes.
The presiding Magistrate advised Victoria Police to conduct a risk assessment for both parties prior to the hearing of the matter on 16 May 2017.86 Victoria Police conducted a risk assessment, indicating their support of the variation, and advised Ms B to attend the next hearing on 16 May 2017.87
On 16 May 2017, the interim FVIO was varied at the Heidelberg Magistrates’ Court to allow Mr A to have contact and reside with Ms B. It continued to include conditions prohibiting Mr A from perpetrating family violence against Ms B and her children, damaging their property, and going to their home when affected by drugs or alcohol.88 This FVIO was made into a final order on 10 July 2017.89
On 27 July 2017, Mr A was released from custody and Ms B drove him to his home.90 80 Defence Documents, Ms B defence response, 2.
81 Coronial brief, Appendix O, 416-418.
82 Form 32 material, additional statements, C Waldron, 2.
83 Ibid.
84 Fulham Correctional Centre, recordings of phone calls made by Mr A, recordings dated 2 March 2017 and 3 March 2017.
85 Ibid, 16 March 2017.
86 Coronial brief, Appendix O, 419-421.
87 Form 32 material, additional statements, C Waldron, 2.
88 Coronial brief, Appendix O, 422-424; Form 32 material, additional statements, C Waldron, 2.
89 Coronial brief, Appendix P, 426-427. Form 32 material, combined redacted materials, 825.
90 Form 32 material, combined redacted material, custody records, 58; Coronial brief, statement of A Bailey, 101.
On 7 August 2017, Mr A allegedly perpetrated family violence against Ms B. Ms B later stated that this was the first incident of family violence that had occurred following his release from prison. Ms B alleged that Mr A had become angry after she had told him that it was too late in the evening for the children to have birthday cake. Mr A purportedly began accusing her of having affairs, called her selfish and derogatory names and tried to get Child 2 out of bed when Ms B was trying to put her down. As a result of this conduct, Ms B asked him to leave.91
Mr A provided an account of this incident to his cousin, Ms C, stating that he was upset as Ms B had not woken the children up for a photo with his daughter and her first birthday cake. He alleged that Ms B had been cheating on him.92
On 9 August 2017, Ms B was expressing frustration about Mr A’s behaviour to Ms C in private messages sent via Facebook. During this conversation, Ms B wrote ‘I feel like I am ready to snap if he disrespects me one more time.’93
On 11 August 2017, Ms B attended Lakes Boulevard Medical and saw a General Practitioner (GP). Notes from this attendance indicate that Ms B was experiencing significant anxiety, that her ex-partner had come home from prison and was ‘mentally causing her distress,’94 and that her ‘ex partners mother died and has caused lots of domestic issues.’95 The GP noted that there was ‘no physical violence’96 and Ms B felt safe, although she reported ‘feeling panicky.’97 The GP prescribed Valium for Ms B and they agreed that she would return the following week for a mental health care plan.98 However, Ms B does not appear to have attended the clinic again prior to the fatal incident.99
On 27 September 2017, Ms C noticed a cut on Mr A’s hand. When she questioned him about it, Mr A indicated that the injury had occurred when Ms B had stabbed him with scissors during an argument about Child 3 having broken his phone charger.100 Ms B later stated to a forensic psychiatrist that on this occasion, Mr A had been abusive towards Child 3 and Ms B had grabbed a pair of children’s scissors and hit him with them. Mr A had then thrown Ms B into a clothes 91 Coronial brief, statement of Ms C 103; Defence documents, psychiatric report of Professor Quadrio, 34.
92 Coronial brief, statement of Ms C, 103.
93 Coronial brief, Appendix M, 397.
94 Lakes Boulevard Medical, medical records of Ms B, 12.
95 Ibid.
96 Ibid.
97 Ibid.
98 Ibid.
99 Ms B’s Medicare claims history indicates two additional medical claims made on 31 August 2017 but these appear to relate to the collection of specimens rather than surgery consultations.
100 Coronial brief, statement of Ms C, 105.
horse in retaliation. Ms B stated she had slept with the children that night due to her fear Mr A would harm them.101
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.
Victoria Police proximate contact with Mr Alexandro and Ms B
I note that police members applied for a FVIO to protect Ms B and her children which was made final on 19 April 2016 and originally was due to expire on 27 February 2017. Police members applied on 27 February 2017 for a variation and extension of the existing FVIO and a risk assessment was performed by police. The available evidence suggests that the risk assessment performed did not cover all the relevant risk factors known to police members.
