Order 1118667: Critique - Domestic Violence

Domestic and Family Violence Death Review and Advisory Board

2016–17 Annual Report

Domestic and Family Violence Death Review and Advisory Board

We honour the voices of those who have lost their lives to domestic and family violence, and extend our sympathies to the loved ones who are left behind, their lives forever changed by their loss.

Our efforts remain with ensuring that domestic and family violence deaths do not go unnoticed, unexamined or forgotten.

A report of the Domestic and Family Violence Death Review and Advisory Board pursuant to section 91Z of the Coroners Act 2003.

Published in Brisbane, Queensland by the Domestic and Family Violence Death Review and Advisory Board.

All enquiries regarding this document should be directed in the first instance to the Secretariat, PO Box 1649, Brisbane, QLD, 4000, or by email: [email protected]

©Domestic and Family Violence Death Review and Advisory Board, Brisbane, 2017.

Copyright permissions

This publication may be copied, distributed, displayed, downloaded and otherwise freely dealt with for any personal or non-commercial purpose, on the condition that proper acknowledgement is included on all uses.

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“A mother’s nurturing is important to make family and community resilient. When mums are protected and supported, they will produce strong community leaders, our future and our hope.”

Betty Williams (nee Yarrak) May

A Mother’s Nurturing

Domestic and Family Violence Death Review and Advisory Board

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About this report The Domestic and Family Violence Death Review and Advisory Board (the Board) is established by the Coroners Act 2003 (the Act) to undertake systemic reviews of domestic and family violence deaths in Queensland. The Board is required to identify common systemic failures, gaps or issues and make recommendations to improve systems, practices and procedures that aim to prevent future domestic and family violence deaths.

This report has been prepared by the Board in accordance with section 91ZB of the Act, which outlines that the Board must, within three months after the end of the financial year, provide a report in relation to the performance of the Board’s functions during that financial year, to the Attorney-General, Minister for Justice, and Minister for Training and Skills (the Attorney-General).

The Annual Report must include information about the progress made during the financial year to implement recommendations made by the Board during that year, or previous financial years.

The Attorney-General must also table a copy of this report in the Queensland Parliament, within one month of receiving it.

The views expressed in this report are reflective of the consensus decision-making model of the Board, and therefore do not necessarily reflect the private or professional views of a member of the Board, or their individual organisations.

It is acknowledged at the outset that many of these deaths occurred prior to, or during the early implementation of significant reforms associated with the Special Taskforce on Domestic and Family Violence (2015), and the Child Protection Commission of Inquiry (2013). A significant number of learnings remained identifiable through consideration of the circumstances leading up to these deaths.

Although some of these reforms may need time to achieve their intended or desired outcomes, it is clear that we can, and should, do more to protect victims and their children.

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Seek help If you, or someone you know, need help, then the following services are available to assist.

» Lifeline is a 24 hour telephone counselling and referral service, and can be contacted on 13 11 14 or www.lifeline.org.au

» Kids Helpline is a 24 hour free counselling service for young people aged between 5 and 25, and can be contacted on 1800 55 1800 or www.kidshelponline.com.au

» Mensline Australia is a 24 hour counselling service for men, and can be contacted on 1300 78 99 78 or www.menslineaus.org.au

» DV Connect is a 24 hour Crisis Support line for anyone affected by domestic or family violence, and can be contacted on 1800 811 811 or www.dvconnect.org.

» Suicide Call Back Service can be contacted on 1300 659 467 or www.suicidecallbackservice.org.au

» Beyondblue can be contacted on 1300 22 4636 or www.beyondblue.org.au

Guidelines for safe reporting in relation to suicide and mental illness for journalists are available here: http://www.mindframe-media.info/for-media/media-resources

Domestic and Family Violence Death Review and Advisory Board

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Chair’s message This Annual Report outlines the work of the Board during the 2016–17 financial year in our first year of operation.

Sadly, during this period of time, 17 homicides have occurred within an intimate partner or family relationship, as well as an additional five ‘collateral’ homicides.

A significant prior history of domestic and family violence was also identifiable in 35 cases of apparent or suspected suicide, during this time period.

While coronial investigations are ongoing into many of these deaths, these numbers reflect the significant, and at times, fatal impact of domestic and family violence.

The reviews of these deaths can be both challenging and rewarding, and I would like to take this opportunity to acknowledge the commitment and dedication of Board members in the performance of their duties.

In particular, our special thanks go to former Queensland Corrective Services Commissioner, Dr Mark Rallings who brought to the Board a wealth of knowledge and insight into how we might work towards enhancing our responses to perpetrators of violence.

In building upon activities undertaken during this reporting period, members have identified a number of priorities moving into the future, including:

» conducting reviews of the domestic and family violence related deaths of people from a culturally and linguistically diverse background; the suicides of young people who identify as Aboriginal and Torres Strait Islander; and homicides within a family relationship

» further consideration of sexual abuse as a form of intimate partner violence noting it was identified in six cases reviewed by the Board,1 and in 13.1% of the intimate partner homicides that have occurred in Queensland between 2011 and 2015

» greater exploration of some of the statistical findings outlined within Chapter 3 of this report including the patterns of risk identified within different priority populations; deaths that occurred during relationship separation; and more detailed analysis of those cases where there was contact with the criminal justice system in relation to domestic and family violence (both within current, and former relationships)

» focused attention on perpetrator interventions, including consideration of the current work being undertaken to review and update the Professional Practice Standards: Working with men who perpetrate domestic and family violence2 and accompanying principles that govern the delivery of these programs

» close monitoring of recent reform initiatives including the impact and implementation of legislative and policy reform regarding non- lethal strangulation, high risk teams, and the trial of the Common Risk Assessment Framework.

While this Annual Report outlines the activities of the Board undertaken during this reporting period, including the key themes and issues identified throughout the review process, and makes a number of recommendations that aim to prevent future deaths, one thing is clear - we must all stand together to achieve change.

It is only through our collective efforts that we can break the cycle of violence. Together we can learn from these tragedies and work towards ensuring that the system protects victims of domestic and family violence and their children, while holding perpetrators to account.

We can, and must, commit to finding ways to prevent these deaths occurring in the future.

1 In two cases this was proximate to the death, in the other three assaults this occurred within former relationships for the deceased and/or offender. In the sixth there was indications that the deceased infant may have been sexually assaulted, and disclosures indicative of sexual abuse by an older sibling in relation to the perpetrator. Given the hidden nature of this type of violence it is likely that this is an under-reporting.

2 As per Recommendation 82; Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author.

Death Review and Advisory Board | Annual Report 2016–17 7

Mr Terry Ryan

State Coroner of Queensland, Chairperson

Dr Kathleen Baird

Deputy Chairperson Senior Lecturer in Midwifery at Griffith University Director of Midwifery and Nursing Education at the Gold Coast University Hospital

Dr Jeanette Young PSM

Chief Health Officer Deputy Director General, Prevention Division, Queensland Health Adjunct Professor, Queensland University of Technology Adjunct Professor, Griffith University

Ms Barbara Shaw

Executive Director Office for Women and Domestic Violence Reform, Department of Communities, Child Safety and Disability Services

Dr Maurice Carless APM

Assistant Commissioner State Crime Command Queensland Police Service

Dr Mark Rallings

Commissioner Queensland Corrective Services

Ms Tammy Williams

Deputy Director General Department of Aboriginal and Torres Strait Islander Partnerships

Ms Natalie Parker

Director Domestic and Family Violence Court Reform, Department of Justice and Attorney General

Dr Silke Meyer

Lecturer in Postgraduate Programs (Certificate and Diploma in Domestic and Family Violence), Centre for Domestic and Family Violence Research, Central Queensland University

Ms Betty Taylor

Director, Betty Taylor Training and Consultancy Director, Red Rose Foundation

Mr Mark Walters

Manager DV Connect (Mensline)

Ms Angela Lynch

Chief Executive Officer Women’s Legal Service Queensland

Secretariat

Domestic and Family Violence Death Review Unit, Coroners Court of Queensland

Board Members

Domestic and Family Violence Death Review and Advisory Board

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Acknowledgements The Queensland Domestic and Family Violence Death Review Process is informed by the collective knowledge and experience of the many domestic and family violence, and child death, review processes that operate for the purposes of reducing the prevalence and incidence of these types of deaths.

During this reporting period, the Board has had the privilege of speaking with a range of experts, Elders and community members regarding key issues identified throughout the review process.

In particular the Board would like to acknowledge the contribution of:

» Aunty Peggy Tidyman, Chairperson and Sheri Merenda, Manager, Murrigunyah Family and Cultural Healing Centre

» Sandy Gillies, A/Chief Operating Officer, Queensland Aboriginal and Islander Health Council

» Uncle Charles Passi, Passi Enterprises

» Shirley Slann, Manager, Boorndawan Willam Aboriginal Healing Service

» Dr Heather Nancarrow, Chief Executive Officer, Australia’s National Research Organisation for Women’s Safety

» Professor Heather Douglas, T. C. Bierne School of Law, University of Queensland

» Anna Jones, Program Manager and Dave Burck, Child and Family Counsellor, Carinity Talera

» Dr Brian Sullivan, YFS Domestic Violence Program (Logan)

» Detective Inspector Marc Hogan, Gold Coast Domestic and Family Violence Taskforce, Queensland Police Service

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Contents Executive Summary ...............................................................................................................................................10

Recommendations ...............................................................................................................................................13

Chapter 1: Overview ...............................................................................................................................................16

Chapter 2: Honouring the stories, and sharing the journey ........................................................................................18

Chapter 3: Enhancing our knowledge ........................................................................................................................34

Chapter 4: Unravelling patterns of abuse, risk, and harm ..........................................................................................51

Coercive controlling violence ....................................................................................................................51

Extreme proprietariness, possessiveness and morbid jealousy ................................................................52

Post-separation violence, and ‘contact abuse’ ..........................................................................................53

Non-lethal strangulation ..........................................................................................................................57

Technology facilitated abuse ....................................................................................................................57

Systems abuse ........................................................................................................................................58

Chapter 5: Strengthening our systems ......................................................................................................................60

Service engagement and response ...........................................................................................................60

Health service system contact ..................................................................................................................61

Maternity and ante-natal care ..................................................................................................62

Mental health, alcohol and other drug services .......................................................................64

Private practitioners ................................................................................................................66

Relationship counsellors .........................................................................................................67

Criminal justice system contact ................................................................................................................67

Police......................................................................................................................................68

Courts .....................................................................................................................................73

Child Safety Services ................................................................................................................................75

Chapter 6: Earlier detection, and targeted intervention and support ..........................................................................79

Early intervention and prevention ............................................................................................................79

Information sharing to support earlier response .......................................................................................80

Interventions with victims who may use violence ......................................................................................82

Perpetrator interventions .........................................................................................................................84

Ongoing monitoring for earlier intervention .............................................................................86

Community and bystander interventions ..................................................................................................88

Family and friends ...................................................................................................................88

Workplace responses ..............................................................................................................89

Chapter 7: A call for change - responding to Aboriginal and Torres Strait Islander family violence ...............................90

Overview ...............................................................................................................................................90

Key issues and themes .............................................................................................................................93

System responses to family violence ........................................................................................................99

Appendix A – Intimate Partner Homicide Lethality Risk Factor Form .........................................................................107

Appendix B – Case characteristics...........................................................................................................................113

Homicide-Suicides and Perpetrator Suicides ..........................................................................................113

Intimate Partner Homicides ....................................................................................................................114

Victim Suicides ......................................................................................................................................115

Aboriginal and Torres Strait Islander intimate partner homicides ............................................................117

Filicides .............................................................................................................................................118

Appendix C – Glossary of terms...............................................................................................................................119

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Domestic and Family Violence Death Review and Advisory Board

Executive Summary First and foremost, we honour the voices of those who have lost their lives to domestic and family violence.

In Queensland, since 2006, 263 women, children and men have been killed by a family member or someone who they were, or had been, in an intimate partner relationship. For every death, the ramifications are immense and widespread; affecting not only loved ones left behind, but also the service providers required to respond to these situations.

This annual report is based on a statistical analysis of these deaths, and in-depth reviews conducted by the Board of twenty nine deaths which occurred between 2011 and 2016.3

By harnessing these collective learnings and our understanding of standards of contemporary practice, we can reinforce and strengthen our collective effort to say, ‘Not Now, Not Ever’ to domestic and family violence in Queensland.

Our foundation

The first step in driving change is to assess and understand the situation and through the Domestic and Family Violence Death Review Unit, we are able to collate a wealth of quantitative data about domestic and family violence deaths in Queensland for the period between 2006 and 30 June 2017.

The datasets outlined in this report help to illustrate the breadth and scope of the problem; the events leading up to the deaths; the presence of any risk indicators; and prior service system contact.

This chapter outlines a number of key findings, including that:

» Of the 263 homicides in this period, an identifiable history of domestic and family violence was established in 165 cases (61.6%). A history of violence was identified in greater proportions of intimate partner homicides (70.7%) and collateral4 homicides (77.8%), in comparison to family homicides (47.3%).

» Females were significantly over-represented as victims in intimate partner homicides, with 81.8% of victims being female. In contrast, there was little variation by gender with respect to family homicide victims. Collateral homicide victims were almost exclusively male with the majority of these deaths involving the former partner of a woman murdering her new partner.

» For intimate partner homicides, the vast majority of female deceased had a prior history of being a victim of domestic and family violence (97.6%); whereas the majority of males were identified as being a perpetrator of domestic and family violence prior to the death (89.5%).

» Aboriginal and Torres Strait Islander people were overrepresented among domestic and family homicide victims. Almost one-fifth (18.1%) of homicide victims identified as Aboriginal and/or Torres Strait Islander, compared with approximately 3.6% of the non- Indigenous Queenslanders.

