Deceased
Fatima Batool
Demographics
39y, female
Coroner
State Coroner Judge John Cain
Date of death
2018-07-07
Finding date
2022-10-10
Cause of death
ligature strangulation
AI-generated summary
Fatima Batool, a 39-year-old woman from Pakistan, was fatally strangled by her husband on 7 July 2018. She had experienced ongoing family violence including physical assault, controlling behaviour, surveillance, and isolation. In the months before her death, she disclosed family violence to her GP and private psychologist, reporting relationship difficulties, anxiety, and depression. Critical clinical lessons include: GPs and mental health practitioners failed to adequately identify and respond to disclosures of family violence despite repeated mentions of relationship concerns and her partner's controlling behaviour. The private psychologist did not identify separation as a high-risk period for intimate partner homicide, despite evidence that this is when victims face greatest danger. Neither the GP nor psychologist appeared to have adequate family violence training. Early, direct questioning about safety and risk assessment, safety planning around separation, and appropriate referrals to specialist family violence services were not provided. Mandatory family violence education for all health practitioners is essential.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2018 003266 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge John Cain, State Coroner Deceased: Fatima Batool Date of birth: 03 April 1979 Date of death: 07 July 2018 Cause of death: 1(a) LIGATURE STRANGULATION Place of death: 19 Redwood Avenue, Hampton Park, Victoria, 3976 Keywords: Intimate partner homicide; cultural and linguistically diverse background; family violence
Fatima Batool was 39 years old when she was found fatally wounded in her home on 7 July
At the time of her death, Ms Batool lived at Hampton Park with her husband Muhammad Hassan and their young daughter, Emel Zahra.
Ms Fatima Batool was born on 3 April 1979 in Quetta, Pakistan and was a part of the Hazara ethnic group in Quetta.1 Ms Batool completed her secondary education in Quetta at the Government Girl’s Degree College.
In approximately 2009, Mr Muhammad Hassan’s family approached Ms Batool’s family in Pakistan in relation to a potential marriage between the pair.2 On 14 May 2010, Ms Batool met Mr Hassan and they were married eight days later, on 22 May 2010.3
On 18 April 2012, Mr Hassan migrated to Australia and on 23 May 2012, Ms Batool gave birth to their daughter, Emel, whilst still residing in Pakistan. On 16 February 2014, Ms Batool and Emel relocated to Australia to live with Mr Hassan.4
Ms Batool’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.
1 Coronial Brief, Statement of J Ali, 43-44; Coronial Brief, Appendix C – PCR Fatima Batool, 135.
2 Coronial Brief, Statement of J Ali, 45.
3 Coronial Brief, Statement of Material Facts, 2.
4 Ibid. 47; Coronial Brief, Statement of Material Facts, 2.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Fatima’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of Fatima Batool 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.5
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
In a subsequent interview following the fatal incident, Emel advised investigating police members that on 7 July 2018, Mr Hassan and Ms Batool began having a verbal fight before she was sent to her room with her mother’s phone to play with.6 Emel recalled hearing Ms Batool tell Mr Hassan that she did not love him anymore and indicate that she may wish to leave the relationship.7
The available evidence suggests that Mr Hassan then strangled Ms Batool with her Hijab, before calling emergency services at approximately 11.48am and informing them that he had killed Ms Batool.8
Police and ambulance paramedics arrived on scene at 12.01pm and located both Mr Hassan, Emel and Ms Batool’s body in the lounge room. Attending ambulance paramedics observed a tightly wrapped hijab around Ms Batool’s neck and after examining her, determined that she was deceased.9 5 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.
6 Coronial Brief, Appendix J – VARE Jaffar Hassan, 221-252 7 Ibid.
8 Coronial Brief, Exhibit 17 – Mr Hassan’s mobile phone call records 9 Coronial Brief, Statement of Edin Dulakovic dated 7 July 2018, 70-71
Mr Hassan was charged with the murder of Ms Batool and was remanded in custody, however, he was found deceased in his cell at the Metropolitan Remand Centre on 9 October 2018. Mr Hassan died in circumstances indicating suicide.10 Identity of the deceased
On 8 July 2018, Fatima Batool, born 3 April 1979, was identified via fingerprint identification.
