Deceased
Caroline Anne Willis
Demographics
69y, female
Coroner
State Coroner Judge John Cain
Date of death
2018-05-25
Finding date
2024-04-23
Cause of death
Multiple stab wounds
AI-generated summary
Caroline Willis, aged 69, was fatally stabbed by her son Jamie in May 2018, two hours after he was served with a Family Violence Intervention Order (FVIO). The death was homicidal and occurred within a context of escalating family violence spanning three years, compounded by Jamie's unmanaged schizophrenia and methamphetamine use. Clinical lessons include: (1) mental health services failed to adequately assess family violence risk despite multiple disclosures from Ms Willis; (2) no referrals to specialist family violence services were made; (3) Ms Willis' GP did not undertake family violence risk assessment or offer specialist referrals despite documented disclosures of threats and financial abuse; (4) Victoria Police missed opportunities to properly investigate FVIO breaches in April-May 2017 by failing to complete required risk assessment forms and pursue criminal/civil pathways. The period immediately following FVIO service represents heightened homicide risk, yet Ms Willis received no proactive safety planning or personal safety devices. Preventability was high: earlier specialist family violence involvement, adequate police investigation of breaches, mandatory family violence training for GPs and mental health staff, and availability of perpetrator accommodation could have altered the outcome.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2018 002451 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: Caroline Anne Willis Date of birth: 25 September 1948 Date of death: 25 May 2018 Cause of death: 1(a) Multiple stab wounds Place of death: 16 Taworri Crescent, Werribee, Victoria Keywords: homicide; family violence; elder abuse; mental health
On 25 May 2018, Caroline Anne Willis was 69 years old when she was discovered deceased in her home on Taworri Crescent, Werribee, Victoria. At the time of her death, Ms Willis was living with her youngest son, Jamie Willis, who co-owned the residence.
Ms Willis left school at the age of 15 and took up employment in the jewellery retail industry.
Ms Willis has five children from previous relationships. Ms Willis was largely estranged from her family and had separated from Jamie’s father around 1981.
Ms Willis suffered a significant back injury around December 1995 and she had difficulties maintaining full time employment.
Jamie completed his Year 10 schooling and then became a forklift driver around 2004, and continued in this occupation until 2014 when his employment was terminated. He remained unemployed at the time of the fatal incident.
In the three years preceding the fatal incident, Ms Willis and Jamie’s relationship deteriorated and was characterised by Jamie’s perpetration of family violence against Ms Willis. Details of this family violence, and of Jamie’s mental health history, are provided in a later section of this finding.
Ms Willis’ 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 Ms Willis’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 Caroline Anne Willis 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 21 May 2018, Ms Willis applied for a Family Violence Intervention Order (FVIO) and was granted an interim order with full exclusion conditions protecting her from Jamie. In her application, Ms Willis described Jamie’s perpetration of family violence against her, including verbal abuse, controlling behaviour and intimidation. Ms Willis also alleged that Jamie was financially abusive as a result of his drug use and poor mental health, including paranoid delusions.
On 24 May 2018, at 11.56am, Jamie was served with a copy of the FVIO by local police who explained to Jamie that he had to leave the property. Jamie complied by packing some things and handing his keys over to attending police members.
At around 1:19pm on the same day, Jamie returned to the Taworri Crescent residence and entered the premises in contravention of the FVIO conditions. Jamie stabbed Ms Willis multiple times with a kitchen knife, then left the premises at approximately 1.23pm.
Jamie then purchased some methamphetamines and returned to the Taworri Crescent residence and stayed overnight. On the morning of 25 May 2018, Jamie contacted emergency services and told the call-taker a fictitious story about a group of men taking him hostage and harming 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.
Ms Willis. Ambulance paramedics and police arrived shortly after, and Jamie was arrested and charged with murder.
Identity of the deceased
Medical cause of death
Forensic Pathologist Dr Essa Saeedi from the Victorian Institute of Forensic Medicine (VIFM), conducted an autopsy on 26 May 2018 and provided a written report of his findings dated 16 August 2018.
The post-mortem examination revealed the following: a) The autopsy revealed multiple stab wounds (19 sharp force injuries) to the torso, upper limbs and left leg; there was also evidence of bilateral hemopneumothorax with 340 ml of blood in the pleural cavities; bilateral rib fractures, incised left ulnar artery, incised liver and incised left hamstring; multiple blunt force injuries to the head and neck.
b) The force required to cause the stab wounds is at least moderate to severe as some of these have caused rib fractures.
c) There was no evidence of any natural disease which may have caused or contributed to death.
2 Tramadol is a narcotic analgesic used for the treatment of moderate to severe pain.
3 Citalopram is a selective serotonin reuptake inhibitor with antidepressant activity.
4 Nordiazepam is a sedative/hypnotic drug of the benzodiazepines class.
Moreover, Jamie’s actions in fatally stabbing Ms Willis and causing her death constitutes ‘family violence’.6
In light of Ms Willis’s death occurring under circumstances of proximate family violence, I requested that the Coroners’ Prevention Unit (CPU)7 examine the circumstances of Ms Willis’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).8 Relevant family violence history between Ms Willis and Jamie
Ms Willis experienced a great deal of trauma during her life, including childhood sexual assault and family violence.9 Ms Willis experienced ‘severe and longstanding’10 mental health issues including depression, anxiety, possible Post-Traumatic Stress Disorder and a personality disorder.11
Jamie was born on 7 September 1979 and was 40 years old at the time of the fatal incident. He had no prior criminal convictions.12 Jamie used cannabis as a teenager but stopped at the age of 21 when he met his wife, Ms Michelle Pithie, and they had children together.13 Jamie started using methylamphetamines in 2011 at the age of 32. He subsequently lost his job, and his marriage began to breakdown. Jamie had a diagnosis of schizophrenia and a psychiatric report 5 Family Violence Protection Act 2008, section 8(1)(c) 6 Family Violence Protection Act 2008, section 5 7 The Coroners Prevention Unit is a specialist service for Coroners established to strengthen their prevention role and provide them with professional assistance on issues pertaining to public health and safety 8 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths.
Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community 9 Coronial brief, Appendix U – Medical History Caroline Willis, 144; Coronial brief, Summary of Circumstances, 2-3.
10 Coronial brief, Appendix U – Medical History Caroline Willis, 2.
11 Ibid; Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 17.
12 The Queen v Willis [2019] VSC 398, 4.
13 Coronial brief, Appendix V - 511291 / 2367109 Volume 2 - Mercy Health Risk Assessment and Management Report, 79; Coronial brief, Statement of M Pithie, 121.
compiled following the fatal incident states that the psychosis he experienced as a result had not been in full remission since he commenced methylamphetamine use.14
Jamie had a history of perpetrating family violence against Ms Pithie, particularly in the context of substance misuse, and in the last years of their relationship Jamie developed paranoid beliefs about Ms Pithie being a sex worker.15
On 22 May 2015, Ms Willis contacted police and reported that Jamie had contacted her and told her to ‘butt out’ after she had raised concerns about one of his children. Ms Willis said she was fearful that he may come to her house to scare her. Police spoke to Jamie who admitted he may have been ‘overzealous’16 when speaking to Ms Willis. Police made referrals for both parties and took no further action as they deemed that no criminal offence had occurred.17
In September 2015, Jamie went to live with Ms Willis after he and Ms Pithie separated.18 In December 2015 Jamie was admitted to the Sunshine Acute Psychiatric Unit due to paranoid delusions. He was subsequently placed on a Community Treatment Order (CTO). Jamie continued to have delusional beliefs but declined community follow up and his CTO was revoked in April 2016.19
On 1 June 2016, Ms Willis’ General Practitioner (GP), witnessed arguing between Ms Willis and Jamie during a home visit. Ms Willis’ GP suggested that Ms Willis and Jamie seek counselling to assist them with listening to each other and living together successfully. She also spoke to Jamie about a referral to a psychiatric nurse which he said he would consider. On 21 June 2016, Ms Willis’ GP spoke to Jamie about his mental health support options again and noted a plan to contact ‘SW triage’ however there is no documentation confirming this occurred.20
In approximately June 2016, Ms Willis and Jamie bought a property together in Werribee where they lived until the fatal incident.21 14 Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 17.
15 Coronial brief, Statement of M Pithie, 124-30; Coronial brief, Appendix T – Historic Family Violence Incidents - Application Warrant and Order 16 Nov 2005 Willis Pithe, 482-3; Coronial brief, Statement of James Willis, 175-6.
16 Coronial brief, Appendix T – Historic Family Violence Incidents - LEAP incident 22 May 2015 Willis v Willis, 5012.
17 Ibid, 502; Department of Families, Fairness and Housing (DFFH), L17 Portal Records, 21.
18 Coronial brief, Statement of M Pithie, 120.
19 Coronial brief, Statement of A Mordia, 284-5.
20 Appendix U – Caroline Willis medical History, 100-1; Appendix V – Jamie Willis Medical Notes Hoppers Lane General Practice, 7-8.
21 The Queen v Willis [2019] VSC 398, 2.
On 15 June 2016, Ms Willis called North West Mental Health (NWMH) Triage service and raised concerns about Jamie’s mental health. She stated that he had recently thrown things at her for no reason, and that he kept knives in his room and outside the house for protection as he believed people were trying to kill him.22 On 12 August 2016 Ms Willis spoke to the Crisis Assessment and Treatment Team (CATT) and raised further concerns about Jamie’s mental health.23
On 30 August 2016, Ms Willis contacted emergency services and reported that Jamie had threatened and verbally abused her. Ms Willis stated ‘I’m scared I’ll die’.24 Police attended the address and Ms Willis reported that Jamie had said “watch it or else” to her twice, swore at her, threatened that she would not be able to see her grandchildren, and punched the garage door because he believed she had stolen his cigarettes. Ms Willis said Jamie had threatened her and thrown ash trays at her while they had been living together, that his behaviour was increasingly erratic, and reiterated that she did not feel safe at home.25
Police issued a Family Violence Safety Notice (FVSN) preventing Jamie from having contact with Ms Willis and made specialist family violence referrals for both parties.26 An interim FVIO was issued on 1 September 2016 that prohibited Jamie from contacting Ms Willis or going to their address.27 The interim FVIO was extended on 29 September 2016 without the condition prohibiting Jamie from contacting Ms Willis. 28 This interim FVIO was served upon Jamie on 6 October 2016,29 and the matter was adjourned to 3 November 2016.30
On 24 September 2016 Jamie contacted Werribee Mercy Mental Health (WMMH) Triage and stated that his mother had a FVIO against him and would not let him return home until he engaged with mental health services. Jamie admitted to being ‘verbally abusive ++’31 towards Ms Willis but denied being aggressive and asked that WMMH contact Ms Willis and tell her 22 Appendix V - Mercy Mental Health Records Volume 1, 199 – 200.
23 Ibid, 299.
24 Coronial brief, Media file 8 - 000 Call 30 August 2016.
25 Coronial brief, Statement of C Willis 30 August 2016, 181-2; Coronial brief, Statement of C Raj, 205-6.
26 DFFH, L17 Portal records, 18.
27 Coronial brief, Appendix T - Historic Family Violence Incidents – FVSN and FVIOs Jamie Caroline 30 August 2016, 5-6.
28 Ibid, 8-9 29 Coronial brief, Statement of C Raj, 206.
30 Coronial brief, Appendix T - Historic Family Violence Incidents – FVSN and FVIOs Jamie Caroline 30 August 2016, 8-9 31 Coronial brief, Appendix V - Mercy Mental health records volume 1, 84.