The Victoria Police Code of Practice for the Investigation of Family Violence (Code of Practice) in place at the time, and currently, provides that a decision to extend or vary a FVIO should be made based on ‘an assessment of the present and future risks. Where children are involved police must ensure they are still protected and appropriate services are in place.’105
Victoria Police noted that police officers are not required to conduct the risk assessment embedded within the former VP Form L17/ current FVR (L17) when applying to vary or extend a FVIO independent of a family violence incident.106 However, police officers are required to actively consider and assess present and future risk when engaging with any party involved in family violence, including when taking action to apply to extend or vary a FVIO.107 The Code of Practice at the time more specifically indicates that: 101 Defence documents, psychiatric report of C Quadrio, 35.
102 Coronial brief, statement of M Mitoski, 240.
103 Coronial brief, statement of C Duff, 226.
104 Ibid.
105 Ibid 41.
106 Victoria Police response provided to the Court dated 5 November 2021, 7 107 Ibid
‘Any agreement to extend, vary or revoke the FVIO must be appropriate in the circumstances, based on an assessment of the present and future risks. Where children are involved police must ensure that they are still protected, and appropriate services are in place’.108
At the time of the extension and variation of the FVIO police were aware of a significant history of family violence perpetrated by Mr A towards Ms B and there were numerous family violence risk factors suggesting a risk of future or ongoing family violence, including; Ms B’ isolation, Mr A’s previous threat to kill her, his attempt to choke her, his stalking of her, his persistent breaches of the FVIO, and his obsessive and jealous behaviour.109
The risk assessment initially conducted by police on 27 February 2017 in relation to the extension and variation of the FVIO was in the form of a VP Form L17.110 This assessment does not appear to have been completed accurately or completely. There was nothing recorded against the questions relating to previous family violence, the most serious family violence incident ever was noted to be the ‘current event’111 the total period of violence was left blank as was the estimated number of previous incidents and the risk of future violence was noted as ‘unlikely.’112 The narrative for the incident also made no mention of the history of family violence or the fact that Mr A was on remand in relation to family violence offences and contravention of the FVIO.113 The affidavit in support of the extension and variation, however, did note that police held concerns that Mr A would continue to offend after his release from custody and continued to hold concerns for the safety of Ms B and her children.114
The updated risk assessment completed by a police member on 23 March 2017 (a general non L17 assessment) also appears to have been deficient in many respects. This assessment did not reference any of the applicable family violence risk and vulnerability factors that were present at the time of the assessment and does not appear to have been completed in consideration of the full history of family violence.115 Instead of considering these risk factors to assess the likelihood of ongoing family violence, as appropriate, under ‘likelihood of ongoing family violence’ the risk assessment noted only that Ms B believed Mr A ‘may have changed in prison 108 Victoria Police Code of Practice for the Investigation of Family Violence 3rd Edition (2017), section 5.13.3.2 109 Department of Human Services, Family Violence Risk Assessment and Risk Management Framework and Practice guides 1-3 (April 2012) V2, 27-28.
110 Form 32 material, Notes and running sheets, C Waldron Notes 2, 11-16.
111 Ibid 14.
112 Ibid.
113 Ibid 11.
114 Ibid 18.
115 Department of Human Services, Family Violence Risk Assessment and Risk Management Framework and Practice guides 1-3 (April 2012) V2, 27-28.
and is supportive of giving him another chance.’116 The risk assessment also made no mention of the children, or whether they were sufficiently protected and had appropriate services in place to protect them.
Corrections Victoria proximate contact with Mr A
Mr A was incarcerated from 22 July 2016 to 27 July 2017 in relation to his perpetration of family violence against Ms B. Mr A served most of his sentence at Barwon Prison, from 27 September 2016 to 5 January 2017, and Fulham Correctional Centre (FCC), from 26 January 2017 to 27 July 2017.
Corrections staff were aware that there was an existing FVIO in place prohibiting Mr A from contacting or communicating with Ms B, Child 3 and Child 1 and a copy of the FVIO was contained in Mr A’s corrections file. This FVIO prohibited Mr A from keeping Ms B, Child 3 or Child 1 under surveillance, contacting or communicating with them by any means or causing another person to do anything that he was prohibited from doing under the order.