Medical cause of death
Forensic Pathologist Dr Michael Burke from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on 8 July 2018 and provided a written report of his findings dated 7 September 2018.
The post-mortem examination revealed the following: a) The ligature mark around the neck was associated with congestion and petechial haemorrhages to the face; b) There was also an associated bruise to the strap muscle within the neck and bilateral fractures of the superior corner of the thyroid cartilages; and c) There was no evidence of any significant natural disease process.
Toxicological analysis of post-mortem samples did not identify the presence of any alcohol or any commons drugs or poisons.
Dr Burke provided an opinion that the medical cause of death was 1 (a) LIGATURE STRANGULATION.
10 Coronial Brief of Muhammad Hassan, COR 2018 5092.
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 Hassan and Ms Batool was one that fell within the definition of ‘spouse’11 under that Act.
Moreover, Mr Hassan’s actions in fatally strangling Ms Batool constitutes ‘family violence’.12
In light of Ms Batool’s death occurring under circumstances of family violence, I requested that the Coroners’ Prevention Unit (CPU)13 examine the circumstances of Ms Batool’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).14
The available evidence indicates that there was both reported and unreported family violence occurring between Ms Batool and Mr Hassan in the lead up to the fatal incident.
History of family violence between Ms Batool and Mr Hassan
In 2014, Ms Batool initially resided with Mr Hassan and his family for several months following their marriage, before returning to her own family home. Upon her return, Ms Batool reported to her family that Mr Hassan had been ‘disrespectful to [her], [and was] not showing enough care for her’.15 Ms Batool made several further attempts to reside with Mr Hassan and his family but repeatedly returned to her family home, advising that she was not happy, that she did not want to live with Mr Hassan, and that his family did not respect her.16 Ms Batool also reported to her family that Mr Hassan’s family had been verbally abusive towards her, that they would undermine her, and that Mr Hassan was patronising towards her.17
During her time in Australia, Ms Batool disclosed to her friend that Mr Hassan ‘was very strict’18 and that she was socially isolated. Ms Batool advised that she was not often able to 11 Family Violence Protection Act 2008, section 9 12 Family Violence Protection Act 2008, section 8(1)(a) 13 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 14 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 15 Coronial Brief, Statement of J Ali, 46.
16 Ibid, 46.
17 Ibid.
18 Coronial Brief, Statement of K Hassani, 52.
visit her friend because her husband was ‘very controlling of her and wouldn’t let her leave the house’.19 Ms Batool further disclosed that Mr Hassan would communicate with her friends using her phone, and that she wished to leave the relationship but was worried about ‘what would happen if they separated’.20 The available evidence indicates that Ms Batool was prescribed medication to help her sleep ‘because of her husband’s behaviour within the house’21 but that ‘her husband took the sleeping pills away from her’.22 Ms Batool also disclosed to her friend that Mr Hassan was verbally abusive towards Emel, and Ms Batool was observed to be ‘very scared’23 of Mr Hassan.
Mr Hassan then locked Ms Batool in a bedroom and told her that she was not allowed to come out. When Ms Batool was allowed out of her room, Mr Hassan informed Ms Batool that she would be allowed to leave but that Emel would stay with him, that he would return to Pakistan with Emel and that Ms Batool would never see their child again.25
Victoria Police were contacted in relation to this incident and Ms Batool and Emel were taken to crisis accommodation.26 Ms Batool later reported to police that Mr Hassan was monitoring her movements with surveillance cameras at their house and that he would monitor her phone usage. When confronted about this behaviour by Ms Batool, Mr Hassan allegedly advised that ‘it was her fault’.27
On 23 June 2014, a Family Violence Intervention Order (FVIO) was issued against Mr Hassan with unknown conditions.28 On 15 December 2014, Mr Hassan was convicted of the assault against Ms Batool and sentenced to a 12-month Community Corrections Order (CCO) with 19 Ibid.