3 This included one death from 2011, five deaths from 2012, eight deaths from 2013, six deaths from 2014, seven deaths from 2015 and two deaths from 2016. 4 These include the deaths of bystanders who died intervening within a domestic dispute or acts of associated domestic and family violence, such as when a new partner was killed by a

former partner. 5 Cross protection orders relate to both parties being listed as the respondent and aggrieved on separate orders. 6 None of the Aboriginal family violence homicide cases occurred during a known period of separation.

» A domestic violence protection order was in place at the time of death in 41.6% of intimate partner homicides where a history of domestic and family violence was established. The deceased was recorded as the aggrieved party on three-quarters (78.6%) of these orders, with cross orders5 in place in 11.9% of cases. The deceased was recorded as the respondent on protection orders in only 9.5% of intimate partner homicides.

As well as homicides, this report also provides insight into apparent suicides occurring in the context of domestic and family violence.

Preliminary data is also provided as to the types of risk factors that were commonly identified in these cases. This may provide the most benefit in helping to prevent these types of deaths from occurring in the future through enhancing our understanding of the underlying dynamics of these types of relationships.

Unravelling patterns of abuse, risk and harm

One of the significant benefits of death review processes is the ability to identify trends and patterns from qualitative review of the circumstances surrounding each of the deaths.

In many of the cases reviewed by the Board this year, where they were reported, the significance of a number of risk indicators were sometimes not recognised by services or other informal supports, and therefore not responded to.

To that end, this section of the report provides invaluable insight into these risk indicators and characteristics and calls for better recognition and understanding of these patterns of risk and harm.

Key findings include:

» Coercive controlling violence was evident in almost all cases however, this was unlikely to be responded to unless reports of physical violence were concurrently made. Covert and nonphysical forms of coercion, such as social isolation, harassing or threatening behaviour, possessiveness or verbal abuse were less likely to be recognised by services as potential indicators of abuse or reported by victims.

» Obsessive possessive behaviours, which presented as sexual or morbid jealousy, were noted in almost all of the intimate partner homicides and was particularly prevalent in the Aboriginal and Torres Strait Islander cases subject to review. Episodes of domestic and family violence that were reported were at times recorded as ‘arguments about infidelity’ and subsequently minimised or considered in isolation of other indicators of harm.

» Five of the intimate partner homicides,6 both of the homicide suicides and four of the perpetrator suicides considered by the Board in this reporting period occurred in the context of actual or pending separation, indicating the need to better understand the heightened risk of harm that is evident during this period.

» Where children were present in the relationship, and the parents were or had separated, there was evidence that the

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» perpetrator used the children as further means of controlling or abusing the victim in over two thirds of cases (69.2%).

» Non-lethal strangulation was identified in seven homicide cases and three victim suicide cases considered by the Board however, this was not generally recognised as a significant indicator of future lethality risk.

» Technology facilitated abuse and harassment via text, email or social media was identified as an emerging trend across the cases.

» Systems abuse (the abuse of processes in the course of domestic and family violence related proceedings) by perpetrators to gain advantage or continue abuse of victims was evident in a number of cases. It was most prevalent in the filicide cases where the perpetrator would use threats of child removal against their female intimate partner.

Strengthening our systems

In all but one case considered by the Board, the victims and perpetrators had contact with a variety of general and specialist services prior to the deaths. This included contact with:

» health services in relation to presentations for assault- related injuries; mental health or alcohol and other drug treatment; maternity and ante-natal care; and/or suicidal or self-harming behaviour

» police and/or the criminal justice system in relation to domestic and family violence in either the current or previous relationships, or other related calls for service

» specialist domestic and family violence services including women’s refuges or perpetrator intervention programs.

In their review of this service system contact the Board recognises the significant reforms currently underway across Queensland and that improving outcomes is not the responsibility of any one sector. This will require collaboration, integration and proactive engagement, often with victims or perpetrators who are reluctant to engage with services and have multiple support needs.

The complex nature of domestic and family violence undoubtedly poses significant barriers to service engagement nevertheless, agencies must be equipped to respond in a nuanced and sensitive way to ensure the safety of victims experiencing domestic and family violence. Upon their review of the service system contact leading up to the death, the Board identified gaps or opportunities to strengthen screening and risk assessment processes; information sharing and collaboration between services; follow-up and continuity of care; as well as standards and accreditation for practitioners and services working with both victims and perpetrators. They also identified the need for further training to improve service responses and enhance understanding of the more nuanced indicators of harm that characterise this type of abuse.

Early detection and targeted interventions

As well as considering the service response, the Board gave consideration to opportunities to intervene, and potentially prevent, these deaths.

Although services must be equipped to provide crisis-based responses to victims in need, cases reviewed in this reporting period highlighted missed opportunities for intervention when the risk was low or medium level, and where interventions may have been more effective at reducing the risk of future harm or lethality.

The scope of this chapter reflects the diversity of issues identified in the cases and considers:

» early intervention and prevention responses when perpetrators or victims present in relation to low or medium levels of violence

» the need for information sharing to support earlier detection of issues and a swifter, more coordinated service response

» working with victims who may use violence and the need to understand how to better respond to the different underlying motivators that may precipitate these behaviours

» perpetrator interventions and their effectiveness, and the need to better tailor these programs to a person’s individual needs

» the need for ongoing monitoring of high-risk perpetrators to ensure earlier detection and intervention across both familial or intimate partner relationships

» the significant impact of domestic and family violence on families and friends, who are often the main point of disclosure, and opportunities to improve supports and referral pathways to assist this cohort

» workplace responses to domestic and family violence, and opportunities to extend existing initiatives in this area.

A call for change in responding to family violence

Finally, this report outlines the complex nature of family violence experienced by some Aboriginal and Torres Strait Islander people in Queensland and highlights the critical need for holistic, culturally informed, and sustainably resourced responses.

The cases reviewed by the Board of Aboriginal and Torres Strait Islander victims of family violence at times demonstrated entrenched, intergenerational disadvantage, and the pervasive impact this has on the health and wellbeing of some individuals, families and communities.

In addition to many of the issues outlined in other chapters, in the Board’s review of these cases special consideration was given in this chapter to:

» the impact of a perceived ‘normalisation’ of violence in some families and communities

» help-seeking behaviour, motivation and barriers to accessing support for victims of family violence

» problematic substance use as an exacerbating factor, and the lack of appropriate support for both victims and perpetrators to address underlying support needs

» the use of violence by Aboriginal and Torres Strait Islander victims and how this may be commonly misunderstood and poorly responded to by services, leading to increased vulnerabilities.

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Domestic and Family Violence Death Review and Advisory Board

The Board considered ten cases where the deceased identified as Aboriginal and Torres Strait Islander, including three filicides, five intimate partner homicides7 and two suicides. With the exception of one victim in this cohort, both the victims and perpetrators in these cases had been in frequent contact with a range of services with the response generally not commensurate with the level of need, and seemingly ineffective in addressing the core, underlying issues. The perpetrators in these cases all had extensive histories of violence which prompted a focus on the justice system response to family violence, with recent reforms being noted which includes the re-establishment of the Murri Court in Queensland.

Shared lessons from a range of Aboriginal and Torres Strait Islander services, and Elders, about achieving better outcomes in responding to family violence were welcomed by the Board. Significantly, it was noted that services must be flexible, responsive and focus on cultural strengths if they are to make a positive difference in the lives of vulnerable victims and children experiencing family violence.

Given the overwhelming impact of family violence on some families and communities, a call for change is resounding and must recognise that family violence is fundamentally very different, and therefore requires a targeted response based on cultural strengths, community ownership and leadership, as well as a commitment to innovation, supported by sustainable and appropriate resourcing.

7 The homicide offenders in each of these cases also identified as Aboriginal and/or Torres Strait Islander.

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Recommendations The Board is established to identify preventative measures, and make recommendations to the Attorney-General for implementation by government and non-government entities to prevent or reduce the likelihood of domestic and family violence deaths in Queensland.

A key consideration throughout the Board’s case review process was the significant reforms currently being undertaken across Queensland that aim to improve protective outcomes for victims and their children, and hold perpetrators to account.

While not discounting the significance of the issues identified from the reviews conducted within this reporting period, the Board recognises that some reforms may take time to embed within practice. It is therefore critical that there is a sustained focus and commitment to achieve the intended outcomes of these reforms, and that the current momentum is sustained over time.

Accordingly, recommendations made by the Board in this reporting period aim to enhance this existing program of work or address identified systemic gaps, where applicable. It is also hoped that the key learnings outlined in this report can be taken into account within planning and implementation processes to further enhance reform.

Based on its review of these deaths, and in accordance with section 91D (e) of the Act, the Board therefore makes the following recommendations to the Attorney-General.

Suicide risk screening in specialist services

1. That a targeted suicide prevention framework, which accounts for the detection of, and response to, vulnerable individuals should be developed and implemented within domestic and family violence refuges by the Department of Communities, Child Safety and Disability Services, in consultation with relevant experts and stakeholders. This framework should include:

a) the implementation of routine, evidence based, suicide risk screening at intake and provisions for timely reassessment during periods of acute crisis or elevated risk (e.g. following contact with a violent ex-partner) to ensure that responses are commensurate with risk

b) referral pathways to relevant support services, and be used to inform a comprehensive safety and risk management plan for individual clients

c) suicide awareness and risk management training for staff, as well as the introduction of standardised policies and procedures that aim to support appropriate storage of, and access to, medications in domestic violence refuges.

Strengthening our systems

2. That the Department of Health introduce mandatory training for staff who may come into contact with victims and their children or perpetrators of domestic and family violence.

The training should be delivered to a standard (or level) that proficiency can be measured. This should cover:

a) risk screening, assessment and management processes

b) enhancing understanding of risk factors

c) comprehensive discharge planning and follow up care that takes into account the safety of both self and others, including appropriate referrals

d) appropriate safe information sharing in accordance with Queensland Health guidelines

e) specialist non-lethal strangulation training for accident and emergency departments that aims to assist in recognition of the signs of this type of violence but also in the collation of forensic information to inform the prosecution of any related criminal charges.

3. That the Department of Health consider ways to enhance the delivery of post-natal care for all families with a focus on equipping them with the requisite skills to care for a newborn infant. The Department should also consider and incorporate intensive and robust maternity and post-natal support models of care for all high-risk and vulnerable families with a focus on continuity of care options (including midwives), the use of multidisciplinary teams to address broader support needs, and specific interventions and support for fathers.

4. That the Department of Health consider ways to ensure culturally appropriate maternity and post-natal care for Aboriginal and Torres Strait Islander families are available. This should include a focus on increasing and supporting a specialist workforce in this area, and the provision of outreach support services that aim to engage with hard to reach families.

5. That the Department of Health liaise with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to promote routine screening for domestic and family violence, and enhanced responses to high-risk and vulnerable families in private obstetrics and health facilities.

6. That the Queensland Government consider ways to improve access to, and availability of, priority alcohol and other drug treatment places for high risk or vulnerable parents who may have contact with the child protection system or be experiencing domestic and family violence. This should also take into account the practical supports that parents may need, such as free access to child-care, to encourage uptake with treatment services, and aim to ensure that services are informed around the intersection between domestic and family violence, trauma and substance use.

7. That the Department of Health implement processes for routine mandatory screening for domestic and family violence victimisation and perpetration, within all Queensland Health and government funded mental health, and alcohol and other drug services. These should be supported by clear local pathways to specialist support services and appropriate training on the intersection between domestic and family violence, mental health and substance

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Domestic and Family Violence Death Review and Advisory Board

use which accords with the National Outcome Standards for Perpetrator Interventions.

8. That the Queensland Government fund and facilitate cross professional training and relationship building between mental health, drug and alcohol, and specialist domestic and family violence services to enhance collaboration, shared understandings and information sharing.

9. That the Queensland Government liaise with peak professional bodies to recommend all registered practitioners who may come into contact with victims and their children or perpetrators of domestic and family violence, complete specialist domestic and family violence awareness training within one year of obtaining registration or membership and be required to complete ongoing refresher training to maintain their registration or membership. Training should include specific information pertaining to working with perpetrators in accordance with the National Outcome Standards for Perpetrator Interventions, as well as responding to victims of domestic and family violence. Peak professional bodies may include, but are not limited to, practitioners registered with the Australian Counselling Association, Australian Association of Psychologists, Australian Association of Social Workers, Royal Australian and New Zealand College of Psychiatrists and accredited relationship counsellors and mediators.

10. That the Queensland Police Service continue to develop operational communiques and training targeted at first responding officers to domestic and family violence related occurrences, which aim to enhance understanding of the broader dynamics of domestic and family violence and the significance of certain risk indicators that may lead to a heightened risk of harm, such as those identified within this report.

11. That the Queensland Police Service ensure that all first responding officers have timely access to electronically available, current, relevant and accurate information held across their data systems in relation to a prior history of domestic and family violence, for perpetrators and victims; in a format which aims to enhance but not disrupt, an operational response. This should be supported by the implementation of strategies that emphasise the importance of this information to call takers and frontline officers, and how to better take this information into account when responding to domestic and family violence related occurrences, particularly repeat calls for service.

12. That a program for specialised and consistent court support for victims of domestic and family violence in criminal proceedings be developed and funded by the Queensland Government.

13. That the Department of Communities, Child Safety and Disability Services, in investigating alleged harm to a child and assessing whether the child is in need of protection, review the appropriateness of conducting interviews with children and young people in front of persons alleged to have caused harm, particularly in the context of domestic and family violence; with a view to strengthening guidelines within the context of statutory obligations as to when this should not occur.

Earlier detection and targeted intervention

14. That the Department of Health develop a mechanism to assist practitioners to identify persons experiencing domestic and family violence or high-risk families who have presented to the service previously; and to better take into account previous presentations to enhance future responses.

15. That the Queensland Police Service implement a process within QPRIME and across the Service which includes consideration of a warning flag, to assist frontline officers to identify when a child may be at risk of harm and to inform their investigations at any calls for service.