to have the FVIO removed. WMMH contacted Ms Willis to gather collateral information and she advised that Jamie had become more threatening in his manner.32
On 25 September 2016, Jamie attended Werribee Mercy Hospital for a mental health assessment and stated that if things did not ‘go right’ with moving back in with Ms Willis ‘something will happen’.33 He stated that he had been living in his car since the FVIO was issued.34
From 25 September 2016 to 11 October 2016, Jamie was admitted to the Clare Moore Psychiatric Unit at Werribee Mercy Hospital.35 Jamie consistently denied thoughts of harming himself or others during this admission,36 but was noted to be experiencing paranoia relating to Ms Willis on several occasions.37 On 10 October 2016 a risk assessment and management report was completed by a Mercy Health Forensic Clinical Specialist. This report notes several factors likely to increase Jamie’s risk of future violence, including a history of threats to kill Ms Willis,38 and likely future problems with accommodation given the history of issues in this area and the current FVIO in place preventing him from living with Ms Willis.39
During the above period, it was noted that Ms Willis had communicated to staff that she would consider removing the FVIO and allowing Jamie to live with her if he accepted mental health treatment and remained abstinent from illicit substances. It was noted that Ms Willis was ‘aware of current risk + accepting of this’.40
On 11 October 2016, Jamie was discharged to a family friend’s house as the FVIO still prohibited him from living with Ms Willis, and he was placed on a 26-week CTO.41 Jamie returned to live with Ms Willis in the weeks following this hospital admission, although the date of his return is not clear.42 Jamie was referred to Wyndham Community Mental Health Team (WCMHT) for case management. His engagement with this service fluctuated and he needed ongoing reminders and chasing up to attend appointments.43 32 Ibid, 94.
33 Coronial brief, Appendix V - Mercy Mental health records volume 1, 71.
34 Ibid, 114.
35 Ibid, 20, 81; Coronial brief, Statement of A Mordia, 285-6..
36 Coronial brief, Appendix V - Mercy Mental health records volume 1, 116-165.
37 Ibid, 115, 119, 133.
38 Coronial brief, Appendix V - Mercy Mental health records volume 2, 81.
39 Ibid, 83.
40 Coronial brief, Appendix V - Mercy Mental health records volume 1, 158.
41 Ibid, 165; Coronial brief, Statement of A Mordia, 286.
42 Coronial brief, Appendix U – Medical History Caroline Willis, 103-4.
43 Coronial brief, Statement of A Mordia, 286.
A final FVIO was issued on 3 November 2016 which prevented Jamie from perpetrating family violence against Ms Willis but did not prohibit him from having contact with Ms Willis or living at their shared address.44 The certificate of service provided by police indicates that this FVIO was not served upon Jamie until 11 May 2017.45 LEAP records suggest this delay related to police having difficulty contacting Jamie.46
On 30 March 2017, a WCMHT registrar contacted Ms Willis to gather collateral information about Jamie. The notes relating to this contact state that Ms Willis was scared of Jamie and that ‘[h]e shouts at her and shuts her up all the time. She even gets pushed/bruised by him.’47 Ms Willis also reported that Mr Willis was using illicit substances and had been stealing from her.48 At around this time Ms Willis also disclosed financial abuse by Jamie to her GP.49
On 27 April 2017, Ms Willis reported to Jamie’s WCMHT case manager Ms Erin Dillon that Jamie had pushed her and said ‘if you call the police, you’ll regret it when I come back’50 when she tried to get him out of bed and refused to leave his room. Ms Dillon reportedly contacted Werribee Police Station at Ms Willis’s request and they advised her to call emergency services as a FVIO was in place preventing Jamie from going within 200 metres of Ms Willis’s address.51 Ms Dillon contacted emergency services and notified them of the FVIO breach by Jamie,52 then called Ms Willis back to update her.53 Police records indicate that police attended the property, but do not document what actions were taken, if any.54 The only record of this service contact made by police is a CAD event record.55
On 1 May 2017, Ms Dillon spoke with Ms Willis who said the police had not visited or otherwise contacted her on 27 April 2017.56 Ms Dillon contacted Werribee Police Station and spoke to Constable McQuaid who said they had no record of her call on 27 April 2017. Ms Dillon relayed that Ms Willis was too scared to call the police herself, and requested that police 44 Coronial brief, Appendix T - Historic Family Violence Incidents – FVSN and FVIOs Jamie Caroline 30 August 2016, 11-2.
45 Ibid, 13.
46 Victoria Police, LEAP records 30 August 2016, 11.
47 Coronial brief, Appendix V - Mercy Mental health records volume 2, 99.
48 Ibid, 99.
49 Coronial brief, Appendix U – Medical History Caroline Willis, 106.
50 Coronial brief, Appendix V - Mercy Mental health records volume 2, 107.
51 Ibid.
52 Coronial brief, Appendix V - Mercy Mental health records volume 2, 108; Victoria police, CAD Event Record 27 April 2017, 1-2.
53 Coronial brief, Appendix V - Mercy Mental health records volume 2, 108.
54 Victoria police, CAD Event Record 27 April 2017, 2-3.
55 Victoria police, CAD Event Record 27 April 2017.
56 Coronial brief, Appendix V - Mercy Mental health records volume 2, 108.
conduct a welfare check.57 Police records indicate that on arrival at the property both parties were spoken to, and that Jamie stated that he had not been served the interim FVIO. Police reportedly explained the FVIO conditions and Jamie collected his personal items then left the property.58 It is not clear which FVIO conditions were explained at this time – the interim FVIO which was issued on 29 September 2016 and prohibited Jamie from being within 200 metres of his shared address with Ms Willis, or the final FVIO issued on 3 November 2016 which had not yet been served upon Jamie but did not prohibit him from being at the address. The only record of this service contact made by police is a CAD event record.59
Ms Dillon’s notes reflect that police contacted her later on 1 May 2017 and advised they had removed Jamie from the address and that he had agreed to attend the police station later that day to be accompanied to the hospital. Police also reportedly stated that they served Jamie with a FVIO. 60 This contradicts other records available to the court which indicate the final FVIO which was issued on 3 November 2016 was not served until 11 May 2017.61 On this occasion police appear not to have completed a Risk Assessment and Management Report (VP Form L17) or pursued any civil or criminal pathways to responding to the family violence, including FVIO breaches, reported on 27 April 2017 and 1 May 2017.