20 Ibid, 53.
21 Ibid.
22 Ibid.
23 Ibid, 54.
24 Coronial Brief, Appendix G – Preliminary Police brief of evidence re: Incident on 11 May 2014, 158.
25 Ibid.
26 Ibid.
27 Ibid, 54.
28 InTouch, Records of Fatima Batool, 5.
conditions that he engage in community work, mental health support, and programs to reduce future offending.29
Ms Batool and Emel remained away from the family home for several months following this incident but returned to live with Mr Hassan at an unknown date.30 During this period of separation, Ms Batool advised Centrelink staff that Mr Hassan had made threats towards her family in Pakistan and that one of her in-laws had attended her family home making threats to kill Ms Batool.31 Ms Batool disclosed that she feared for her safety, and had been subject to abuse from Mr Hassan’s family in the past.32
No further incidents of family violence were reported to police prior to the fatal incident.
Approximately one week before the fatal incident, Ms Batool contacted her father and advised that Mr Hassan had put cameras up in the house to ‘control her movements’.33 On approximately 1 July 2018, Mr Hassan contacted Ms Batool’s father and advised that Ms Batool wished to separate from him and that they were planning to sell their residence and divide the proceeds.
On this occasion, Mr Hassan was noted to be ‘very angry’34 that Ms Batool wished to separate and sell their property.
On 4 July 2018, Ms Batool attended Centrelink offices and advised a social worker that she was experiencing family violence. In response to this disclosure, the social worker contacted Safe Steps, a 24-hour family violence crisis telephone service, for assistance and it was agreed that Ms Batool would contact their service again the following day.35
On 6 July 2018, Ms Batool attended Centrelink again and met with a social worker. On this occasion, Ms Batool was provided with support to seek legal advice and transfer her Centrelink payments into her own accounts.36
On 6 July 2018, Mr Hassan contacted Ms Batool’s father and informed him that Ms Batool had ‘left him’37 and that he did not know where she was. On the same day Mr Hassan contacted a friend and organised to stay with him. Whilst at his friend’s home, Mr Hassan received a call 29 Ibid, 182-183.
30 Coronial Brief, Statement of J Ali, 47-48.
31 Centrelink, Records of Fatima Batool, 11.
32 Ibid, 9-10.
33 Ibid, 49.
34 Ibid, 49.
35 Centrelink, Records of Fatima Batool 1, 4.
36 Ibid, 6.
37 Ibid.
from Ms Batool, during which she asked him where he was and if he was coming home. Mr Hassan noted that he would return and shortly departed.38
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.
Medical services provided by Ms Batool’s GP and the assessment of family violence
Ms Batool first attended general medical service to see a General Practitioner (GP) on 7 February 2017 and continued to attend with the GP regularly until the time of her death.39
On 22 May 2018, Ms Batool advised her GP that she ‘need[ed] some help for anxiety and depression’40 and that her ‘relationship [was] not very good’. On this occasion, Ms Batool was provided with a Mental Health Care Plan and referred to a private psychologist.
On 31 May 2018, Ms Batool attended her GP and was noted to be ‘upset and teary’41. Ms Batool disclosed that her relationship with her husband was ‘not good’42, that he was ‘not a good person’43 and that he ‘doesn’t know the problem what [sic] she is dealing with’.44 During this appointment it was agreed that Ms Batool would begin medication to manage her mental health, with a plan for her to attend a psychiatrist if this proved ineffective.45
On 8 June 2018, Ms Batool returned to see her GP and advised them that the medication had not been effective, and that Mr Hassan had warned her not to take medication as it ‘can cause more problems’.46 Ms Batool was subsequently referred to another medical centre for further psychiatric treatment.47
Ms Batool’s final appointment with her GP was on 13 June 2018. During this appointment, Ms Batool advised that her ‘stress is going on [sic]’48 and that ‘anxiety’ was ‘the main problem’.49 Ms Batool further advised that she was ‘thinking about to leave [sic] the partner he is not kind 38 Coronial Brief, Statement of K Jaffari, 59-60.