16. That the Queensland Government commission research which aims to identify how best to respond to the person most in need of protection where there are mutual allegations of violence and abuse. This research should take into account the identification of potential training or education needs for service providers across applicable sectors to better assist in the early identification of, and response to, victims who may use violence particularly where they come to the attention of services during relevant civil proceedings for domestic and family violence protection orders.

17. That the Queensland Government consider opportunities to strengthen legislative, policy and practice requirements within Child Safety Services and the Queensland Police Service to enable each agency to have timely access to relevant information about past offending conduct including charge and conviction information from Queensland and other jurisdictions when undertaking their respective and joint investigative functions and powers. This should include but not be limited to, a review of prescribed offences within the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004, to consider the appropriateness of broadening the scope to other violent offences against children (e.g. manslaughter or torture) for the duration of reporting obligations, and the feasibility of broadening access to the National Child Offender System to Child Safety Services.

18. That the Director of Public Prosecutions and the Queensland Police Service develop guidelines and educational resources with regard to the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004 to ensure that prosecutors have the necessary knowledge to make applications for an Offender Reporting Order as a matter of course for serious offences against children that are not prescribed offences, even if they do not proceed to trial by virtue of a guilty plea.

19. That the Queensland Government review existing responses that provide support, practical advice and referral pathways for families and friends concerned about loved ones who may be at risk of domestic and family violence, and employers who identify that their staff may be experiencing domestic and family violence, in order to ensure the state- wide availability and accessibility of dedicated supports in this area.

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A call for change in responding to family violence

20. That the Queensland Government, in partnership with community Elders and other recognised experts, develop a specific Aboriginal and Torres Strait Islander family violence strategy as a matter of urgent priority. This work should be informed by the Queensland Government’s Supporting Families Changing Futures reforms, Our Way: A generational strategy for Aboriginal and Torres Strait Islander children and families 2017-2039 and Changing Tracks: An action plan for Aboriginal and Torres Strait Islander children and families (2017-2019).

The strategy should:

a) be led and implemented by Elders and the community

b) be informed by evidence and account for the various drivers perpetuating family violence

c) focus on cultural strengths and family-centred services and programs

d) recognise and seek to address the unique construct, challenges and co-morbidities of this type of violence

e) have an urban focus as well as addressing the needs of regional and discrete communities

f) complement broader domestic and family violence strategies and others of relevance including health, justice, education and child protection strategies where appropriate

g) embed trauma-informed approaches that recognise historical and contemporary issues

h) include a tertiary response but provide equal focus and investment on primary prevention and early intervention

i) include primary prevention strategies for Aboriginal and Torres Strait Islander children which should be developed in consultation with young people to ensure their needs are met

j) be sustainably and sufficiently funded, noting the cost benefit to be accrued through reducing the burden on resource intensive services such as emergency departments and child safety services

k) include allied, wrap-around services to support the development and implementation of the strategy

l) be formally monitored and independently evaluated using culturally appropriate outcome measures, methodologies and providers. This should include a strong focus on building the evidence base and data around what works in this area

m) be publicly reported at regular intervals to increase accountability. This should include tracking the investment to ascertain whether it is proportionate to the current investment in crisis response.

n) be supported by a governance body to oversee a co-design approach to the development and implementation of this strategy.

21. That the Queensland Government extend upon culturally informed, family responsive alcohol and other drug treatment options, to ensure they include options for residential treatment or outpatient support and provide ongoing care as part of the treatment program.

Death Review and Advisory Board | Annual Report 2016–1716

Domestic and Family Violence Death Review and Advisory Board

This chapter provides an overview of the role and function of the Board and key activities undertaken throughout the 2016–17 financial year.

The discussions and findings of the Board throughout this reporting period are explored in further detail in subsequent chapters.

Domestic and family violence death review mechanisms are based on the premise that these types of fatalities are generally preceded by episodes of violence or abuse indicating a heightened risk of future harm, as well as missed opportunities for agencies and individuals to intervene, before the death.

It is because of these indicators that these types of deaths are considered some of the most preventable.

Findings from reviews are invaluable in informing the development of more effective interventions, improving the service system through recommendations for change, and in preventing future deaths in similar circumstances.

The establishment of the Board was a key recommendation of the Special Taskforce on Domestic and Family Violence in its Final Report, Not Now Not Ever: putting an end to domestic and family violence in Queensland (2015) to enhance the systemic reviews of these types of deaths.8

The Board is established under the Act to:

» identify preventative measures to reduce the likelihood of domestic and family violence deaths in Queensland

» increase recognition of the impact of, and circumstances surrounding, domestic and family violence and gain a greater understanding of the context in which these types of deaths occur

» make recommendations to the Attorney-General for implementation by government and non-government entities to prevent or reduce the likelihood of domestic and family violence deaths.

Following a state-wide recruitment process for non-government members, the Attorney-General announced the appointment of the Board members in early July 2016.

Upon the commencement of the appointments, the Board met and subsequently entered into the necessary Administrative Arrangements to allow information sharing between the Board and the State Coroner under section 91Z of the Act. It also endorsed its Procedural Guidelines9 which outline the domestic and family violence death case categorisation and review process in Queensland, and set the governance arrangements for the Board.

While the Board is required to report annually to the Attorney- General, the Not Now, Not Ever report recommended that the Board report to the oversight body (specifically the Domestic and

8 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 9 http://www.courts.qld.gov.au/__data/assets/pdf_file/0007/489175/ccq-dfv-board-procedural-guidelines.pdf 10 These reports are available on the Coroners Court of Queensland website at: http://www.courts.qld.gov.au/courts/coroners-court/review-of-deaths-from-domestic-and-family-violence

Family Violence Implementation Council) every six months on its findings and recommendations.

As such, a reciprocal reporting relationship was established between these two bodies in late 2016, with the Board providing a noting paper to Council every six months on the progress of its activities, and any interim or provisional findings or recommendations.

During this reporting period, the Board has also released two statistical overviews to provide accessible preliminary data pertaining to (suspected or apparent) domestic and family violence deaths that occurred in Queensland, to ensure currency and timeliness in statistical reporting.

In the 2016–17 reporting period, the Board reviewed in depth, 27 cases involving 29 deaths that occurred between 2011 and 2016.

As the intent of the Board is to systemically review these types of deaths, cases were clustered together focusing on different types of deaths including: homicide suicides and perpetrator suicides; intimate partner homicides; victim suicides; Aboriginal and Torres Strait Islander family violence homicides; and filicides.

For this reporting period, cases were selected for review by the Board based on the availability of information in relation to a case, the relevance of that case to the focus of the meetings, as well as the similarities or differences between that case and others reviewed in the meeting.

In recognition of sector interest in the activities of the Board and the domestic and family violence death review process, the Board committed to releasing communiques from case review meetings held which outline a summary of discussions by the Board in the review of applicable cases.

Based on discussions of these cases, the Board also released three Systemic Review Reports10 pertaining to domestic and family violence deaths that occurred in Queensland specifically:

» the Intimate Partner Homicide of ‘Kelly’ which considered the benefit of reviewing bail legislation in circumstances where there was high likelihood of recidivism and a significant history of domestic and family violence

» the Domestic and Family Violence Related Death of ‘Frank’ which highlighted the importance of ensuring that support is provided to perpetrators of domestic and family violence which addresses both immediate and underlying issues

» the Domestic and Family Violence Related Death of ‘Tricia’ which outlined the need for high-risk teams and integrated service models to prioritise victim safety in the context of multiple and complex support needs.

Chapter 1: Overview

Death Review and Advisory Board | Annual Report 2016–17 17

Suicide risk screening in specialist services

In June 2017, the Board made its first preventative recommendations subsequent to a review of two deaths that occurred within women’s shelters, as part of the Victim Suicide case review meeting.

The two female deceased were residing at domestic and family violence refuges at the time of their deaths. In both cases, the women had sought safety and protection from these services while separating from their former abusive partners. Both women had a prior history of mental health problems, suicidal ideation and self-harm.

Despite some knowledge across services of these historical and presenting vulnerabilities, there was limited identifiable assessment, planning or management of suicide or self-harm risk by refuge staff.

Research indicates intimate partner violence is a significant and compelling risk factor for suicide in female victims, with some studies suggesting women who have been abused by their intimate partners are almost four times more likely to experience suicidal ideation compared to non-abused women in the general population.11

It has been further suggested there is an elevation in suicide risk among female victims of domestic and family violence in circumstances where a victim has sought crisis support in relation to intimate partner violence, with research indicating one third of women in these circumstances may experience suicidal ideation or attempt suicide.12

While the Board recognised that refuge staff, or those providing crisis responses to victims of domestic and family violence, may not have all the necessary qualifications or skills to intervene in relation to mental health problems and suicide risk, ‘gatekeeper training’ has proven efficacy and is suitable for these types of services. It aims to enhance the capacity of professionals or para-professionals to screen and refer people at risk of suicide to appropriate supports.

Limiting access to lethal means has also been shown to have a strong impact in the prevention of suicide.13Significant success has been achieved in the implementation of suicide resistant rooms and cells in health and corrections settings where ligature points have been reduced or removed.

Given that many domestic and family violence refuges are existing houses, it was considered by the Board there may be few opportunities to implement new safety measures at current refuges without a significant financial investment. Consideration could be given to these factors when future infrastructure works are planned to build or modify accommodation facilities.

This must be balanced with the need for clients to reside within a comfortable environment as similar to home as possible.

Overdose of prescribed medication was the cause of death in these two cases. It became apparent during the review process that refuges may not always have policies and procedures that support the safe storage of, and access to, medications.

11 Taft, A. (2003). Promoting Women’s Mental Health: The Challenges of Intimate/Domestic Violence against Women. Australian Domestic and Family Violence Clearinghouse Issues Paper (8) UNSW, Sydney.

12 Golding, J.M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14, 99-132. 13 Queensland Health. (2013). Mental Health Presentation, History and Assessment. Primary Clinical Care Manual.

Individual care planning with a client who has been identified as at risk of suicide can extend to safety planning regarding medication access, to assist in voluntarily limiting their access to lethal means.

In health settings where a person may be identified as at risk of suicide, safety planning can be put in place to restrict that person’s access to medications that may be potentially lethal, prior to discharge. This planning is mutually agreed upon between staff, the patient and their family. It is important at all stages that victims are empowered to make independent decisions regarding this type of safety planning.

Policies and procedures are also in place in other types of residential facilities, including those without clinical staff, to ensure appropriate medication management. These procedures could be adapted for use by refuges for victims of domestic and family violence with their consent.

Based on its review of these deaths and in accordance with section 91D (e) of the Act, the Board made the following recommendations to the Attorney-General in June 2017:

1. A targeted suicide prevention framework, which accounts for the detection of, and response to, vulnerable individuals should be developed and implemented within domestic and family violence refuges by the Department of Communities, Child Safety and Disability Services (DCCSDS), in consultation with relevant experts and stakeholders.

a) This framework should include the implementation of routine, evidence based, suicide risk screening at intake and provisions for timely reassessment during periods of acute crisis or elevated risk (e.g. following contact with a violent ex-partner) to ensure that responses are commensurate with risk.

b) This framework should also include referral pathways to relevant support services and be used to inform a comprehensive safety and risk management plan for individual clients.

c) Any such framework would need to include suicide awareness and risk management training for staff.

d) The introduction of standardised policies and procedures that aim to support appropriate storage of, and access to, medications in domestic violence refuges.

Death Review and Advisory Board | Annual Report 2016–1718

Domestic and Family Violence Death Review and Advisory Board

The Board is established under the Act to increase recognition of the impact and circumstances surrounding domestic and family violence, and gain a greater understanding of the context in which these types of deaths occur.14

In the fulfilment of this function, the Board brings together the stories and journeys of those who have tragically lost their lives to, or who have been otherwise affected by, domestic and family violence.

This chapter provides a brief summary of each of the cases reviewed within the 2016–17 reporting period, to enhance understanding of the complex dynamics of domestic and family violence, and highlight the personal, familial, and community impact of these types of deaths.

While distressing, they are also stories of strength and resilience, often in the face of relentless and enduring violence. The courage of the victims in these cases should not go unacknowledged.

While the material may be confronting for some readers, the Board trusts that we can all learn from these tragedies, to prevent future deaths.

Cases have been de-identified to protect the identities of the deceased and their loved ones.

Kate and Jeffrey

Kate was in her early 30s when she was killed by her estranged boyfriend of two years, before taking his own life.

Although there was no identifiable system contact in relation to domestic and family violence within this relationship, friends and family members described a pattern of jealous, obsessive and controlling behaviour by the much older Jeffrey towards Kate which escalated significantly after the relationship ended, a few weeks prior to the death.

Jeffrey had a past history of committing other violent criminal offences, including assault, and was described as aggressive and threatening towards others.

His former partners also described significant acts of violence perpetrated against them, including non-lethal strangulation, sexual assault, property damage, stalking, pet abuse, obsessive phone calls and text messages, and threats to kill them or their family; all of which escalated significantly post-separation.

Despite this extreme violence, Jeffrey’s former partners largely relied on informal support networks, and there was limited identifiable contact with police or other services. One former partner did make a private application for a protection order although she later withdrew this because she moved interstate and believed she was no longer at risk.

14 Section 91 A of the Coroners Act 2003.

Another partner made a complaint to police after a brutal sexual assault but later withdrew her complaint to police after Jeffrey continued his abusive and threatening behaviours, and indicated that he knew where her and her children were staying. She later disclosed that she had remained fearful of him up until his death.

In the days before the deaths, Jeffrey reportedly observed Kate at a social outing with another male and became extremely jealous. Jeffrey begged her to take him back and said that he would marry her, but Kate refused to reconcile. This triggered a series of excessive phone calls and text messages at all hours in which Jeffrey would ask her whether the other male was there, or breathe heavily over the phone.