On 2 May 2017, Jamie presented to Werribee Mercy Hospital Emergency Department and was admitted to the Clare Moore Psychiatric Unit.62 Ms Dillon contacted Jamie on this day to discuss his accommodation options. Jamie reportedly stated that he would stay in hospital until he could go to court to have the FVIO revoked. He reportedly stated ‘I’ll be staying in hospital or else I’ll hurt someone’, and ‘I’ll do it if they let me out’.63 During this admission Ms Willis told staff that Jamie had been keeping a knife with him at home.64 Jamie denied this,65 and was discharged from hospital into a share house on 10 May 2017.66 On 11 May 2017 Jamie was served the FVIO issued on 3 November 2016 which allowed for him to live with Ms Willis,67 57 Ibid, 109; Victoria police, CAD Event Record 1 May 2017, 2.
58 Victoria police, CAD Event Record 1 May 2017, 1-3.
59 Victoria police, CAD Event Record 1 May 2017.
60 Coronial brief, Appendix V - Mercy Mental health records volume 2, 110.
61 Victoria Police, NPRS report for J Willis, 2; Coronial brief, Appendix T - Historic Family Violence Incidents – FVSN and FVIOs Jamie Caroline 30 August 2016, 13.
62 Coronial brief, Appendix V - Mercy Mental health records volume 3, 192-3; Coronial brief, Statement of A Mordia, 286.
63 Coronial brief, Appendix V - Mercy Mental health records volume 2, 121.
64 Ibid, 243.
65 Ibid, 251.
66 Coronial brief, Statement of A Mordia, 286.
67 Victoria Police, NPRS Person Report for J Willis, 2; Coronial brief, Appendix T - Historic Family Violence Incidents – FVSN and FVIOs Jamie Caroline 30 August 2016, 13; Coronial brief, Appendix V - Mercy Mental health records volume 3, 80.
and returned to their shared address shortly thereafter.68 Evidence within the coronial brief suggests that Jamie’s mental health remained stable from May to September 2017, and Ms Willis did not report any further family violence incidents during this period.69
Jamie consistently presented late for his depot medication from September 2017 onwards,70 and in October and November 2017 Ms Willis expressed concerns that Jamie was using illicit substances again,71 and that he was ‘getting worse’.72
On 28 December 2017, Ms Willis contacted WMMH and reported that Jamie’s bullying and aggressive behaviour towards her was escalating. Ms Willis attributed this to Jamie’s drug use and stated that Jamie had not threatened violence or self-harm. The WMMH worker who took the call did some basic safety planning with Ms Willis, and Ms Willis advised that she was considering applying for a new FVIO.73
On 2 January 2018, Ms Willis contacted emergency services and reported that she was becoming increasingly scared of Jamie and that he was using methylamphetamines, stating ‘I don’t want him pushing me around and putting bruises on me’.74 When police attended the address Ms Willis stated that she wanted the previous FVIO reinstated but did not report any recent family violence. Police spoke to Jamie who denied recent illicit substance use and stated he had ‘no intention of causing any issues’75 for Ms Willis. Police advised Ms Willis to apply for a FVIO at Werribee Magistrates Court and made referrals for both parties.76 Both referrals were closed after the referral agencies were unable to contact Jamie and Ms Willis.77
On 29 January 2018, Ms Willis met with her GP. She stated that Jamie had been threatening her and she believed he was stealing her prescriptions. The option of moving into aged care was discussed however Ms Willis did not want to do this, primarily because of the implications for Jamie’s accommodation and care. Ms Willis’ GP also suggested that Ms Willis engage with a psychiatric nurse,78 and on 16 March 2018 made a referral to mental health service Care in 68 Coronial brief, Statement of A Mordia, 286.
69 Coronial brief, Appendix U – Medical History Caroline Willis, 108; Coronial brief, Appendix V - Mercy Mental health records volume 3, 83, 102; Coronial brief, Statement of A Mordia, 286; 70 Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 9.
71 Coronial brief, Appendix V – Jamie Willis Electronic Medical Record, 77; Coronial brief, Appendix U – Medical History Caroline Willis, 110-2.
72 Coronial brief, Appendix U – Medical History Caroline Willis,112.
73 Coronial brief, Appendix V – Jamie Willis Electronic Medical Record, 86-7; 74 Coronial brief, Media File 8 – Historic 000 Calls – 02 Jan 2018.
75 Coronial brief, Statement of A Gemin, 207-8.
76 Coronial brief, Statement of A Gemin, 207-8; DFFH, L17 Portal records, 10.
77 DFFH, L17 Portal records, 15.
78 Hoppers Lane General Practice, records of C Willis, 130.
Mind for a mental health nurse and social work support.79 Ms Willis commenced seeing a counsellor arranged by Care in Mind, Lydia Lypkewycz, on 17 April 2018.80
In early May 2018, Ms Willis told Jamie’s father that Jamie was doing better since he had been taking medication, but also disclosed that she and Jamie had had an argument and that she had been frightened of him.81
On 15 May 2018, WMMH carried out a mental health review with Jamie. Jamie reportedly displayed poor insight into his mental health needs and stated that he had recommenced methylamphetamine use after a few months of abstinence. Jamie denied thoughts of self-harm or harm to others.82
On 21 May 2018, Ms Willis applied for a FVIO against Jamie. 83 Ms Lypkewycz conveyed Ms Willis to court on this occasion and provided support to her.84 Ms Willis detailed verbal abuse, controlling behaviour, financial abuse and intimidation perpetrated by Jamie starting three years prior when they began living together. Ms Willis stated that in the past Jamie had pushed her, thrown things at her, and threatened to kill her.85 An interim FVIO was issued which prohibited Jamie from having contact with Ms Willis or going within 200 metres of their shared address.86
At 11.56am on 24 May 2018, police attended Jamie and Ms Willis’ address and served the interim FVIO upon Jamie. Police waited with Ms Willis while Jamie packed his belongings.