39 Medical Centre records provided to the Court, Medical Records of Fatima Batool.
40 Ibid, 10.
41 Ibid, 11.
42 Ibid.
43 Ibid.
44 Ibid.
45 Ibid.
46 Ibid, 11-12.
47 Ibid, 12.
48 Ibid.
49 Ibid.
not caring not supportive’50 and that it was ‘difficult to live like this’.51 Ms Batool noted that she was seeing a psychologist and was prescribed with Avanza Soltab to manage her anxiety.52
Whilst the GP’s notes suggest that Ms Batool did not directly disclose her experience of family violence, she made repeated mention of relationship issues and concerns regarding Ms Hassan’s behaviour which should have prompted further exploration by her treating practitioners, especially in the context of Ms Batool’s declining mental health.
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.
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.
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. The RACGP has also embedded family violence education into the Curriculum for Australian General Practice and makes references to the White Book for all new medical practitioners seeking accreditation with the college.126
Whilst I commend the RACGP for its continued work trying to promote family violence education amongst its existing members, I confirm that a number of recently closed coronial 50 Ibid.
51 Ibid.
52 Ibid.
investigations evidencing a continued lack of occupation-specific understanding of family violence is evidence amongst GPs treating the general public.53
Mental health services provided to Ms Batool and the assessment of family violence
Ms Batool was referred to a private psychologist by her general practitioner on 22 May 2018 due to symptoms of anxiety and depression.54 Ms Batool first attended her private psychologist on 28 May 2018. During this appointment, Ms Batool discussed her history of depression and noted that she was experiencing negative thoughts.55 Ms Batool also disclosed that Mr Hassan had blamed her for a recent miscarriage and had said to her that she ‘can’t even give him a baby’.56 In addition, Ms Batool noted that ‘her husband is not very supportive’57 and that ‘he has been physically abusive in the past’.58 Ms Batool went onto explain the incident of family violence that occurred in 201459 and that she had discussed separating with Mr Hassan but that she was concerned for her daughter.60 Ms Batool explained that she had spoken with a counsellor at her daughter’s school about the family violence and that she had been encouraged to speak to the counsellor regarding supports that her daughter may need in the future.61
Ms Batool had a further appointment with her private psychologist on 12 June 2018. During this appointment, Ms Batool advised that her husband had refused to allow her to take medication to treat her mental health, that he was not supportive of her and ‘treats her like a child’.62 Ms Batool also reported that Mr Hassan questions her parenting and that he had told her that she would not be entitled to Australian citizenship if they separated.63 Ms Batool further disclosed that Mr Hassan had told her that he had placed camera’s in the home ‘so he can see everything she does, then he said he was joking’.64 53 See coronial investigations COR 2017 4986 and COR 2019 1858 54 GP Medical Records of Fatima Batool, 10.
55 Private psychologist medical records for Fatima Batool, 1.
56 Ibid, 1.
57 Ibid, 2.
58 Ibid.
59 Ibid.
60 Ibid.
61 Ibid.
62 Ibid, 3.
63 Ibid.
64 Ibid.
Ms Batool went onto note that they agreed to separate in February of that year and that Mr Hassan had raised concerns about their daughter, however it is unclear what these concerns were and why the separation did not occur.65 At the conclusion of the appointment, the private psychologist documented that Ms Batool would ‘speak with [her] husband about separation’66, seek information about mediation, contact the Law Institute of Victoria for free legal advice, contact her general practitioner for a new anti-depressant and call the Women’s Information Referral and Exchange phone line for family violence information.67
Ms Batool attended her third and last appointment with the private psychologist on 18 June
During this appointment, Ms Batool advised that she had been prescribed new antidepressants and made further disclosures of family violence.68 Ms Batool noted that her husband did not like her engaging with her neighbour who was ‘a very independent woman’69 and that she was concerned about Mr Hassan ‘taking her daughter’70 if they were to separate.
At the conclusion of this appointment, it was agreed that Ms Batool would speak with Centrelink and change her post office box. It was also clarified during this appointment that Ms Batool had a separate bank account and had contacted a legal service who had provided some legal advice to her.71
The available evidence suggests that Ms Batool’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. The private psychologist appropriately referred Ms Batool to family violence and legal support and sought information to assist in determining the level of risk posed to Ms Batool. Despite this, it appears that the private psychologist failed to respond to some key risk factors disclosed by Ms Batool during their appointments.