Phone records from FCC indicate that between 3 February 2017 and 28 February 2017 Mr A made numerous phone calls to his mother and brother. During these phone calls he asked whether they had seen Ms B or her children, what Ms B had been doing and what had been said in their conversations with her. Mr A also asked his mother to pass messages on to Ms B, such as wishing her and her children a happy valentine’s day from him. All of this behaviour appears to have been in contravention of the FVIO in place at the time protecting Ms B and her children.
The FVIO protecting Ms B and her children was due to expire at midnight on 28 February 2017, however an interim order was made on 27 February 2017 which extended the order on an 116 Form 32 material, additional statements, 4.
interim basis and added Sophia to the order as an Affected Family Member. The conditions of the interim FVIO were the same as the previous FVIO.
The available evidence suggests that there was some delay in the interim order being served upon Mr A and brought to the attention of FCC. As a result of this delay, Mr A was able to have Ms B listed as an approved contact after 28 February 2017. On 2 and 3 March 2017, Mr A spoke with Ms B via telephone and arranged for her to come and visit him.
Mr A appears to have been served with the new FVIO after these conversations occurred, as on 16 March 2017, he advised his mother that he had been served with a FVIO and that Ms B had been removed from his approved contact list.
Between 16 March 2017 and 16 May 2017, Mr A repeatedly asked his mother and brother about Ms B, whether they had seen her and what the contents of their conversations with her had been. He also asked them to pass on messages to her and to purchase Easter eggs for her and the children and pass them on to her from him. This behaviour again appears to have been in contravention of the interim FVIO in place at the time.
On 16 May 2017, the interim FVIO was altered to permit Mr A to have contact with Ms B and her children.
Although there were policies with respect to Prisoner Communications and the Prisoner Telephone System at the time, the only guidance within these documents as to family violence related to prisoners being clearly abusive or threatening to the recipient of the phone call. This guidance would not have been applicable in relation to the above incidents.
Corrections Victoria confirm that whilst regulations and guidelines exist currently to make it a prison offence to ‘commission a third party to commit an act of family violence on the prisoner’s behalf’, there is no requirement to monitor calls made by prisoners for this specific prohibited behaviour.117 Corrections Victoria confirm that in March 2021, new amendments were introduced to refer matters to Victoria Police if the prisoner breached an FVIO however it does not appear that at the time or currently that Corrections Victoria will monitor approved persons calls for content that may breach an FVIO beyond direct threats of violence, i.e. screening calls to a family member to pass on messages to protected person or make enquiries about a protected person that the prisoner is not allowed to communicate with.118 117 Corrections Victoria response provided to the Court dated 23 September 2021, 2-3 118 Corrections Victoria response provided to the Court dated 27 August 2021, 2
Victoria Police confirm that there are no specific timeframes within which police members are to serve FVIOs on respondents who are incarcerated.119 This appears to be a gap in best practice as unlike difficulties of locating a respondent in the community, incarcerated respondents can be found easily. It seems reasonable to expect that such respondents should be served within 48 hours to prevent lapse in protection of affected family members under an active FVIO.
GP treatment for Ms B
Ms B made disclosures of family violence to a GP at Lakes Boulevard Medical on 11 August
Records from this service indicate that Ms B had not made any disclosures of family violence to her treating practitioners at the clinic prior to this occasion.
I note that when responding to disclosures of family violence, GPs can seek guidance by reviewing the Royal Australian College of General Practitioners (RACGP) manual Abuse and Violence: Working With our Patients in General Practice (also known as the White Book).120 The White Book provides clinicians with guidance on how to work with patients experiencing family violence and provides that GPs ‘have a role in prevention, early identification, responding to disclosures of intimate partner abuse, and follow-up and support of patients and their children experiencing the health effects of violence and abuse.’121 This guidance directs clinicians to encourage accountability, prioritize the safety of the woman and children and to identify the most appropriate program or support service for the patient.