Ms Willis reportedly stated that Jamie would have to stay with friends as his family ‘wanted nothing to do with him’.87 Police asked Jamie for his house key, which he provided before leaving the premises in his car.88 Police left the address shortly thereafter at approximately 12.16pm. Police state that Jamie did not appear substance affected at this time, nor did he ‘display any extreme anger about the intervention order’.89 Jamie later stated that he was 79 Coronial brief, Appendix U – Medical History Caroline Willis,133-5; Hoppers Lane General Practice, records of C Willis, 132, 701.
80 Lydia Lypkewycz, records relating to Caroline Willis.
81 Coronial brief, Statement of James Willis, 178.
82 Coronial brief, Statement of A Mordia, 287-8; Coronial brief, Appendix V – Jamie Willis Electronic Medical Record, 116-7.
83 Coronial brief, Appendix H – Interim IVO J11324689, 1.
84 Lydia Lypkewycz, records relating to Caroline Willis, ‘Caroline Willis Notes 24-4-18’.
85 Coronial brief, Appendix H – Application and Summons IVO J11324689, 1-2.
86 Coronial brief, Appendix H – Interim IVO J11324689, 1.
87 Coronial brief, Statement one of S Bowan, 185-6; Coronial brief, Statement two of S Bowan, 193; Coronial brief, Statement of G Dunn, 189.
88 Coronial brief, Statement of G Dunn, 189.
89 Coronial brief, Statement one of S Bowan, 186.
shocked by the FVIO being served upon him, 90 and ‘shattered’91 at being excluded from his home.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.
Adequacy of proximate mental health services provided to Ms Willis
Ms Willis disclosed Jamie’s perpetration of family violence against her to Mercy Mental Health staff on numerous occasions. Responses to these disclosures included appropriate actions such as safety planning92 and contacting emergency services.93
Whilst Mercy Mental Health staff actively engaged in noting referrals and supports generally, there appears to be a lack of referrals to specialist family violence services at any time. This represents a missed opportunity to engage Ms Willis with specialist support which may have enhanced her safety. However, it is unclear whether such a referral would have had a preventative impact, given that specialist family violence services were unable to contact Ms Willis following a police referral in January 2018.94
In 2018, the year of Ms Willis’ death, the applicable family violence risk assessment tool in Victoria was the Family Violence Risk Assessment and Risk Management Framework (known as the Common Risk Assessment Framework (CRAF). The CRAF indicated that mainstream services, including mental health services, are a key entry point into the integrated family violence system for both victims and perpetrators.95 Best practice under the CRAF required mainstream services which identified indicators of family violence to ask questions about family violence and then take action accordingly, for example, by making referrals to specialist family violence services for assessment.96
The Victorian Royal Commission into Family Violence (RCFV) found that mechanisms to ensure service sector use of the CRAF were insufficient.97 Subsequently, the RCFV 90 Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 18.
91 Coronial brief, Appendix K – Transcript of Video Recording with Accused, 443.
92 Coronial brief, Appendix V – Jamie Willis Electronic Medical Record, 86-7; Statement of Associate Professor Dean Stevenson (Associate Clinical Services Director – Mercy Mental Health Services) dated 26 October 2023, 1-2 93 Coronial brief, Appendix V - Mercy Mental health records volume 2, 108; Statement of Associate Professor Dean Stevenson (Associate Clinical Services Director – Mercy Mental Health Services) dated 26 October 2023, 2 94 DFFH, L17 Portal records, 15.
95 Department of Health and Human Services (DHHS), Family Violence Risk Assessment and Risk Management Framework and Practice Guides 1-3 (2012), 2nd Edition, 7.
96 Ibid, 60.
97 RCFV, Summary and Recommendations (March 2016), 123.
recommended that the CRAF be reviewed and that the new framework be legislated within the Family Violence Protection Act 2008 (Vic), so that prescribed organizations would be required to align their policies, procedures, practices and tools with it.98 These recommendations have since been implemented, and mental health services were prescribed under the new framework, the MARAM framework, in September 2018.99 The MARAM requires a more comprehensive response to family violence from mainstream services such as mental health services, including consultation with family violence specialists for the purposes of risk assessment and the management of both victims and perpetrators.100
It is hoped that the introduction of the MARAM, and the legislative requirement for prescribed organisations to align with it, will improve responses to family violence by mental health services and referrals to specialist family violence supports for victim survivors and alleged perpetrators.
Since the introduction of MARAM, Mercy Health have confirmed that the following has been implemented:101 a) The introduction of a Specialist Family Violence Advisor, a permanent and ongoing position; b) Training programs for staff, specifically including, ‘working with men who use family violence’ and general family violence training with the Western Integrated Family Violence Committee; and c) Family violence training aligned to the MARAM added to the staff e-learning portal in 2022 as well as a health-justice partnership with WestJustice Legal Service.
Proximate medical treatment and support from Ms Willis’ GP
99 Family Violence Reform Implementation Monitor (FVRIM), Report of the FVRIM (1 November 2019), 23.
100 Family Safety Victoria, Multi-Agency Risk Assessment and Management Framework (2018), 46.
101 Statement of Associate Professor Dean Stevenson (Associate Clinical Services Director – Mercy Mental Health Services) dated 26 October 2023, 2-3
29 January 2018 in which Ms Willis disclosed financial abuse and threats made by Jamie states ‘[t]his discussion goes round and round and will never be resolved’.102 This commentary reflects a lack of knowledge regarding possible responses to family violence, and the importance of consultation with and referral to specialist family violence services.