Significantly, the private psychologist does not appear to have identified Ms Batool’s proposal to discuss a separation with Mr Hassan as a high-risk time and no safety planning appears to have occurred around this. Evidence suggests that the time immediately prior to or following separation from an intimate partner is a period of heightened risk for a victim of family violence and their children and is evidenced as being an increased period of risk for a victim being killed or almost killed.72 This is thought to be the case as it is a period of time in which the 65 Ibid.
66 Ibid, 4.
67 Ibid, 4-5.
68 Ibid.
69 Ibid.
70 Ibid.
71 Ibid.
72 Victorian Government, Family Violence Multi-Agency Risk Assessment and Management Framework, https://www.vic.gov.au/sites/default/files/2019-01/Family%20violence%20multiagency%20risk%20assessment%20and%20management%20framework.pdf, 12 & 27.
perpetrator’s degree of control over a victim and their children is threatened or perceived to be threatened.73 Failure to identify this as a high risk period, suggests that there may have been gaps in the private psychologist’s knowledge of family violence. This is consistent with conclusions of the Royal Commission into Family Violence (RCFV)74 which found that health professionals often lack the knowledge or resources to appropriately or effectively respond to family violence.
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).75
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.76
Since this time, 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.
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 73 Ibid.
74 Royal Commission into Family Violence Final Report (March 2016) 75 Ibid, Volume 4, Chapter 19, 55 76 Exhibit 75, Statement from the Office of the Chief Psychiatrist entitled, ‘Commitment to a family violence learning agenda,’ dated June 2019.
into their clinical problem solving’.77 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’78 and that ‘a recent study suggested there is 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.’79
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’80 for a range of professions including psychologists.
As noted above, in 2018, the Victorian Government introduced the Multi-agency Risk Assessment and Management Framework (MARAM) to support practitioners in assessing, monitoring, and managing family violence risk.81 The MARAM prescribes certain organisations and professionals with responsibilities in identifying and responding to family violence. The responsibilities 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’82 which ‘promotes an effective, integrated service response to family violence.’ 83 This includes an understanding of the spectrum of family violence types, family violence risk factors and the complexity of experiences across the community.84
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 77 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/2020-09/Submission%20%23089%20- %20Organisation~aland%20College%20of%20Psychiatrists_0.PDF>, 3.
78 Ibid, 3.
79 Ibid.
80 Australian Psychological Society, Re: Inquiry into family, domestic and sexual violence submission 246 (October 2020), < https://psychology.org.au/getmedia/6657e51d-87a0-4247-ab4f-da00bcabcc65/20aps_submission_family_domestic_sexual_violence.pdf>, 4.
81 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018).
82 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018), 19.
83 Ibid.
84 Ibid.
practitioners like private counsellors or psychiatrists. As such, there is no mandatory family violence training currently in place for these professionals.
The availability of culturally sensitive support services for family violence victims
In assessing the service system response in this matter, it is important to view Ms Batool’s experience of violence against her sociocultural context. Ms Batool was born in Pakistan and belonged to the Hazara ethic group in Quetta.85 Ms Batool was Shia Muslim and immigrated to Australia, with a young child and without family support to be with Mr Hassan.