On the day of the deaths, Jeffrey told a neighbour that he had finally found ‘proof’ Kate was cheating on him and arranged for her to come to his house so she could collect some of her belongings. Kate told her employer of these plans and despite her employer expressing significant concerns about Jeffrey’s behaviour and the potential risk to her safety, Kate maintained that Jeffrey would never hurt her.

Kate went to Jeffrey’s home later that day where he killed his pet and shot Kate before turning the gun on himself. After the deaths had been reported, police found sufficient evidence to suspect Jeffrey was planning to torture Kate prior to fatally shooting her.

Amy and Paul

Amy was a female in her mid-30s who was killed by her de facto partner of approximately five years, Paul. Paul then took his own life.

Paul was significantly older then Amy and this relationship was punctuated by repeated periods of separation and reconciliation. Although there was limited system contact in relation to domestic and family violence during the relationship, there is evidence that Paul was jealous and controlling.

For example, he would constantly monitor Amy’s phone calls and text messages; control her movements; seek to prohibit her contact with mutual male friends; and make constant allegations of Amy’s infidelity. Friends reported sighting bruises and other injuries on Amy throughout the relationship that they suspected had been inflicted by Paul although Amy reportedly denied this.

Police contact was limited to two episodes occurring in the early stages of the relationship including once where officers responded to an argument over jealousy issues in which it was alleged Paul had smashed the door with his fist and later grabbed Amy by the waist and pushed her onto the bed. This matter was recorded as a DV Referral and no further action was taken by police.

On the other occasion Paul was listed as a named person on an order, after police made an application listing Amy as the respondent and a family member as the aggrieved, after they responded to an occurrence a few months later.

Chapter 2: Honouring the stories, and sharing the journey

Death Review and Advisory Board | Annual Report 2016–17 19

With respect to previous relationships, Amy also had a prior history of being both a respondent and aggrieved on other protection orders, and was reported to behave aggressively towards others when intoxicated.

Paul had no history of contact with police or other services in relation to domestic and family violence; and his former wife reported he had not been violent towards her during their relationship.

In the months before the death, Amy expressed a desire to end this relationship to others but also that she was fearful that Paul would harm himself as he had made numerous threats and at least one attempt to do so.

Amy’s attempts to end the relationship triggered a pattern of erratic, suicidal and increasingly controlling behaviour by Paul, including travelling overseas unannounced and uninvited while Amy was on holiday, before pressuring her to stay a further week during which time they reconciled.

He also assaulted her, including an act of non-lethal strangulation to the point of unconsciousness, after he went through her phone and discovered she had a brief sexual relationship with another person when they had been previously separated.

While this was disclosed to a number of other persons at the time, it appears that this behaviour was seen as uncharacteristic of Paul.

In the months prior to the death, Paul told people he was seeing a counsellor and taking medication for depression which allayed some of their concerns about his mental health; this was unable to be confirmed as part of the police investigation.

Shane

Shane was a man in his early 50s who took his own life after breaking into his former partner’s house and assaulting her, stopping only when a third party intervened, in an attempted homicide suicide.

While there was some evidence of Shane exhibiting controlling behaviour throughout the relationship, this escalated significantly after his relationship with Mary ended and was further exacerbated by Shane’s declining mental health, impulsivity and alcohol misuse.

After the couple separated, Shane engaged in a number of abusive behaviours including:

» verbal abuse and harassment via excessive and unwanted phone calls including in the workplace

» stalking Mary’s movements including by driving by places she was known to live and work

» impersonating other people by using their phone to text Mary and find out her location

» repeatedly making allegations of her infidelity

» damaging Mary’s property including disposing of personal property.

Before his death, Shane was engaged with a number of private and public health services in relation to his declining mental health; chronic suicidal ideation; and self-harming behaviour which he continued to attribute to his separation from Mary.

In his engagement with service providers he frequently cited the breakdown of their relationship as the trigger for his suicidal behaviour. Shane also self-disclosed that he engaged in frequent acts of suicidal and self-harming behaviour as a means to manipulate and coerce Mary into maintaining contact with him.

For example, on one occasion Shane broke into Mary’s home and self-harmed. On another occasion he arrived at her home after an episode of self-harm and was discharged into Mary’s care after she took him to the hospital for treatment.

Shane was located by police on multiple occasions in or near where Mary was staying, including at times in the middle of an act of self-harm. At other times family members would also request police to conduct welfare checks on him as he would go missing, or they held concerns for his safety

While the couple briefly reconciled shortly prior to the death, they separated shortly afterwards as a result of the intensity of Shane’s abuse.

Mary (aggrieved) did file a private application for a protection order against Shane in the weeks prior to the death because of this escalating abuse. A few days later, Mary presented at the police station seeking assistance as she suspected Shane had damaged her property and she expressed fear that Shane was a risk of harm to both himself and others (including her). Police subsequently completed an intelligence report, and flagged her address, with no further action taken.

On the day of Shane’s death, he broke into the house where Mary was staying and seriously assaulted her while she was sleeping.

Shane fled the premises after being chased by another occupant of the house and was located a short distance from the premises with self-inflicted injuries which he died from shortly after.

Keith

Keith was in his mid-20s when he died by suicide. He had separated from his partner of approximately six months, Donna, only a few months earlier. The couple had recently moved in together, but she asked him to move out only a few days later when she realised the situation was untenable

Shortly after, he committed an act of self-harm in front of Donna which prompted responding police officers to apply for a temporary protection order. He was subsequently taken to the emergency department for treatment. Keith was discharged the following day into the care of a family member. He then fled and went to Donna’s house in breach of the conditions of the order. Although police were subsequently called and had some limited involvement, Keith’s family and friends largely assumed the responsibility of finding Keith and taking him home, with the officers taking no further action.

On this occasion, they located him at Donna’s home behaving erratically, with Donna trying to get away from him and begging him to leave. These informal supports were eventually able to remove Keith from the premises but they held significant concerns for his well-being.

Keith continued to exhibit increasingly obsessive and controlling behaviour towards Donna, and would harass her via excessive text messages, emails and social media posts, which included publicly blaming her for his poor mental health and accusing her of being a sex worker. He also made repeated suicide threats.

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Domestic and Family Violence Death Review and Advisory Board

In the context of his declining mental health and ongoing suicidality, Keith received treatment by public health services as well as a private psychologist and general practitioner. During this contact, Keith disclosed that he was grieving as he was recently bereaved by suicide. The issue of domestic and family violence was not directly canvassed during these sessions by the psychologist, despite some disclosures of violent behaviour and the psychologist being aware that a protection order was in place at the time.

Upon receiving further reports of abuse, police officers did subsequently pursue charges relating to breaches of the protection order against Keith, and the psychologist wrote a letter to the court to support the associated proceedings in which he attributed Keith’s behaviours in relation to this breach as a result of negative coping within the context of loss and grief and stresses associated with other negative life events, as well as significant life pressures associated with these losses.

The conditions of the protection order were later varied to allow contact between the couple following an application by Donna, who cited a desire to attempt a reconciliation amid increasing pressure from Keith and out of her concern for his mental health.

The day before Keith’s death he became increasingly erratic upon learning that Donna had been talking to another male, threatening to kill this person; although later apologised when realising it was a misunderstanding.

He attempted to see Donna that evening. She refused to see him due to the emotional strain of this abuse, and the next morning, Keith sent multiple emails to Donna asking to speak with her. He then confronted Donna outside her home and took his life shortly afterwards.

Tony

Tony was almost 40 years old and had been estranged from his wife, Kym, for a number of months before he took his own life.

Tony had a long history of substance use concerns. In the year before the death he began using novel psychoactive substances which was reported by others to have triggered a rapid decline in his mental health and increased aggression.

Kym described a history of some verbal abuse throughout their relationship. This escalated significantly after their separation. The deceased became verbally and physically aggressive towards Kym including frequent abusive texts, as well as to members of his family and others. Tony repeatedly expressed suicidal and homicidal ideation.

Kym ultimately submitted a private application for a protection order which, when granted, prohibited contact between the couple except in relation to child custody arrangements. Kym reported that Tony capitalised on opportunities to continue his abuse during periods of contact to facilitate child visitation including by damaging property and verbally abusing her.

A month later, an anonymous informant contacted Crime Stoppers with concerns relating to Tony’s anger, aggression and unpredictable behaviour directed at Kym and his family members, in the context of substance abuse. There were concerns that Tony was armed and was a risk to himself, his family and others. This intelligence submission was initially disregarded by police, despite police possessing confirmatory information. It wasn’t until police responded to a physical incident between Tony and

an associate three days later that they investigated the legitimacy of the submission. However, action was limited to ensuring the management of Tony’s immediate mental health episode.

He was subsequently admitted to a public health service as an involuntary patient for treatment of mental health related concerns with his behaviour being identified as abusive to family members and staff. Tony behaved inappropriately towards female staff and patients, and he was noted to have attempted to buy drugs. Following his discharge some six weeks later, Tony completed a short-stay rehabilitation program at a private facility, and was thereafter actively engaged with public and private health practitioners.

It is apparent that during this time Tony would drink heavily and was reportedly depressed and preoccupied with hopes of reconciling his marriage. Family raised multiple concerns with his practitioners in the lead up to the death regarding Tony’s behaviours and risk of suicide, although he routinely denied any suicidal intention when enquiries were made.

James

At the time of his death James was in his late 20s and had been separated from his de-facto partner of seven years, Simone, for just over 18 months.

Throughout the course of their relationship, James exhibited behaviour towards Simone consistent with coercive controlling violence including: financial abuse, social isolation and attempting to control and monitor her contact with others, as well as verbal abuse focused on Simone’s ability to parent; the types of clothes she wore; and whether the house was cleaned to an acceptable standard.

The dissolution of the relationship resulted in a significant escalation in the frequency and severity of domestic and family violence, and a subsequent increase in the number of police call outs in response to these episodes.

This included abusive and harassing texts; acts of physical abuse; and, withholding access to their children for prolonged periods of time. Simone subsequently filed a private application for protection order naming James as the respondent.

James was subsequently charged with a contravention of the order, after continued acts of technology facilitated abuse.

Prior to the relationship ending, there were multiple recorded instances of attempted systems abuse in which James sought to maliciously involve child safety services and the police against Simone in relation to her personal mental health, and ability to care for the children.

Police records also demonstrate that in the year before his death, James was violent and threatening towards other family members resulting in domestic and family violence protection orders being filed, listing James as the respondent.

While there was concerns for James’s welfare among family and friends due to his decline in mental health and erratic behaviours in the lead up to the death; there was limited contact with health or other services in relation to these issues.

Death Review and Advisory Board | Annual Report 2016–17 21

Michael

Michael, a nearly 30-year-old male, died as a result of intentional self-harm in the context of intimate partner violence, problematic substance use, criminal offending, unemployment, and concurrent mental health concerns.

While there was very limited contact with services prior to his death in relation to domestic and family violence, Michael’s former partner, Grace, describes a long history of abuse in the relationship which was often perpetrated in front of their children, such as:

» physical assaults including punching, and frequent acts of non-lethal strangulation

» sexual assault and verbally denigrating her

» threatening physical injury or death, including intimidating her with weapons and damaging property

» controlling Grace’s appearance and monitoring her contact with others, especially men, and attempting to isolate her socially

» making constant allegations of Grace’s infidelity.

Despite this pervasive history there was minimal recorded history of domestic and family violence known to police which occurred a number of years prior to the death. Michael was well known to police with a substantial criminal history for traffic, drug and property related offences.

In the year prior to his death, he had been charged with respect to significant drug offences, and had subsequently been fired; and remained unemployed up until his death. These charges were a source of stress for Michael as he believed that he would be incarcerated, and he failed to appear in court in relation to these proceedings on a number of occasions.

A close family member of Michael’s also had a serious illness which was identified as an additional stressor. As a result of his criminal charges, his firearms licence had been suspended and the firearms were scheduled to be confiscated.

On the day of his death, a prolonged episode of domestic and family violence occurred with Michael making allegations that Grace was in a sexual relationship with another man. This included threats with a firearm, sexual assault, and non-lethal strangulation.

With the assistance of informal supports Grace was able to remove the children to safety before returning to the home, where Michael subsequently took his own life.

Kelly

Kelly, a female in her mid-30s, was killed by her de-facto partner of approximately two years, Robert. Kelly was the mother of one child from a previous relationship. The child lived in the full-time care of the biological father and saw Kelly through regular visitation arrangements.

The couple initially lived a transient lifestyle and had been living in a regional town for approximately five months before Robert killed Kelly.

Robert had a violent criminal history both within Queensland and interstate and was abusive towards Kelly. He was known to monitor her phone conversations, prohibit her contact with friends and family by deleting her phone contacts, and would sit outside

her work during lunch breaks and yell if she was not ready to be picked up on time. Friends also reported sighting black eyes and bruising to Kelly’s body throughout the course of her relationship to Robert; although she would either minimise the severity of her injuries, or deny he was responsible.

System contact with respect to reported domestic and family violence in the relationship was limited to two occasions approximately nine months prior to the death. On the first occasion, police located Kelly sitting in the gutter intoxicated and highly emotional with observable injuries, including a fractured cheek bone requiring hospitalisation. Kelly reported that Robert had assaulted her a few days earlier and police observed her to appear extremely nervous and terrified of Robert, stating that he would kill her if he found out that she had spoken to police.

Police officers transported Kelly to a regional hospital for treatment of her injuries; attempted (unsuccessfully) to locate crisis accommodation; and sought a protection order with extra conditions prohibiting Robert from coming into contact with Kelly.

Robert was subsequently charged with assault and, although police submitted an objection to bail, he was released under conditions which prohibited his contact with Kelly, and required him to report to an agreed police station several times per week.

Several weeks later, Kelly attempted to have the charges revoked stating that the assault was just an accident. Suspecting Kelly had been pressured by Robert, a station wide alert was sent to all officers due to suspicions Robert was in breach of the bail conditions. Police officers subsequently conducted a bail check and found the couple together at a caravan park. Robert was apprehended and charged with breaching the bail and protection order conditions, although he was again released with bail conditions enlarged.