When responding to family violence GPs should be guided by 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). The White Book in place at the time of the fatal incident encouraged GPs to ensure victim survivors received counselling and support from specialist family violence services,103 and provided some information on family violence risk assessment, albeit focussed on intimate partner violence.104
The White Book was updated in 2022 and provides a list of possible specialist family violence services, however references to referrals to specialist family violence services are generally made in the context of discussions about intimate partner violence, and do not make it clear that these services can and should also be referred to for support with addressing family violence in other types of relationships. The updated White Book also contains information about the Multi Agency Risk Assessment and Management Framework (MARAM) and provides a more thorough overview of family violence risk assessment, including assessment and referral considerations specific to older people who may be experiencing abuse.105
Whilst the White Book has been updated to include the new MARAM risk framework, private GPs are not prescribed under the MARAM, and are therefore not required to align their policies, procedures, practices and tools with it. Whilst the RACGP have developed a six hour online professional development program on family violence for GPs, it is not compulsory for GPs to undertake this or any other continuing professional development family violence training.106 This means that there are gaps within the broader GP community relating to their knowledge and skills in identifying and responding to family violence.
In 2015 Judge Ian Gray recommended that the RACGP consider the introduction of compulsory family violence training for GPs .107 Similarly, in 2016 the Royal Commission into Family Violence (RCFV) in Victoria noted concerns in relation to the ability of GPs to identify family 102 Hoppers Lane General Practice, Records for C Willis, 130.
103 RACGP, Abuse and Violence: Working With our Patients in General Practice (2014), 4th Edition, 38.
104 Ibid, 20.
105 RACGP, Abuse and Violence: Working With our Patients in General Practice (2022), 5th Edition, 255-61.
106 RACGP statement in case 2020/3618, dated 4 November 2020.
107 Case 2009/0447 https://www.coronerscourt.vic.gov.au/sites/default/files/2018-12/darceyiris_044709.pdf
violence,108 and recommended the Victorian Government encourage the Ministerial Council to approve standards that facilitate a mandatory requirement that GPs complete family violence training as part of their continuing professional development.109 While the Victorian Minister for Health raised this recommendation with the Australian Health Workforce Ministerial Council, the Medical Board of Australia, the RACGP, the Australian College of Rural and Remote Medicine, and the Australian Health Practitioner Regulation Agency,110 family violence professional development training is still not mandatory for GPs.
Elder abuse can take various forms such as financial, physical, psychological and sexual.
It can also be the result of intentional or unintentional neglect.111
In Ms Willis’ case, she reported financial abuse and threats of violence to her by her adult son Jamie in the context of being an older (70 years old at the time of the fatal incident) and vulnerable patient. The Silver Book provides guidance to GPs to identify the factors evidencing elder abuse and further prevention measures to be taken to protect a patient’s safety. This includes making appropriate support referrals, exploring respite care and reporting immediate safety issues to police.
In October 2021 Coroner Jamieson recommended that the RACGP ‘consider mandating that GPs attend a fixed amount of continuing medical education (as required by the Medical Board of Australia) per year which includes at least four hours of training and education within a twoyear period related to Family Violence (including but not limited to identification, risk assessment or understanding of the relevant frameworks)’.112 In response the RACGP stated: 108 State of Victoria, Royal Commission into Family Violence: Summary and Recommendations Volume IV, 6.
109 Ibid, 55.
110 Victorian Government, Establish mandatory training for general practitioners in family violence training through professional development (Web Page) https://www.vic.gov.au/family-violencerecommendations/establish-mandatory-training-general-practitioners-family-violence 111 RACGP, Aged Care Clinical Guide (Silver Book), 5th Edition, Part B – Abuse of older people, available online at: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgpguidelines/silver-book/silver-book-part-b/abuse-of-older-people 112 CCOV, Findings for Anthony Beckworth COR 2019 1858, 13 <COR 2019 001858_Finding_Amended.pdf>
Although GPs are expected to achieve general practice family violence management competencies, the RACGP does not support a ‘one-size’ approach for family violence training and does not support specific once-off mandatory training. Rather, a wide variety of approaches and resources, taking into account the different levels of professional competence of GPs in this area, ensure that family violence remains an ongoing general practice priority.113
Proximate Victoria Police contact with Ms Willis and Jamie
The police response to the family violence reports they received from WCMHT on 27 April 2017 and 1 May 2017, as detailed in the background above, raises concerns. The only record of these service contacts made by police were CAD event reports.114 Police appear not to have made any records in LEAP, nor did they complete VP Form L17s or pursue any civil or criminal pathways to respond to the family violence reported on 27 April 2017 and 1 May 2017.
On 1 May 2017, police inaccurately noted that Jamie had not been served with the interim FVIO issued on 29 September 2016 which prohibited him from being within 200 metres of his shared address with Ms Willis and did not address Jamie’s breaches of this FVIO on 27 April or 1 May 2017.
The Code of Practice for the Investigation of Family Violence (Code of Practice) in place at the time of the reports and currently state that ‘[p]olice will respond to and take action on any family violence incident reported to them’.115 The Code of Practice outlines several compulsory 113 Response from the RACGP dated 10 December 2021, 2 114 Victoria Police, CAD Event Record 27 April 2017; Victoria Police, CAD Event Record 1 May 2017.
115 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3nd Edition V2, 8; Victoria Police, Code of Practice for the Investigation of Family Violence (2019) 3nd Edition V4, 15.
police actions in response to a report of family violence,116 including the completion of a VP Form L17,117 and pursuing criminal and civil options to hold the perpetrator accountable.118
The Victoria Police Manual in place at the time, and its current iteration, state that ‘[a]ll reports of family violence must be investigated, no matter where they originated from.’119 Police policy confirms that a breach of a FVIO is itself a serious family violence incident and a criminal offence to investigate.120 By failing to complete a VP form L17, make appropriate referrals to family violence services, consider whether to vary the final FVIO issued on 3 November 2016 to include more restrictive conditions or to investigate the possible FVIO breaches and other criminal offences by Jamie, police appear to have missed an opportunity to hold Jamie to account and provide Ms Willis with adequate support.