Pakistan is reported to have high levels of family violence and research indicates that traditional gender roles informed by patriarchal neoliberal structures are prevalent in Pakistan and position women as subordinate to men.86 In such settings, the concept of ‘honour’ ‘is a sense of pride attached to a family when long-lasting traditions, customs, and behaviours are upheld’.87 Whilst honour-based abuse occurs amongst many cultures, research has found that it is prevalent within South Asian countries.88 In such cultures, a family’s honour is heavily reliant on the behaviour and presentation of the female members. If ‘female members of the family do not comply with actions that emphasize family honour, it is said to bring ‘shame’ on the household’.89 In such contexts, the control of women and their obedience to this power dynamic is a key symbol of male pride.90 As power and control are key pillars of family violence, it is theorised that this belief system may contribute to the higher rates of family violence in South Asian counties.91
The available evidence in this case suggests that such beliefs may have played a role in Ms Batool’s experience of family violence. In a statement provided to the Court, a close friend of Ms Batool’s, advised that: In our culture it is very embarrassing and a sign of shame when the wife calls police, meaning that the husband has lost power and control. The men in our culture are judged by the community about the level of power and control that they have, especially in a family relationship. In our culture, the women are required to be full time at home, looking after the family and the house, cleaning and cooking. Women are required to be obedient in our culture 85 Coronial Brief, Statement of J Ali, 43-44; Coronial Brief, Appendix C – PCR Fatima Batool, 135.
86 Azad, M. S. (2021). Experiences of domestic abuse within the South Asian community. Journal of Global Faultlines, 8(1), 50-68; Ahmad, F., Driver, N., McNally, M. J., & Stewart, D. E. (2009). “Why doesn't she seek help for partner abuse?” An exploratory study with South Asian immigrant women. Social science & medicine, 69(4), 613-622; Finfgeld-Connett, D., & Johnson, E. D. (2013). Abused South Asian women in westernized countries and their experiences seeking help. Issues in Mental Health Nursing, 34(12), 863-873.
87 Azad, M. S. (2021). Experiences of domestic abuse within the South Asian community. Journal of Global Faultlines, 8(1), 54.
88 Ibid.
89 Ibid.
90 Ibid.
91 Ibid.
and most of the time the men control the friends that women have and places where women can go.92
Research indicates that migrant South Asian women who experience family violence outside of their home country face several unique challenges. In a study reviewing migrant South Asian women’s experiences of family violence in Canada, researchers have found that this population did not seek professional assistance ‘for a very long time even though they suffered multiple mental, physical and social health consequences of partner abuse’.93 This population reported concerns that they may face social stigma if they disclosed their experience of violence or sought assistance from support services. They also reported that socio-culturally defined gender roles which ‘silence’ women, confine them to the marital home and uphold marital obligation, increased their reluctance in seeking support.94 Participants in the study also discussed concerns that their children would be raised in a single household if they left the relationship, noting this as a major factor in their ‘delayed help-seeking’.95
Researchers also found that migrant South Asian women who experienced family violence were also socially isolated, often having left their family and friends in their home country and having limited opportunities to socialise in their new country due to socio-cultural understandings of women that confined them to the home.96 It was also found that this population were unfamiliar with the local service systems and were unaware of where they could seek assistance.97 South Asian women who have migrated to a Western country also faced additional challenges if they wished to seek assistance for, or leave, an abusive relationship. In addition to losing their relationship with their partner, these women also risked losing access to their children, their relationship with their extended family, their own family, and their community. This group of women also cited concerns that they may lose their economic security and risked losing their immigration status and the life that they had built since leaving their home country.98
The available evidence suggests that these concerns may have impacted upon Ms Batool’s experience of family violence. In a statement provided to the Court, Ms Batool’s close friend 92 Coronial Brief, Statement of K Hassani, 53.
93 Ahmad, F., Driver, N., McNally, M. J., & Stewart, D. E. (2009). “Why doesn't she seek help for partner abuse?” An exploratory study with South Asian immigrant women. Social science & medicine, 69(4), 616.
94 Abused South Asian women in westernized countries and their experiences seeking help. Issues in Mental Health Nursing, 34(12), 870-871; Ahmad, F., Driver, N., McNally, M. J., & Stewart, D. E. (2009). “Why doesn't she seek help for partner abuse?” An exploratory study with South Asian immigrant women. Social science & medicine, 69(4), 616.
95 Ahmad, F., Driver, N., McNally, M. J., & Stewart, D. E. (2009). “Why doesn't she seek help for partner abuse?” An exploratory study with South Asian immigrant women. Social science & medicine, 69(4), 617.