Robert appeared to comply with his bail reporting requirements after this time. Police suspected the couple continued to reside together yet no further action was taken. Records indicate that Kelly attended another police station several months later and requested the charges be dropped again.

The couple continued to live together. In the week before her death, Kelly told friends and family members she intended to end the relationship and cease living with Robert.

Robert ultimately killed Kelly, three days before he was due to appear in court for the assault and related charges, some nine months after he had originally been charged.

Rosie

Rosie, a mother in her mid-20s, was killed by her former husband, Dean, when the pair met one afternoon to discuss child custody arrangements. The couple had been separated for many years prior to the death.

Rosie and Dean commenced a romantic relationship while both were in high school. Dean was physically and verbally abusive towards Rosie. She described Dean as having a high temper and told others he would crack if things didn’t go his way.

Dean joined the Australian Defence Force (ADF) in the mid-2000s and had recently returned from an overseas deployment when he physically assaulted Rosie during an argument. The relationship ended around this time. While this assault was initially not reported to police, she later disclosed it after a subsequent

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Domestic and Family Violence Death Review and Advisory Board

episode of violence in which Dean attempted to remove the children from Rosie’s care. On this occasion he damaged property and sustained an injury requiring hospitalisation; which police later determined was self-inflicted.

Dean was sent on a further overseas deployment. He served only half his tour before returning home as his new partner, Mary had miscarried. He reported ongoing conflict with Rosie over the custody of the children and disclosed homicidal intent to treating practitioners within the ADF a year later; which was not reported to police or Rosie.

After a decline in his mental health and expressed suicidal and homicidal ideation, Dean subsequently received a medical discharge from the ADF.

Although there was some evidence that Dean disclosed conflict in the relationship as a prevailing issue to health practitioners and others who were providing support, there is no indication that domestic and family violence was formally identified, and no specialist referrals, were made by these formal supports.

Child Safety Services had recurrent contact with the family in relation to a number of reports of potential harm to the children. There were three substantiated reports of physical and emotional harm due to the children witnessing violence against their mother by Dean; and between Rosie and her new partner, who was also an ADF officer.

Police had some limited involvement after Rosie and Dean had separated and largely considered the arguments as symptomatic of custody disputes; rather than being indicative of an underlying pattern of coercive controlling violence.

On one of these occasions, approximately four years prior to the death, police applied for a protection order, listing Rosie as the respondent and Dean as the aggrieved after he refused to return the children to her in accordance with agreed custody arrangements.

She attended the premises with her new partner in an attempt to collect the children, when an altercation ensued between multiple family members.

While court orders were subsequently put into place, this had limited effect in stabilising the shared parenting arrangements.

Amid continued abuse perpetrated by Dean, Rosie applied for a protection order about six months before her death after he threatened her younger sister. In this application, she wrote that he was angry, threatening and she was frightened of him; and that she did not want to have to live in fear.

This application was subsequently dismissed as Rosie did not show up when it was due to be heard. Rosie was also seeking formal assistance to stabilise the child custody arrangements through family dispute resolution.

Nicole

Nicole was killed by her former de-facto partner, Tim. Nicole was a mother, and the designated full-time carer of one of Tim’s family members.

The relationship between Nicole and Tim was characterised by verbal, psychological and emotional abuse with a significant escalation in violence following the couple’s separation.

Nicole told police that their relationship began to deteriorate when Tim injured himself at work and developed a dependency on his pain medication. She reported that she began to suspect he had a mental illness and a gambling problem after approximately one year of dating. The couple sought individual and couple counselling.

Circumstances did not improve and Nicole asked Tim to move out of the house shortly after.

The dissolution of the relationship saw a considerable escalation in Tim’s perpetration of violence towards Nicole, including: threats to kill; stalking, harassment and intimidation; publicly posting derogatory comments; intimate photographs and personal details online; seeking to portray himself as a victim while denigrating Nicole to authorities; episodes of threatened or actual violence while driving a car in an intimidating manner; property damage; and the use of suicide threats and attempts as a means of control.

Records indicate Tim also perpetrated significant and similar acts of violence against other partners, particularly his former wife after their separation which involved some contact with police and the health system.

Subsequent to an act of violence with potentially fatal outcomes, his former wife was forced to ultimately change her identity and move interstate to escape Tim’s stalking and violence.

With respect to this relationship, Tim was convicted of multiple charges of breaching the protection order and other minor offences, but no criminal charges for assault-related offending were made. He was sentenced to six months imprisonment concurrent, wholly suspended for two years, and did not serve time.

In the months prior to the death, Tim and Nicole had contact with police, the courts, child safety services, domestic violence specialist support services, and mental health services in relation to Tim’s mental illness, suicidality and perpetration of domestic violence.

Nicole submitted an application for a protection order two weeks prior to her death, citing fears for her safety and that of the children in her care. A referral was sent to a specialist domestic and family violence support service and Nicole was advised of her options to enter a refuge if urgent assistance was required. She reported feeling safe as she was residing with others.

A Temporary Protection Order was issued although police were unsuccessful in their attempts to serve Tim with the documentation until several days later.

When police attempted to serve him with a domestic violence protection order, Tim was conveyed to hospital under an Emergency Examination Order in relation to displays of suicidal and homicidal ideation. Despite being assessed as a high risk of suicide and aggression, and although hospital staff were advised by police that they needed to be contacted prior to Tim’s discharge, the treating psychiatrist revoked the inpatient assessment order and released Tim from hospital as he alleged he was receiving treatment in the community.

After police finally made contact with Tim to serve the documentation on him, Tim stated to police, it won’t stop me.

Nicole continued to have contact with the specialist domestic and family violence service during this time.

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As a result of Tim’s escalating abuse towards Nicole, Child Safety Services also raised concerns, and notified Tim that he was prohibited from having contact with his family member who was in Nicole’s care.

Tim subsequently made repeated disclosures to informal supports of his intention to kill Nicole in the days preceding the death. While Nicole was advised of these threats, no reports were made to the police or any other agency.

Tim broke into Nicole’s house several days later and killed her.

Joshua

Joshua was a father, who was killed by his partner, Monique’s, former husband, Grant.

This happened several hours after police served Grant (respondent) with a full protection order prohibiting him from making contact with or committing further acts of violence against both Joshua (named person) and Monique (aggrieved).

Grant had an extensive history as a perpetrator of domestic and family violence against Monique during the course of their relationship of more than a decade. He perpetrated acts of physical and non-physical abuse against Monique which included frequent threats to harm and kill her, often in front of their children. He also committed serious physical assaults by head- butting her; throwing objects at her head; punching and kicking her; threats to harm the children; and multiple acts of non-lethal strangulation to the point of near unconsciousness.

While contraventions of these orders were pursued, the outcomes tended to be fines or suspended sentences.

After separating from Grant, Monique commenced a relationship with Joshua. Within a fortnight Monique attended a regional police station to report she had an altercation with Grant and she was concerned for their children who were currently in his care. Police then spoke with Grant, and sighted the children who did not present with welfare concerns. They recorded the matter as ‘No DV’ with notes indicating the couple had had an argument about Monique’s alleged infidelity.

On this occasion Monique later alleged that police had told Grant there was a crazy lady at the police station.

In the months that followed, Grant continued his abuse, and made persistent threats to harm Monique, Joshua and their children. One night, the couple made repeated calls to police for assistance after Grant made multiple threats to kill Joshua.

While records are somewhat conflicting as to the actual response on this occasion, statements taken after the death indicate that a follow-up phone call was made in the morning by officers to obtain further information, but no further action was taken and the matter was recorded as a ‘community assist’.

After this call, Monique made an urgent application for a protection order the same afternoon.

A temporary protection order was subsequently granted which included additional conditions prohibiting Grant from contacting or approaching Monique or any other named person on the order which included Monique’s children as well as Joshua and one of his children.

The temporary order was subsequently served on Grant which triggered further harassment and abuse both in person and via text which Monique and Joshua reported to police that same day.

Despite these, and other, reports made by Joshua and Monique of threatening behaviour constituting contraventions of the temporary protection order to Triple Zero, Policelink and the local police station, the police response appears to have been impeded by a lack of timely action and resources, as well as reports being recorded in different police systems. Both Joshua and Monique expressed significant frustration at the perceived lack of response by this agency and fear that Grant would carry out his threats.

Grant also used his children repeatedly to locate and stalk Monique. The abuse escalated to the point where handovers occurred within the police station parking area.

A number of weeks later, police attended Grant’s home and served him with a copy of the finalised protection order and informed him they would be investigating allegations of further breaches. Grant told the officer at this time that an order would not stop him.

Officers subsequently arranged for Grant to attend the station the following week as they did not consider it necessary for him to attend that evening as they felt they had no reason to believe he would not comply with their instructions.

They later attributed previous delays in the service of the final orders to difficulties in locating Grant.

Approximately an hour after being served with the protection order, Grant killed Joshua.

Gabby

Gabby died after being attacked by her former partner, Damian, in the middle of a relationship separation.

Approximately one week before the fatal assault on Gabby, there was an escalation of violence towards her by Damian as he suspected Gabby was having a sexual relationship with another male.

After returning from a holiday, Damian assaulted Gabby and held her hostage overnight. He forcibly restricted her access to their child and restricted her access to finances. Further, Damian posted revenge porn images of her, and a video of her being interrogated by him about her alleged infidelity, on social media platforms.

Damian also denigrated Gabby to her work colleagues.

With Damian away for work, Gabby took the opportunity to flee. With assistance from her boss (Bill) and family, Gabby attended the local police station and sought assistance for her protection.

Responding officers compiled an intelligence report, and took no further action.

That same day, Gabby made a private application at the court house, and arranged crisis accommodation through DV Connect. Bill advised police that the protection order had been granted and officers took no further action to locate or serve Damian with the order.

Bill, who was a lawyer, assisted in establishing an interim custody agreement between the couple, and also provided Damien’s lawyer with a copy of the protection order.

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Gabby and her child spent a few days at the refuge before she returned to her home town, convinced she would be safe after a successful contact visit between Damian and the child. Gabby wanted to find a place of her own but wanted to ensure their daughter had regular visitation with Damian.

Throughout this time Damian made repeated attempts to locate Gabby through her family and friends and bombarded her with repeated texts and calls.

He eventually located Gabby through care arrangements for their child, and subsequently killed her, before fleeing the scene and attempting suicide which resulted in superficial injuries.

A protection order had been previously put in place by police when Gabby was pregnant, listing Damien as the respondent. She did not wish to pursue criminal charges for the assault on this occasion as she was afraid of repercussions by Damien and his criminal associates.

Damian breached the conditions of this protection order on two occasions before it expired, resulting in a short period of incarceration. The couple were also flagged for case management by the police.

Gabby also briefly sought support through a domestic and family violence service. She was told that child safety services would not hesitate to remove her child if the abuse continued. Hospital staff also became aware of the domestic and family violence in the relationship when Damien was abusive to family members when Gabby was giving birth. They subsequently put in place a management plan to facilitate access by Damian to the infant at this time.

In a previous relationship, where there was also a protection order in place listing him as the respondent, Damian had been ordered to complete a perpetrator intervention program through a domestic violence specialist service.

While he attended these sessions, it was noted Damian did not adequately participate in the program, minimised his violence, and was assessed to be a high-risk of future violence at each of the program sessions.

Paula

Paula was located deceased in her bedroom at a women’s shelter where she resided for a short period after fleeing a violent relationship with her then partner, Rick.

Paula disclosed being the victim of physical violence perpetrated by Rick, inclusive of non-lethal strangulation, and displayed an unwillingness to report her experiences of abuse due to a fear that formal intervention might escalate Rick’s behaviour. Paula also felt conflicted in her attempts to escape the violent relationship due to her concerns for the safety of her family and her pets if she were to leave them behind.

The family dynamics were highly enmeshed between Rick’s and Paula’s family.

After an admission in a regional hospital for expressed suicidal ideation and domestic and family violence, Paula was discharged to a safe house in another town.

These events caused significant distress to Paula, and there is some indication that after her discharge, Rick was contacted by

hospital staff in relation to Paula’s welfare. Corresponding records indicate that there was an escalation in abuse by Rick shortly after this as he attempted to locate her, because he had thought she was returning after a few days.

After Paula left, there were allegations that Rick assaulted and held hostage, one of her family members. He had also threatened other members of her family in an attempt to locate her as well as allegedly committed significant acts of pet abuse and elder abuse to a member of his family.

Paula sought assistance from the staff at the refuge but found it was unattended over the weekend. She then called the after-hours crisis support. The worker advised her to turn her phone off and no further follow up was taken by that staff member.

Paula was not seen by staff or other residents for a couple of days. She was located deceased when external parties contacted the residence seeking to follow up with her; including a community social worker who had been working with Paula, and had just returned from leave.

Although Rick had a prior police history of being a perpetrator of domestic and family violence in multiple other relationships, there was no recorded contact with police in relation to domestic violence between Paula and Rick.

Paula’s childhood was traumatic and included a history of abuse in other familial or intimate partner relationships. She had a recorded history of suicidal behaviours within the context of her experiences of domestic and family violence; which was exacerbated by other stressors.

In the two years preceding her death, Paula was linked with a broad range of services including hospitals, mental health support services, community health services, and specialist support workers in relation to her experiences of domestic and family violence and suicidal ideation.

Tricia

Tricia died by suicide shortly after police responded to an episode of domestic and family violence in which they made an application for a protection order listing her as the respondent, and her intimate partner at the time, Peter, as an aggrieved.

Tricia had a history of being recorded as a victim of domestic and family violence in at least five previous relationships, and she was listed as a respondent on protection orders in three different relationships. In two of these former relationships her partners had perpetrated extensive and significant acts of violence against her, and there were existing protection orders in place listing her as the aggrieved.

Tricia endured extreme acts of violence including physical assaults, threats to kill, and multiple acts of non-lethal strangulation leading to loss of consciousness.