The available evidence confirms that the VP Form L17 completed by police in response to Ms Willis’s contact on 2 January 2018 was inaccurate. As a result of police inadequacies outlined above, the police responding to Ms Willis's contact in January 2018 were unaware of the family violence reports in April and May 2017, and inaccurately recorded that there was no history of reports of FVIO breaches, and no previous reports of family violence to police.' Ms Willis had also contacted police to report family violence in August 2016.121 Police also did not appear to have accurately recorded that Jamie had mental health problems.122
Since this incident the police have implemented policies and procedures which require more stringent monitoring of VP Form L17 compliance rates by Family Violence Liaison Officers,123 and provide for assistance from Family Violence Training Officers with addressing inadequate VP Form L17s.124 It is hoped that this will improve the overall accuracy of risk assessments in future investigations.
116 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3nd Edition V2, 8; Victoria Police, Code of Practice for the Investigation of Family Violence (2019) 3nd Edition V4, 15.
117 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3nd Edition V2, 37; Victoria Police, Code of Practice for the Investigation of Family Violence (2019) 3nd Edition V4, 44.
118 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3nd Edition V2, 8; Victoria Police, Code of Practice for the Investigation of Family Violence (2019) 3nd Edition V4, 15.
119 Victoria Police, Victoria Police Manual Policy Rules Family Violence (October 2015), 3; Victoria Police, Victoria Police Manual - Family Violence (February 2021 2018), 5.
120 Victoria Police, Code of Practice for the Investigation of Family Violence (2014) 3nd Edition V2, 29; Victoria Police, Code of Practice for the Investigation of Family Violence (2019) 3nd Edition V4, 35.
121 Coronial brief, Media file 8 - 000 Call 30 August 2016.
122 DFFH, L17 Portal Records, 13.
123 Victoria Police, Practice Guide- Family Violence Roles and Responsibilities, 3-4; Victoria Police response dated 13 October 2023, 3-4 124 Victoria Police, Practice Guide- Family Violence Roles and Responsibilities, 11-12; Victoria Police response dated 13 October 2023, 3-4
Availability of accommodation for family violence perpetrators who are excluded from their normal residence
The RCFV identified perpetrator accommodation as a potential service gap in the family violence sector and encouraged the Victorian Government to conduct an investigation into demand for perpetrator accommodation and the most appropriate model for its delivery.125 In a statement provided to the court Family Safety Victoria (FSV) noted that perpetrators are more likely to have the capacity to take responsibility for their behaviour if their basic needs, including housing, are met.126 FSV also noted that the Family Violence Reform Implementation Monitor’s (FVRIM) 2020 report concluded that providing accommodation for perpetrators is an important development in perpetrator responses.127
In the circumstances of this case, it is likely that Jamie’s accommodation options were extremely limited after the FVIO was served upon him on 24 May 2018. Ms Willis indicated to police that Jamie’s family would not accommodate him,128 and there was a lack of crisis accommodation for men who use violence at this time.129
The available evidence indicates that Jamie lived in his car immediately after being removed from his address by police in September 2016,130 and a psychiatric report compiled after the fatal incident notes that the FVIO left Jamie without accommodation.131
A Risk Assessment and Management report completed while Jamie was an inpatient at Clare Moore Psychiatric Unit on 10 October 2016 foresaw future problems with accommodation based on past difficulties relating to FVIOs in protection of Ms Willis, and listed this as a factor likely to increase Jamie’s risk of perpetrating future violence.132 Had Jamie been able to access perpetrator accommodation after the FVIO excluding him from his shared address with Ms Willis was served upon him on 24 May 2018 this may have had a preventative effect.
There have been several significant developments in Victoria to address the shortage of perpetrator specific accommodation. In September 2020, FSV funded The Salvation Army’s St 125 Royal Commission into Family Violence (Final Report, March 2016) Vol 2, 92.
126 FSV, Statement dated 14 April 2022, 2; Centre for Innovative Justice, Opportunities for Early Intervention: Bringing Perpetrators of Family Violence Into View (Report, RMIT University, March 2015).
127 FSV, Statement dated 14 April 2022, 2; FVRIM, Report of the Family Violence Reform Implementation Monitor 2020 (November 2020).
128 Coronial brief, Statement two of S Bowan, 193.
129 NTV, Evaluation of the Perpetrator Accommodation and Support Service (26 May 2021), 2.
130 Coronial brief, Appendix V - Mercy Mental health records volume 1, 114.
131 Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 20.
132 Coronial brief, Appendix V - Mercy Mental Health records volume 2, 83.
Kilda Crisis Contact Centre (SKCCC) and specialist family violence service No To Violence (NTV) to deliver a pilot of the Perpetrator Accommodation and Support Service (PASS).133
The PASS program provides up to 14 days of emergency accommodation and counselling to men who have used violence and have been excluded from the home on a FVSN or a FVIO in order ‘to ensure that a perpetrator has a safe and secure living situation to facilitate meaningful service engagement during a period of crisis and heightened risk to the victim-survivor, and to reduce the risk of further violence being perpetrated’.134 An evaluation of the PASS program carried out in February 2021 suggested that PASS increased victim/survivor safety during the high-risk period immediately following the perpetrator’s exclusion from the home and successfully provided crisis accommodation to perpetrators in a timely way. Results as to the therapeutic benefits of the program, and its promotion of ongoing service engagement and perpetrator accountability were mixed. Long-term housing outcomes for perpetrators were also mixed, reflecting broader challenges with respect to the housing sector.135
At the time of the evaluation referrals into PASS were lower than expected, possibly due in part to a lack of awareness of the program across the service system, particularly on the part of Victoria Police and The Orange Door.136 However, NTV have advised that as awareness of this program has grown demand for it has progressively increased.137 As at the end of March 2022 over 400 men have been supported through the PASS program.138 The evaluation report makes seven recommendations to further strengthen the PASS program, including a focus on developing partnerships with key referral agencies including Victoria Police, an expansion of counselling services past 14 days to support ongoing client engagement with services, and implementation of an advocacy and support function to support PASS clients to access ongoing accommodation and support.139
Another further development involves the Medium-term Perpetrator Accommodation Service (MPAS) which was funded in April 2021 in three pilot sites across Victoria. This service provides up to six months of accommodation for people using family violence, and requires clients to engage with perpetrator interventions.140 In late 2021 two Aboriginal Community Controlled Organizations were added to this initiative and they are currently developing their 133 NTV, Statement dated 8 April 2022; FSV, Statement dated 14 April 2022, 2.