96 Ibid.
97 Ibid.
98 Ibid; Abused South Asian women in westernized countries and their experiences seeking help. Issues in Mental Health Nursing, 34(12), 870-871.
advised that Mr Hassan ‘blamed [Ms Batool] for calling the Police’99 given the shame that it bought upon him and his family. Ms Batool’s close friend further noted that Ms Batool was concerned about divorcing Mr Hassan as ‘women are particularly ostracized if they divorce from their husbands, and if they are a single mother.’100
When accessing their services just prior to her death, Ms Batool informed Centrelink that Mr Hassan had threatened to take Emel to Pakistan and that she would not be allowed to see their child if they separated.101 At the time of the fatal incident, Ms Batool was financially reliant on Mr Hassan and it is unclear if her immigration status was also reliant upon her marriage to him.
In discussions with Centrelink in 2014, Ms Batool provided further insight into her difficulties seeking support and ending the relationship with Mr Hassan, noting that her in-laws had perpetrated family violence towards her in the past, that she was forced to stay in the kitchen and ‘advised that she must accept the violence from her husband’.102 Ms Batool further disclosed that her in-laws had threatened her family members whilst being separated from Mr Hassan in 2014, and had made threats to kill her.103
Significant work is being done in Victoria in order to provide better responses to the unique challenges faced by Culturally and Linguistically Diverse (CALD) women experiencing family violence. Recommendation 163 of the RCFV directed that the Office of Multicultural Affairs and Citizenship Multifaith Advisory Group and the Victorian Multicultural Commission, in partnership with expert family violence practitioners ‘develop training packages on family violence and sexual assault for faith leaders and communities’.104
In response to Recommendation 163, the Victorian Government co-developed a range of training sessions and resources, a steering committee, advisory groups and partnerships with specialist prevention organisations with faith leaders and communities from the Anglican, Buddhist, Hindu, Sikh and Uniting communities.105 In addition, the Victorian Government funded the Board of Imams Victoria to deliver the Family Violence Project to raise awareness of family violence, and how to respond to family violence, within their communities.106 The 99 Coronial Brief, Statement of K Hassani, 53.
100 Ibid.
101 Centrelink, Records of Fatima Batool, 6.
102 Ibid, 9-10.
103 Ibid, 11.
104 Victorian Government, ‘Develop training packages for faith leaders and communities’, < https://www.vic.gov.au/family-violencerecommendations/develop-training-packages-faith-leaders-and-communities>.
105 Ibid.
106 Ibid.
Victorian Government has also allocated $9.67 million over four years in the 2020 – 2021 State Budget to support multicultural and faith communities to prevent family violence.107
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:
With the aim of promoting public health, preventing deaths and supporting medical practitioners to address family violence, I recommend that the National Federation Reform Council (NFRC) review the current registration standards required of medical practitioners with a view to updating CPD requirements for General Practitioners. A specific portion of CPD training undertaken by General Practitioners should be dedicated to family violence to reach an occupation-specific level of family violence understanding and referrals for further support where a patient is identified as experiencing or suspected to be experiencing family violence.
I recommend that similar measures be taken to introduce family violence mandatory CPD for registered psychologists and psychiatrists to provide for an occupation-specific 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.
108 Victorian Government, ‘Ensure the standards for specialist family violence service providers take account of the needs of people in faith communities’, https://www.vic.gov.au/family-violence-recommendations/ensure-standards-specialist-family-violence-service-providers-take.
109 Ibid.
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: Jaffar ALI & Zahra KHANUM, Senior Next of Kin The Honourable Anthony Albanese MP, Prime Minister of Australia, Chair, National Federation Reform Council Rita Butera, CEO, Safe Steps Paul Wappett, CEO, Royal Australian College of General Practitioners Michal Morris, CEO, Intouch Multicultural Services, Victoria Eleri Butler, CEO, Family Safety Victoria Dr Neil Coventry, Chief Psychiatrist, Office of the Chief Psychiatrist Dr Zena Burgess, CEO, Australian Psychological Society Detective Sergeant Scott Jones, Coroner’s Investigator Signature: ___________________________________
JUDGE JOHN CAIN STATE CORONER Date : 10 October 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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