One former partner non-lethally strangled and sexually assaulted Tricia however, criminal prosecution was not pursued due to a perceived lack of evidence. Another violent former partner made several threats to kill her and her children.

Records indicate that Tricia would call police for assistance, but when they responded would refuse to make a statement or cooperate with officers.

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Tricia’s lifestyle was characterised by polysubstance use; criminality including assault, armed robbery, property and drug-related offences; sex work; homelessness; and enduring suicidality and self-harming behaviour

In the year before her death, Tricia had recently ended a violent relationship and relocated to another regional town to escape the abuse. She was living in a hostel and had made arrangements to participate in an opioid substitution program (although she died before this commenced).

During this time, Tricia had commenced a new relationship with Peter and was reportedly feeling extremely positive about the relationship.

On the day before her death, police responded to an incident whereby Tricia alleged that Peter, had skull dragged her across the floor by grabbing her hair. Peter contested he had tried to restrain her in a bear hug after she damaged property during an argument about her drug use.

After conducting their investigations, police determined that Tricia was the respondent and Peter the aggrieved, citing the physical evidence of property damage and the fact that Tricia’s hair was tied up; suggesting she must not have been dragged by the hair.

Police subsequently made an application for a domestic violence protection order for Peter’s protection, citing a belief he was at risk because Tricia was experiencing drug withdrawal symptoms, and took Tricia into police custody.

Tricia was released from police custody later that evening. She called her friend in distress stating suicidal intent and she died by suicide shortly afterwards.

Stacey

Stacey was a woman in her late 30s who was found deceased in a room at a women’s refuge where she had resided for a short time. This occurred in the middle of a separation from her former intimate partner of approximately four years, Angelo.

Evidence suggests that the relationship was characterised by a consistent pattern of physical and psychological abuse by Angelo which escalated significantly in the year prior to Stacey’s death and in the context of their separation.

Angelo’s behaviour triggered multiple episodes of contact with police and health services and included:

» making threats and intimidation, including making or threatening to make false allegations to police against Stacey about her use of violence against him as well as other criminal acts

» stalking and monitoring Stacey’s movements

» breaking into her home

» harassment via repeated phone calls and text messages

» escalating incidence and severity of physical violence including punching and stabbing Stacey.

There was a range of other stressors identified in the relationship which included the couple’s mutual problematic substance use; their lack of stable accommodation, employment and financial

resources; Stacey’s past history of abuse and trauma; and chronic health concerns.

Stacey had been in relatively frequent contact with a range of health services for treatment of several physical and mental health concerns.

This included attending hospital and emergency services with assault related injuries, as a result of Angelo’s abuse. While some attempts were made to refer Stacey to specialist services she was generally reluctant to engage and expressed fear of reprisal if she attempted to leave Angelo.

While Angelo had a criminal history that includes a number of non-violent, property and drug-related charges, there was no prior police contact in relation to domestic and family violence in any previous relationships (noting that this does not preclude the possibility of its occurrence).

Stacey would on occasion retaliate or use violence to protect herself against Angelo’s abuse, which resulted in cross-protection orders being established between the couple.

About a week before Stacey’s death, Angelo was due to attend court in relation to a breach of the protection order listing him as the respondent. He sent a number of threatening texts to Stacey demanding she attend to provide him with support.

She attended and later told police that Angelo was drinking heavily throughout the day with the matter being subsequently adjourned. Upon leaving, Angelo made several threats of physical violence to coerce Stacey to get in the car with him. Angelo drove off and immediately began to verbally abuse Stacey. He grabbed her by the hair and shoved her against the passenger door, making repeated threats of physical violence.

Shortly after, he crashed the vehicle and was conveyed to hospital by ambulance where he continued to send threatening text messages because Stacey had refused to accompany him to the hospital. He later discharged himself and went directly to Stacey’s house. Stacey had called police terrified he would break in and harm her and Angelo was taken into custody that evening. The following morning, Stacey sought refuge at the women’s shelter.

Stacey remained a resident there until her death by apparent suicide a few days later, during which time staff at the refuge engaged with Stacey and sought to link her with health and housing support services.

Melissa

Melissa was a young Aboriginal female, who took her own life in the context of a prolonged episode of family violence perpetrated by her then partner of approximately 18 months, Oscar.

Melissa had a history of contact with a range of agencies from a young age, including child safety services, health and justice services for a range of issues including family violence, child abuse and maltreatment concerns, suicidal ideation and behaviour, mental health and substance use issues, and criminal offending.

Despite these presentations, for the most part, there was limited ongoing support or intervention offered to Melissa. She was often unwilling to engage with relevant services, or disclose information, even when directed through formal avenues including the courts.

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Both Oscar and Melissa had a history of suicidal behaviours, and had contact with hospital and health services following self-harm and suicide attempts within the context of relationship conflict.

Oscar has a criminal history for offences dating back to his very early teens when he was issued a caution for indecent treatment of children under 16. He demonstrated further offending as a juvenile and an adult resulting in convictions predominantly for violence or property related offences.

From her mid-teens Melissa was subjected to abuse both from Oscar and other previous intimate partners. These relationships were characterised by sexual jealousy, verbal abuse, threatening behaviour and violent physical assaults with intoxication a common feature of most reports of violence.

Much of Oscar’s violence against Melissa was unreported although it was apparent he would often threaten Melissa with knives; punch and push her to the ground; and had a history of committing acts of non-lethal strangulation against her. He frequently accused her of infidelity and often threatened suicide or physical violence during arguments.

Although there is evidence Melissa used violence herself, records indicate the primary perpetrator of violence in the relationship was Oscar. Melissa reported acting in self-defence and records indicate she used violence against Oscar in retaliation or to stop him attempting suicide.

Police investigations into these occurrences identified Melissa as the respondent, with officers taking out a protection order to protect Oscar and also pursuing subsequent breaches of this order.

A week prior to the death, police made an application for a protection order listing Melissa as the aggrieved, after Oscar (respondent) committed a significant physical assault against her during an argument.

The couple were at a friend’s house when they started arguing. Melissa walked off down the road and Oscar pursued her, punching her in the right temple and pushing her to the ground. He then fell on top of her and non-lethally strangled her. Melissa fought back, scratching and punching Oscar, and was able to escape. Police responded and completed an application for a protection order listing Melissa as an aggrieved after completing a protective assessment which found that she was high risk of harm. Extra conditions on the order included that Oscar was not to attend or remain at the residence of the aggrieved with a blood alcohol concentration of more than 0.05% and to submit to breath tests by the Queensland Police Service (QPS) to verify compliance.

On the night of her death, Oscar and Melissa were drinking with friends and family members. The couple began fighting about Melissa’s previous relationships and she was overheard making threats of suicide before leaving the property.

Oscar left shortly after, armed with weapons to find Melissa.

Police subsequently received reports of a woman screaming in the street and a man standing in the middle of the road with an object in his hand. Oscar was intercepted by police, charged with breaching the conditions of the protection order and detained in custody.

Police were unable to locate Melissa that evening despite conducting an emergent search of the property. She was found deceased the following morning after taking her own life.

Travis

This case review involved the apparent suicide of an Aboriginal boy in his early teens.

At the time of the death, there was an existing domestic violence protection order naming the step-father as the respondent and the mother as the aggrieved. The deceased and his siblings were all named persons on this protection order.

The deceased child (and his siblings) had been exposed to domestic and family violence for most of their short life. These episodes of violence resulted in the involvement of the statutory child protection system through referrals from police upon attending these incidents.

The relationship between the child’s biological parents was characterised by both physical and non-physical abuse directed towards the mother. After this relationship broke down, the mother re-partnered in a relationship which was also characterised by significant acts of violence.

The child’s step-father from this new relationship frequently became physically and verbally abusive when intoxicated and perpetrated acts of violence against both the mother and children, including by:

» assaulting the mother (including while pregnant), punching her, committing acts of non-lethal strangulation, and verbally abusing her

» verbally abusing, threatening and physically assaulting the children

» damaging property and committing acts of intimidation.

Police responded to a number of occurrences relating to domestic and family violence perpetrated by the step-father; and while they applied for protection orders listing him as the respondent, police considered there was insufficient evidence to pursue contraventions of these orders on future occasions.

Travis was also exposed to family violence when his biological father commenced a new relationship with another woman. Although the couple had separated several years before the child’s death, this relationship was characterised by significant physical and verbal abuse.

For example, the children witnessed several episodes of violence including an episode where their father punched his new partner repeatedly before assaulting her with a weapon. This particular argument only stopped when the female victim armed herself and was able to call police for assistance.

There were multiple notifications to Child Safety Services with respect to suspected harm involving the deceased and his siblings. In their assessments of harm, the children seeking assistance from neighbours, or calling for help, was noted as a protective factor, specifically that the mother protects children by having them remove themselves from home and to contact police.

Records indicate the stepfather would on occasion prevent the children from calling for help, by taking the phone from them when they tried to call police.

Two notifications to Child Safety Services were recorded in a three month period. One was in relation to the aforementioned episode of domestic violence which the deceased and his siblings witnessed in his biological father’s household; and the

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other was in relation to reports of physical harm, emotional harm and exposure to domestic violence in the biological mother’s household.

In their assessment, some 16 months after one of the notifications had been made, child safety officers reported that the biological father had shown a pattern of domestic violence perpetration across the two relationships, and without any intervention, was at risk of continuing to perpetrate such acts when he re-partners. The children expressed to child safety officers during interview that they did not like going to their father’s home because of the violence they witnessed.

The outcome of this investigation was recorded as ‘Substantiated’, but the children were found to no longer be in need of protection in part because of the dissolution of this relationship. There is nothing to indicate that the father was referred to, or participated in any intervention programs as part of this closure, or at any other time.

Records indicate that a determination was made that while this risk was there, there was no other information to suggest the children were at an unacceptable risk of harm, and the Department held no other concerns about the level of care or protection the father was providing. In a departmental review into this death, it was identified that the father had not disclosed a prior offending history, and no collateral information checking was undertaken, to verify his (incorrect) self-reports.

There was also no indication in available files of communication or sharing of information between the child safety officers investigating this occurrence, and those in the other regional office who were investigating the notification of harm with respect to the maternal household.

The outcome of this latter assessment was recorded as unsubstantiated – children not in need of protection. While the children were assessed to be at moderate risk of future harm, the mother and step-father were both assessed to be willing and able to protect and meet the care needs of the children.

A number of referrals were made to the same Recognised Entity with respect to the family however, they did not choose to engage with this service over the longer term. While the notifications were primarily in relation to domestic and family violence, there is nothing to indicate the mother was referred to any specialist domestic and family violence services, and it appears limited exploration was undertaken into the appropriateness of prior referrals when she came back to their attention.

The deceased was also exhibiting behavioural issues in school in the year prior to his death, and there was a noted decline in his attendance, with records indicating he may have been experiencing bullying at school.

Shortly before his death the deceased was exposed to altercations involving multiple close family members regarding a dispute over visitation arrangements.

May

This case review involved the suicide of a teenage girl, May who was known to Child Safety Services, police, and the education and mental health system at the time of her death.

A range of stressors was noted in the lead up to the death which included: ongoing family conflict in the home; low self-

esteem and body image; gender identity issues; and conflicts with school peers.

May had exhibited self-harming behaviours and communicated suicidal ideation from a very young age.

Prior notifications to Child Safety Services had been made which cited a risk of harm because of domestic and family violence between the parents; potential exposure to risk of sexual assault by a family friend; neglect and poor living conditions; and concerns about poor parental mental health.

Records indicate there was ongoing domestic and family violence between the child’s parents that had escalated in the weeks before the death as the couple separated. It was also alleged that the father had physically and verbally assaulted the child and that this parent-child relationship was estranged.

Police responded to an episode of violence between the parents about three weeks before the child’s death in which it was alleged the children had witnessed escalating verbal and physical violence, including threats to kill, made by the mother. A protection order was established naming the father as the aggrieved and mother as the respondent. The parents had separated but were still living together at this time and custody was a core source of conflict.

About a week later, Child Safety Services received a notification that the child had communicated suicidal intent and was at risk of harm through exposure to parental domestic and family violence and because of abuse directed towards her. Collateral information from the school did not identify any noted behavioural changes but they did note that she was experiencing unrelated personal stressors.

A number of days later, the deceased communicated suicidal intent and attempted suicide. A friend alerted the school who arranged for the child to attend a public mental health facility for assessment. The child was assessed as a high risk of suicide but was discharged to the care of a family member later that day despite some evidence this relationship was also problematic.

Over the course of the following week, the child was engaged with public mental health services and attended appointments with both her parents, and by phone. Clinical records indicate she continued to acknowledge thoughts of suicide but denied any current intent or plan. She also said she had spent some time staying with a family member and only attended school sporadically, although this left a negative impact on her mental health.

Child safety officers, who had sought information from these mental health services, met with the child and both her parents on the day before her death to investigate the harm notification. The officers interviewed the child in the presence of her parents, with limited disclosures of any concerns or recent suicidal behaviours.

Fran

Fran, a mother in her late 30s, was killed by her de-facto partner of approximately 10 years, Scott. Both Fran and Scott identified as Aboriginal.

The relationship between Fran and Scott endured multiple periods of separation and reconciliation and was characterised by a pattern of coercive controlling violence, whereby Scott was

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jealous, threatening, and verbally and physically abusive. Scott also exhibited a similar pattern of violence in his other intimate partner and familial relationships, for which he served multiple periods of incarceration.

Throughout the course of his relationship with Fran, Scott was subject to multiple protection orders listing him as the respondent and Fran as the aggrieved. He demonstrated a recurrent failure to comply with authority by not adhering to the conditions of these orders and a poor response to community supervision.