It appears that the GP appropriately queried Ms B about her experience of abuse, as he made notes about the type of violence, whether physical abuse had occurred and Ms B’ perception of her own safety. These notes cover many of the suggested questions from the White Book122 however, it is unclear whether the GP offered Ms B referral information in relation to family violence, as suggested by the White Book.123 The GP provided a response to the court confirming that he did not provide any referrals to Ms B to family violence support services on the basis that there was no physical violence and she reported that she felt safe.124 This assessment fails to consider the fact that she reported significant stress and anxiety about her relationship with her ex-partner and his recent release from prison. The White Book notes that 119 Victoria Police response provided to the Court dated 10 September 2021, 4 120 RACGP, Abuse and Violence: Working With our Patients in General Practice (2014), 5th Edition.
121 Ibid, 11.
122 Ibid 23.
123 Ibid 18.
124 Response provided to the Court by Lakes Boulevard Medical Clinic GP dated 21 August 2021
intimate partner abuse can manifest itself in both psychological and physical symptoms, the psychological can include anxiety symptoms.125
I confirm that since the 2016 Royal Commission into Family Violence, the Multi Agency Risk Assessment and Management (MARAM) Framework was developed to improve guidance for services to identify and respond to family violence. The MARAM Framework was introduced in 2018 and is in the process of being rolled out across Victoria. The Framework provides services and support workers with guidance on how to identify the presence of family violence, family violence risk and how to respond to the identification of family violence. At present this tool is heavily focused on working with victims of family violence, with further instructions relating to perpetrator responses released in 2021.
Unlike publicly funded health services, private GPs are not prescribed under the MARAM Framework and so are not legally obligated to align their services with it. However, the RACGP have recently confirmed that the White Book was updated in December 2021, with reference to updated risk assessment tools such as the MARAM, and that the RACGP Curriculum for Australian General Practice has embedded education for family violence and references to the White Book for all new medical practitioners seeking accreditation with the college.126 Child Protection service contact with Mr A and his children
Child Protection received a report following the family violence incident between Ms B and Mr A on 30 December 2015 and commenced an investigation.
The available evidence suggests that Child Protection appear to have not complied with existing applicable procedures when closing this notification in October 2016. In particular, they appear to have not communicated their closure to the services involved with Ms B and her children or clarified the continuing roles and responsibilities of those services.
One of the most significant service gaps in this case occurred after Mr A was incarcerated and support services ended their engagement with Ms B and her children with no measures put in place to reassess their safety upon Mr A’s release.
The Child Protection Manual in place at the time of closure, and currently, provides that when Child Protection are closing a case they should ‘confirm and communicate the continuing roles 125 Ibid, 21 126 RACGP statement in case 2019/1858, dated 10 December 2021
and responsibilities of services, family members and all parties’ and ensure ‘key services are informed before case closure.’
Based on the available materials, Child Protection do not appear to have notified Victoria Police or Berry Street of their closure, or the basis for the closure. Had this been implemented, this may have facilitated care team meetings with key services involved with the family, timely information sharing, stronger risk assessment and shared decision making.
In spite of this oversight, Child Protection acted largely in accordance with the relevant policies and procedures in place at the time of their interaction with Ms B and her family. Child Protection appropriately identified that the risks to Ms B’ children related primarily to Mr A, and to Ms B bringing them into contact with Mr A. Child Protection also made numerous attempts to engage Mr A with services targeted towards his family violence risk, however on the very few occasions when Mr A contacted Child Protection via telephone, he showed no insight into his behaviour and insisted that he was not a perpetrator of family violence.
b) With the aim of improving the administration of justice, preventing deaths and supporting prison systems to address family violence, I recommend that Corrections Victoria monitor phone calls of prisoners who are respondents to a FVIO for breaches including specifically “using another to do something they are not permitted to do” and report these in a timely manner to Victoria Police for investigation.
a) the identity of the deceased was Mr A, born 02 July 1980; b) the death occurred on 29 September 2017 at Mernda, Victoria, from STAB WOUND TO THE LEFT KIDNEY; and c) the death occurred in the circumstances described above.
Pursuant to section 73(1B) 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: Ms C, Senior Next of Kin Ms Melissa Westin ACM, Deputy Commissioner, Custodial Operations, Corrections Victoria Ms Sally Robertson, Principal Solicitor, Victoria Government Solicitor’s Office Ms Rose Calabro, Deputy Area Operations Manager, Department of Families, Fairness and Housing Detective Sergeant Sean Campbell, Coroner’s Investigator Signature: ___________________________________ Coroner John Olle Date : 23 May 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.
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