134 NTV, Evaluation of the Perpetrator Accommodation and Support Service (26 May 2021), 2.
135 Ibid, 4.
136 Ibid, 21.
137 NTV, Statement dated 8 April 2022.
138 FSV, Statement dated 14 April 2022, 2.
139 NTV, Evaluation of the Perpetrator Accommodation and Support Service (26 May 2021), 42-3.
140 FSV, Statement dated 14 April 2022, 2.
service models.141 FSV state that as at the end of March 2022, 27 men have been supported by the MPAS program, and note that there have been challenges in relation to housing availability, particularly in rural areas. FSV state that MPAS pilot services have reported some early positive outcomes for victim survivors including a reduction in their level of fear and stress, cessation of breaches of intervention orders, positive shifts in perpetrator attitudes, and perpetrators returning to the workforce. MPAS is currently undergoing formal evaluation.142
Family violence specialist support packages available to victim-survivors
The circumstances under which Jamie killed Ms Willis exemplify the high-risk nature of the period immediately following the service or enforcement of a FVIO. The fatal incident occurred less than two hours after Jamie was served with a FVIO in protection of Ms Willis. Following the fatal incident Jamie stated that he was shocked by the FVIO being served upon him,143 and expressed significant anger about the FVIO.144 Similarly, in May 2017, after being removed from his shared address with Ms Willis and admitted to the Clare Moore Psychiatric Unit following to a possible FVIO breach, Jamie stated that if he did not stay in hospital until the FVIO was revoked he would ‘hurt someone’.145
Research suggests that the largest proportion of protection order breaches occur in the period immediately following the granting of a protection order,146 and the risk of further revictimization increases with each subsequent family violence incident.147 It is important therefore that FVIOs are accompanied by safety planning and that risk management strategies are implemented swiftly if they are to be as effective as possible.148 Unfortunately there is no 141 Ibid, 2-3.
142 FSV, Statement dated 14 April 2022, 3.
143 Coronial brief, Appendix V - Zimmerman Dr Nina Evidentiary report Willis Jamie, 18; Coronial brief, Appendix K – Transcript of Video Recording with Accused, 442.
144 Coronial brief, Appendix K – Transcript of Video Recording with Accused, 445-6.
145 Coronial brief, Appendix V - Mercy Mental health records volume 2, 121.
146 Hayley Boxall et al, ‘The “Pathways to intimate partner homicide” project Key stages and events in male-perpetrated intimate partner homicide in Australia’ (Research Report Issue 4, ANROWS, February 2022), 3; Christopher Dowling et al, ‘Protection Orders for Domestic Violence: A Systematic Review’ (June 2018), no. 551 Trends and Issues in Crime and Criminal Justice, 14.
147 Anthony Morgan, Hayley Boxall, and Rick Brown, ‘Targeting Repeat Domestic Violence: Assessing Short-Term Risk of Reoffending’ (June 2018), 552 Trends and Issues in Crime and Criminal Justice, 3 148 Hayley Boxall et al, ‘The “Pathways to intimate partner homicide” project Key stages and events in male-perpetrated intimate partner homicide in Australia’ (Research Report Issue 4, ANROWS, February 2022), 107.
evidence to suggest that Ms Willis was offered support with safety planning when applying for the FVIO at court or while the FVIO was served on Jamie.
The Australian Institute of Criminology found evidence that personal alarms have been effective in increasing the efficacy of protection orders by increasing the compliance of respondents,149 whilst also making it easier for victims to report breaches in a timelier way.150 This evidence includes studies which reported 40–70 percent reductions in the prevalence of family violence revictimization following provision of rapid alert devices to victim/survivors with protection orders in place.151 The RCFV also outlined the benefits of such technology, such as monitored Bsafe and Safe-T-Card personal alarms which have an in-built GPS and can be used by victim/survivors to easily and subtly report FVIO breaches.152
Victim/survivors in Victoria can currently access personal safety devices through the Personal Safety Initiative (PSI). A 2017 evaluation of the PSI found that monitored personal safety devices were particularly effective in increasing victim survivors’ sense of safety, and reducing perpetrator breaches of FVIOs.153 However, the eligibility criteria for the PSI does not allow for the provision of this technology to many victim/survivors who do not engage with specialist family violence or related agencies. Further, the application and implementation processes for the PSI can take several weeks, which does not to allow for the provision of security technology in the period immediately following the granting of a FVIO or FVSN. This means that victim/survivors do not have access to the added protection of personal safety alarms and other safe at home responses during one of the most high-risk periods.
551 Trends and Issues in Crime and Criminal Justice, 8.
150 Ibid.
151 Ibid.
152 Royal Commission into Family Violence (Final Report, March 2016) Vol 1, 99.
153 Family Safety Victoria, Personal Safety Initiative Operational Guidelines (September 2019), 12.
FVIO applications. This includes consulting with Victoria Police Family Violence Command and the Magistrates Court of Victoria Family Violence Action Taskforce.
Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Lindsay Cosgrove, Senior Next of Kin Dr Neil Coventry, Office of the Chief Psychiatrist Kellie Dell’Oro, Principal, Meridian Lawyers Associate Professor Dean Stevenson, Mercy Mental Health Services Assistant Commissioner Lauren Callaway, Family Violence Command, Victoria Police Cameron Hannebery, Partner, Lander & Rogers Eleri Butler, CEO, Family Safety Victoria Tania Farha, CEO, Safe and Equal Australia Detective Sergeant Brett Parker, Homicide Squad, Victoria Police Detective Sergeant Patrick Derksen, Coroner’s Investigator
Signature: ___________________________________ Judge John Cain
STATE CORONER Date: 23 April 2024 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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