After a two year protection order was issued in the early 2000s between the couple listing Fran as the aggrieved, Scott breached the order on five separate occasions within an eight month period. This resulted in a six month term of imprisonment after he repeatedly threatened and physically assaulted Fran. When police responded to the third breach, Fran was observed to have numerous injuries that were previously unreported, including a black eye, a stab wound to the leg and finger marks on her throat (indicative of a prior act of non-lethal strangulation).

Although Fran was occasionally identified as being uncooperative with emergency service providers, for the most part she generally disclosed the abuse being perpetrated against her and, at times, actively sought assistance from police to report the violence when presenting at stations for support.

Scott was also known to exhibit sexual jealousy as a precursor to acts of violence in his relationship with Fran, as well as other former intimate partners, in response to an actual or perceived threat of sexual infidelity. A couple of years prior to the death, Scott repeatedly assaulted Fran and held her hostage over a two day period, causing significant injuries because she had spoken to another man.

This episode of violence also represents the last known service system contact between the couple prior to her death, and on this occasion Fran was hospitalised with severe head injuries; discharging herself early and against medical advice.

Fran was also recorded as a respondent in this and other relationships.

Subsequent analysis of these occurrences identified these acts of violence by Fran were primarily within the context of self-defence, retaliation, or as a pre-emptive act to violence being perpetrated against her.

Alcohol abuse and intoxication; reported homelessness and itinerancy; prior sexual abuse; and mental health concerns were identified as presenting issues by emergency services responding to episodes of violence or assault related injuries involving Fran and/or Scott.

A few months prior to the couple reconciling, Scott was listed as a respondent on an application for a protection order, in which it was alleged he had brutally assaulted another intimate partner at a party including biting her face. She was hospitalised unconscious with severe injuries, and expressed significant fear of Scott believing that she would need to disappear to escape his abuse.

On the day of the death, the couple had been drinking with family members, before Scott picked up Fran and locked them both in the room which he alleged, was to stop her from drinking. He assaulted her over a number of hours, and Fran was heard calling out for help to family; one of whom had also previously been assaulted by Scott a number of years earlier.

While the family member checked on Fran and asked Scott to stop his violence, she only sought help from police via Policelink hours after the assault first commenced as she could no longer hear Fran.

By the time officers attended the premises, over an hour later, Fran was located naked and deceased.

Lucy

Lucy was an Aboriginal woman in her late 20s who had children from a previous relationship. She was stabbed to death by her de facto partner of approximately two years, David, who was also of Aboriginal descent.

Lucy’s life was characterised by entrenched disadvantage and included a history of mental illness; chronic substance misuse; involvement with child protection services, and prior suicide attempts, commonly occurring in the context of intoxication and relationship conflict.

She had a history of repetitive victimisation in her relationships and had recurrent contact with police and health services although she was generally reluctant to engage with them over the longer term.

Lucy was also known to be verbally and physically abusive in relationships. When appropriately contextualised, it is clear Lucy’s use of violence generally occurred in retaliation to the abuse she had, and/or was experiencing at the time. Despite her violent behaviour, she remained the primary victim of abuse on most occasions.

David had a history of criminal offending and violence against other intimate partners and family members. He consistently demonstrated poor compliance with protection orders as well as community based supervision and parole orders. During periods of incarceration and parole, he was mandated to complete anger management and substance abuse programs, although it appears these programs were not completed as they were not available at the time. David also had a history of mental illness and substance misuse.

Throughout their relationship, David perpetrated coercive, controlling violence against Lucy including severe physical assaults.

The reported episodes of violence that came to the attention of police generally involved severe levels of intoxication for both parties.

It is salient to note that less than a fortnight before Lucy’s death, the couple sought admission to a rehabilitation facility but were ultimately refused admission.

A few days later, Lucy and David had an argument where he committed an act of non-lethal strangulation. Fearing for her life, Lucy begged police officers to take out a protection order against David. He was conveyed to the watchhouse and served with a temporary protection order upon his conditional release that same day; both the order and release conditions prohibited him from coming into contact with Lucy.

Lucy subsequently presented at a public hospital emergency department and reported injuries, stating she had been assaulted by her partner and this had happened multiple times before. There was no indication of any psychosocial support or referral provided to Lucy by hospital staff on this occasion.

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The following day, David breached the release conditions by making contact with Lucy. David was subsequently taken into custody by officers again and charged with a breach. The following day, during another altercation, Lucy was taken to the watchhouse heavily intoxicated after she damaged David’s television. David asked police to take him to a shelter because he was fearful of reprisals after Lucy had been arrested.

Two days later, police responded to a public incident involving a large group who were noted to be intoxicated and arguing in the street. David said that Lucy had thrown a plastic bottle at him during the argument. She was not at the scene by the time police arrived. Due to David’s intoxication, police made a note to follow up with him about applying for a protection order on his behalf listing him as the aggrieved.

Police received multiple calls for service on the day before Lucy’s death when David initially contacted them to report that she was stalking and hitting him. Police were unable to find a current address for the couple, although later received another phone call reporting that David and Lucy were drinking and arguing at a residence.

Police attended the address and took up with David but Lucy had left by this time. Officers returned to other duties without serving the protection order on David listing him as the respondent and her as the aggrieved.

Lucy reportedly returned in the early hours of that morning and the couple resumed arguing. A witness contacted police about 45 minutes later to report that there was a disturbance at the address and sounds of someone being hit were audible to call-takers. Residents of the property overheard David threaten to kill Lucy and saw him lunge at her with a knife, before stabbing her to death.

Brian

Brian was a 40-year-old Aboriginal man who had been involved in a relationship with his de-facto partner, an Aboriginal woman named Wendy, (then aged in her early 30s) over a period of approximately six years.

Wendy fatally stabbed Brian during an argument while the pair were heavily intoxicated.

Wendy was with Brian and another man, Jerry, over a period of five to ten years, and had a child with each of them. Each of these relationships was characterised by domestic and family violence and recurrent periods of separation (some as a result of incarceration). Wendy’s relationship with Jerry was a constant source of conflict between her and Brian; and this, as well as alcohol intoxication, was recorded as a factor in almost all reported episodes of violence.

Police records indicate that Brian’s use of violence against Wendy included acts of non-lethal strangulation, kicking her (sometimes with steel capped boots), punching her in the face and stabbing her with scissors.

Brian was also abusive towards at least one other intimate partner as well as family members.

Prior to Brian’s death, there is no record or reports that Wendy was physically violent towards Brian except in self-defence or following an assault by him. Further records indicate that she was very petite, at one stage weighing less than 40 kilograms while he weighed well over 100 kilograms.

Brian’s criminal history included violent offences such as assault; grievous bodily harm; and indecently dealing with a child under the age of 12. He had several episodes of contact with Queensland Corrective Services, and generally demonstrated a failure to comply with authority (including resisting and assaulting police and breaches of orders) as well as property and alcohol related offending.

The risks associated with Brian’s drug and alcohol issues, use of violence, and aggression were routinely identified as significant. He completed a number of relevant short programs during his incarceration and community-based supervision to try and address these concerns.

Wendy also had an extensive criminal history largely comprising of charges for drunk and disorderly behaviour; breaches of bail, parole and fine option orders; public nuisance; and obstructing or assaulting police officers. Additionally, she was charged and convicted of eight counts of contravening protection orders in which she was the nominated respondent and her former partner, Jerry, was the aggrieved. All of these assaults occurred during periods of acute intoxication.

It is salient to note that on review of the available records, the level of violence perpetrated by Jerry against Wendy far exceeded any assault she committed and her use of violence was often retaliatory. She sustained multiple injuries as a result of his assaults, including severe swelling, lacerations, bites and other facial injuries, with there being limited evidence to indicate he was ever seriously injured.

Jerry had also been incarcerated in relation to assaults against Wendy throughout the course of their relationship.

Wendy completed programs while in custody or on parole in relation to substance misuse, family violence and anger management. Attempts to link her with longer term relapse and rehabilitation services were largely unsuccessful.

She had a small number of hospital admissions in relation to alcohol-related issues and assault-related injuries. These were generally limited to immediate medical treatment and there is little evidence of attempts to provide psychosocial support to her, despite clear evidence of family violence and a range of other stressors in her life.

In the lead up to the death, Brian had been living with his mother in accordance with the terms of a community based supervision order for about five months after he was released from prison for an assault on Wendy the year before.

A protection order was current requiring that Brian (respondent) be of good behaviour and not commit domestic violence against Wendy (aggrieved).

About a week before the death, Wendy was released on parole in relation to an earlier assault of Jerry from a breach of the protection order listing her as the respondent in this relationship.

Records indicate that corrective services staff were aware of the heightened risk associated with having both Brian and Wendy in the community and received several reports that Brian had been seen drinking, which was prohibited under his parole order conditions. Brian also failed to attend scheduled appointments and although parole officers considered initiating breach proceedings against him they had not yet done so.

On the day of the death, Wendy and Brian had been drinking with others in the morning. They had returned home sometime that

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afternoon, when an argument commenced between the couple about Jerry.

Wendy later admitted to police that she had approached Brian with a knife during an argument and stabbed him, causing his death.

Ella

Ella was a 20-year-old Aboriginal woman who was killed by her much older partner of approximately two years, Jayden, who also identified as Aboriginal, after a prolonged series of attacks.

On the night of her death, the couple had attended a party and witnesses observed several arguments in which sexual jealousy was a recurrent issue. Several attempts were made by bystanders to intervene throughout the course of the evening nevertheless, Ella ultimately sustained extensive head trauma, bite marks and other assault related injuries. Passing paramedics were hailed by a witness and despite Jayden’s attempts to divert them they were able to convey Ella to a hospital.

She was pronounced deceased the next day.

The couple shared a seven-month-old son, and lived in a remote camp site. While this was Ella’s only child, the available records indicate that Jayden had multiple children to other women.

Jayden had extensive contact with the criminal justice system not only as a result of his perpetration of domestic violence against intimate partners, but also as a result of his propensity to commit acts of violence against others. His childhood was marred by abuse, violence and neglect while in the care of his mother and several of her de-facto partners.

He was implicated in attempting to burn down the local school at age five, began hearing voices at the age of six, and was hospitalised at the age of eight after being stabbed in the head by his uncle for refusing to go to the shops with him. In retaliation for this event, Jayden stabbed his uncle’s dog to death. Jayden began consuming alcohol, using marijuana and engaging in volatile substance misuse in his very early teens, which appeared to exacerbate his predisposition for violence perpetration.

Jayden was fostered out to multiple different families across Queensland and interstate over the course of his childhood.

The constant upheaval in his life and the effects of cumulative harm associated with ongoing exposure to severe family violence was recognised as, in part, the causation of his anger and resentment towards his mother. These feelings of anger and resentment towards his mother appear to extend to other relationships he had with women, including both intimate partners and family relatives, to whom he directed extreme physical abuse.

Jayden was known to spit on victims, bite, and use weapons such as sticks and rocks during episodes of violence, which occurred within the context of extreme alcohol intoxication.

At the time of Ella’s death, Jayden had only been released from prison on parole for approximately seven months for convictions pertaining to breaching a protection order involving his former intimate partner, Cheryl. Prior to this, Jayden was convicted of charges of torture and assault occasioning bodily harm, among other offences, after he dragged another former partner over a fire and assaulted her while pregnant.

Over the course of his lifetime, Jayden was subject to community based orders, psychiatric evaluations, corrective services intervention programs, alcohol and other drug programs, and specialist men’s support programs.

He was clinically diagnosed as a psychopath at the age of 27.

System contact with respect to domestic and family violence involving Ella and Jayden was minimal, with only one incident of verbal abuse having been reported to police by a third party in the year prior to the death. On this occasion, Ella denied being fearful of Jayden to police despite concerns expressed by family members.

Subsequent to their investigations, police ended up taking a protection order out listing a close family member of Ella’s as the aggrieved and Jayden as the respondent.

While there is a paucity of information available regarding the contextual background of the relationship between Ella and Jayden due to this lack of service system contact proximate to the death, Ella’s family suspected that Jayden was physically abusive towards Ella after having observed her to have what looked to be assault related injuries on four or five occasions preceding her death. Ella was never forthcoming in disclosing the relationship history or the circumstances within which the injuries were sustained, and the records depict a reluctance on the part of Ella to allow intervention by informal support networks such as family or friends.

Lauren

Lauren, an Aboriginal woman, was killed by her long-time partner Eddie, also of Aboriginal descent. Domestic and family violence was a feature of this relationship throughout their time together.

Lauren was located deceased outside a local business. Witness reports indicate that Lauren was last seen alive two days before she was located and pathology reports indicate she had been deceased for some time before being located.

In his statement to police after the death, Eddie disclosed that during an argument, he had stomped on Lauren multiple times in her chest. He then went to sleep beside her and awoke to find her dead the following morning. Eddie was observed by others to have blood on his hands that day, and was stating that he had done something bad.

Eddie was previously known to have used knives, rocks, iron bars, tree branches and other weapons to assault Lauren.

A domestic violence protection order was first issued in 2004, after Eddie hit Lauren over the head and to the leg with an iron bar. Eddie repeatedly breached the conditions of this protection order and was sentenced to six months imprisonment the following year. Police made two more applications for protection orders in the intervening years to protect Lauren.

A total of 11 contraventions of protection orders were recorded, with Eddie imprisoned on multiple occasions as a result of these and other offences.

The most recent breach occurred just three days after Eddie had been released from prison when he chased Lauren and threatened to kill her. He was returned to custody and released to board-ordered parole, just 12 days before Lauren’s body was discovered. Eddie failed to report to his approved

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accommodation as scheduled, and upon release did not make contact with Queensland Corrective Services, or other support services.

Alcohol abuse was a common feature in the relationship between Lauren and Eddie, and was also recorded as being associated with multiple episodes of domestic and family violence between the couple. At times, Lauren disclosed that she was unable to remember these occurrences due to her high levels of intoxication.

Just a fortnight before she died, Lauren expressed a desire to enter an alcohol rehabilitation program. It appears that with Eddie’s release from prison she returned to drinking and was not able to be contacted for planned home visits.

While substance use was identified as a criminogenic and mental health need, Eddie showed no inclination to address his alcohol consumption while under the supervision of Corrective Services and prison mental health services.

Lauren also had physical health concerns and would regularly have seizures, in the context of excessive alcohol intoxication and non-compliance with her epilepsy medication. She was chronically homeless, and was known to lead an itinerant lifestyle. This inhibited services who were trying to provide support for Lauren for her multiple and complex needs.

Lauren was referred to a diversionary centre for intoxicated people at risk to themselves or the public some 97 times in the two years preceding her death, including 17 contacts in the previous two months.

A wide range of services had contact with the deceased and perpetrator in this case, engagement with many of these providers was sporadic and superficial on most occasions.

Alice

This case review involved the filicide of Alice, a one-month-old female infant who was found in her cot by her father, John.

Alice died as a result of being subjected to abuse at the hands of her father from the first week of her short life; having sustained nearly fifty separate injuries in the weeks preceding her death. No medical treatment was ever sought for these assault related injuries.

Alice’s parents, John and Kristy, had been in a de-facto relationship for approximately one year prior to the death. The familial environment was characterised by paternal substance misuse; paternal mental health concerns; child abuse and maltreatment; and, ongoing domestic and family violence (including intimate partner and associated acts of domestic violence towards an older family member of Kristy’s who was also residing at the premises).

John was a chronic substance user who reportedly injected amphetamines and consumed cannabis on a daily basis.

He had a history of perpetrating violence against intimate partners, including Kristy, and had also been implicated in the serious abuse of multiple children in a number of other relationships, including a near fatal assault on another infant interstate, two years prior to this death.

Episodes of domestic violence commenced when Kristy was pregnant with Alice and included acts of verbal abuse,

physical violence, property damage, financial abuse, and isolating behaviours.

John self-attributed his use of violence to his substance dependency issues and he was known to be highly controlling in his intimate partner relationships.

John had a propensity to act violently and abusively towards Alice when using substances. Statements taken after the death indicate that Kristy would attempt to keep Alice calm so that John would not flip out. At times when Alice continued to cry, John was known to direct abuse towards the victim child, including slapping her across the face and screaming obscenities towards her.

On one occasion, approximately two weeks prior to the death, Kristy returned home after Alice was left in the sole care of John to find that she had significant pronounced swelling to her head. John explained that Alice had rolled off the bed by herself and struck her head on the leg of the bassinette however, witnesses confirmed that the child was unable to roll at this early stage of infancy.

After suffering injuries suspected to be as a result of John’s actions, Alice’s access to potentially life-saving medical care was restricted by John’s refusal to allow Kristy, or others, to seek medical attention for Alice.

Kristy later disclosed that John had held her by the throat (an act of non-lethal strangulation), prohibiting her from taking Alice to the hospital after she had suffered one of many accidents that would eventually lead to her death. She further reported that John threatened that if she went to the authorities, her children would be removed from her custody.

While the records indicate the family were previously engaged with a multitude of services in relation to concerns pertaining to the presence of substance abuse, mental health and domestic violence within the familial setting, there was an absence of any identifiable service contact in the four weeks between Alice’s birth and subsequent death.

Although it is apparent that informal support networks, such as family members including Kristy’s mother, were aware of Alice’s experiences of child abuse and maltreatment while in the care of her parents, these concerns did not come to the attention of statutory authorities, thereby limiting the capacity for services to intervene prior to the death. Records indicate that John also perpetrated abuse against Alice’s older siblings, including suspected sexual abuse, with some indication that Alice may have been sexually assaulted due to the nature of her injuries.

Ben

Ben, was an almost three-month-old Aboriginal male infant who sustained significant injuries from multiple traumatic assaults, including episodes of shaking, suspected to be as a result of the actions of his father, Xavier, aged in his late 20s.

Ben was born to Kerry and her partner, Xavier, who believed he was the biological father of Ben up until the death, which may not have been the case. After giving birth to Ben five weeks prematurely, Kerry discharged herself from hospital that same day and left her son in the care of the staff at the special needs neonatal ward.

When neither Kerry, nor Xavier, showed a willingness to return to the hospital three days later at the request of clinical staff, child

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protection concerns were reported to child safety services in relation to the parents’ apparent lack of attachment and concerns about their ability to safely care for, and respond to, the needs of the newborn child.

An investigation and assessment by child safety services commenced. It was ultimately determined that no ongoing departmental intervention was necessary and the victim child was safe to be discharged into the care of his parents. A referral was made to a Family Support Service, as the parents had expressed a desire for assistance to relocate to another regional location to get away from familial conflict. Contact with this service was infrequent and focused on identifying accommodation options and transporting the couple to appointments.

While there is some indication that Kerry attended antenatal appointments this was sporadic. She had also presented pregnant and heavily intoxicated to the hospital emergency department in the early stages of her pregnancy.

Both parents had a history of problematic substance use and prior criminal offending with a background of vulnerabilities including experiences of intergenerational child protection concerns, homelessness, and unemployment.

Xavier had a history of suicidality resulting in several prior suicide attempts and self-harming behaviours. Kerry suffered from diagnosed anxiety and foetal alcohol syndrome which impaired her levels of functioning and communication. Her older daughter resided in a kinship arrangement and there had been previous concerns raised regarding Kerry’s capacity to care for that child.

Because of these multiple and complex issues, the history of service system contact with this family is extensive and spans over several decades, both as subject children, and as young parents.

While heavily intoxicated Xavier and Kerry attempted to remove four-week-old Ben from the home of a family member who had raised concerns about their capacity to care for the infant. Upon refusing to hand Ben over, the family member was assaulted and threatened by Kerry’s extended family and her property was damaged. The occurrence was recorded by police as burglary with violence or threats. No protective action was taken with respect to concerns for Ben’s welfare raised with police, and the couple were permitted to leave the residence with him in their care.

While police requested that the family member re-present at the station at a later date to make a statement, this did not occur with records indicating police did attempt unsuccessfully to contact her at a later date.

Xavier was subject to community supervision pursuant to the conditions of a parole order at the time of the death and, while under supervision, had supplied multiple positive urine samples to cannabis (the most recent of which was one month prior to Ben’s birth). As a degree of discretion is afforded to Probation and Parole officers when taking action around minor drug infractions, Xavier was issued a warning and was not returned to custody.

Both corrective services staff and police subsequently became aware that Xavier had insecure accommodation, and had intentions to relocate the family to another regional town to reside in an Indigenous hostel.

Xavier was also known to be highly controlling and violent towards Kerry during their two year relationship, which was characterised by sexual jealousy, physical violence and verbal abuse.

The records indicate that Xavier actively attempted to isolate Kerry from her protective support networks and would threaten to go to child safety services to have Kerry’s other daughter removed from the kin arrangement in place at the time.

During one episode of violence, Kerry reported that Xavier began growling at her because she was talking to another male at a gathering. He followed her upstairs and punched her in the face, resulting in a black eye which required her to conceal the injury with sunglasses.

After the death, Kerry disclosed that she was afraid of Xavier, afraid of his reactions and afraid that she would be further ‘bashed’ by him ‘if she did something’. Kerry subsequently did not report the assaults and, if she was questioned about injuries inflicted on her by Xavier, she would deny his involvement.

There is no recorded service contact in relation to the abuse perpetrated by Xavier against Kerry prior to the death however, the records indicate Kerry presented to the Emergency Department on four occasions for assault related injuries previously. It is unclear if these were related to domestic and family violence. It is not clear from the timeframes whether these were within her current or former relationships, but there is limited evidence of any psychosocial support around these injuries being afforded to her.

Cameron

Cameron was almost three months old when he died from severe head and spinal injuries after being in the care of his father, Dennis.

Dennis had only just become involved in Cameron’s life approximately a month prior, with his drug taking and violent behaviour towards Cameron and his mother, Heather, escalating shortly after this reconciliation.

Leading up to the death, Dennis was reported to be injecting morphine multiple times per day and regularly smoked cannabis. Witnesses reported that Dennis’s drug habit and behaviour while intoxicated was escalating during the two weeks prior to Cameron’s death, and his moods became increasingly more irritable and unstable, particularly when he was withdrawing from morphine.

Dennis was described as abusive, both physically and verbally, towards the victim child, with accounts that he repeatedly punched the infant in the forehead and stomach ‘to toughen him up’. It was also reported that Dennis had been observed to head-butt Cameron on one occasion causing him to scream in pain.

Two days prior to his death, Dennis took Cameron to the park and when Heather attended the park to check on Cameron’s wellbeing approximately one hour later, she observed two large bruises on the victim child’s forehead and noted he appeared to look different and ‘out of it’. Heather reported that she wanted to take Cameron to the doctor for medical attention but Dennis convinced her not to. Cameron’s health deteriorated rapidly over the subsequent two days.

Although there are no service records of domestic violence between Dennis and Heather, the investigation into the death of Cameron revealed that Dennis was abusive towards Heather in the weeks before the death when she would confront him about the rough treatment, physical abuse and violent outbursts of swearing directed at Cameron.

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Dennis’s history of violence against intimate partners and other persons is apparent within the records. Dennis came to the attention of the police for (non-lethally) strangling his former partner, with whom he had other children (and an unborn baby).

This episode of domestic violence, in particular, is worthy of noting considering the proximity of this episode to the fatal assault on Cameron (within three months). Despite noting their intention to initiate a protection order when this occurrence was reported to them, police did not do so and no further contact occurred until 10 months after Cameron died when police were called out after Dennis attempted to burn the house down.

On this occasion, a protection order was sought, and granted.

Child safety services had conducted an investigation and assessment after Heather was hospitalised when she was pregnant and had attempted to harm her unborn child during a psychotic episode.

At the time, Heather disclosed she had been diagnosed with substance-induced paranoid schizophrenia and bipolar affective disorder. She was placed on an antipsychotic medication regime which had ceased during the early stages of pregnancy. This had precipitated the relapse incident. She further disclosed a history of drug use, but reportedly stopped upon the conception of Cameron, and was noted as engaging well with services.

Both parents had a history of intergenerational child protection concerns as subject children and had reported being physically abused in their respective familial networks throughout their upbringing.

Dominique

Two-month-old female infant Dominique, died from multiple severe injuries inflicted by her father, Ian, approximately one week prior to her death. Despite efforts from her mother, Amy, to seek medical attention, Dominique’s access to potentially life-saving medical care was prevented by Ian’s repeated refusal to allow others to intervene in the lead up to her death.

While there was no recorded history of domestic and family violence prior to the death in this relationship, it became apparent during police investigations that Ian had socially isolated Amy and exerted significant power and control over her. In her statement to

police, Amy disclosed that Ian was physically violent towards her, including striking her in the head with his fist or other implements, and hitting her head against walls when angry or upset.

He was also noted as being emotionally manipulative, and had socially isolated her from her family, increasing her dependency on him. Ian further isolated Amy by restricting her communication with others by limiting her access to the computer and internet.

As Amy suffered from physical disabilities, and mental health problems, Ian would exploit this vulnerability, threatening that she would lose custody of the children if she were to leave him, or if she contacted support services, due to her disability.

In response to Ian’s abusive behaviour, Amy stated that she would ‘walk on egg-shells’ and would often take Dominique away from the house all day to ensure that Ian was not disturbed for fear of what he might do to her. During police investigations, both Amy and Ian disclosed several incidents that occurred in the week preceding the death which caused injury to Dominique although medical treatment was not sought. This included separate incidents of her ‘falling’ from Ian’s arms, and sustaining bruising and a puncture to the sole of her foot by unknown means.

On another occasion, Amy describes hearing Dominique cry and, upon investigation, Amy reported observing Ian hit Dominique hard on her back several times, causing the baby to scream inconsolably for over an hour despite efforts from Amy to calm her. Amy disclosed that she had wanted to take Dominique to the hospital as she believed Dominique was so badly injured she might die.

Ian refused repeated requests from Amy to take the victim child for medical attention.

Ian again refused to allow Amy to call emergency services, or anyone else, for assistance upon finding Dominique unresponsive, as he needed time to dispose of illicit substances he had in his possession.

He eventually allowed her to contact a family member to take the infant to a hospital, telling Amy what to say to the staff as a cover story, but by this time she had no pulse and was not breathing. Resuscitation attempts by the hospital were unsuccessful.

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Chapter 3: Enhancing our knowledge

15 Collateral homicides’ include a person who may have been killed intervening in a domestic dispute or a new partner who is killed by their current partner’s former abusive spouse.

In carrying out its statutory function, the Board is required to analyse data and apply research to identify patterns, trends and risk factors relating to domestic and family violence deaths in Queensland.

This chapter provides a statistical overview of homicides within an intimate partner or family relationship that occurred in Queensland since 2006, and reports on a range of demographic characteristics, as well as the history of domestic and family violence and service system contact prior to these deaths.

It also provides preliminary analysis of a range of ‘lethality’ risk indicators identified through the review of a subset of intimate partner homicides, to inform research and understanding in this area.

A preliminary exploration of apparent suicides in the context of domestic and family violence from 2015 is also featured in this chapter.

Notably, as some of the data on these types of deaths pre-dates the establishment of the domestic and family violence death

review process in Queensland in 2011, the calibre of the data is likely to result in some under-reporting.

The data also includes open and closed coronial cases, and as such it may be subject to change pending any further investigation.

It is further recognised within this report that, similar to the case of Dominique outlined above, there may be instances in which a history of domestic and family violence prior to the death went undetected and/or unreported and therefore the history of domestic and family violence may be underreported within these statistics.

As at 30 June 2017, a total of 263 women, men and children had been killed by a family member or by someone who they were, or had been, in an intimate partner relationship, over the previous 11 years.

A further 19 collateral homicides15 have also occurred in this period.

Death Review and Advisory Board | Annual Report 2016–17 35

Figure 1 depicts homicides by relationship type across financial years from 2006–07 to 2016–17. In this period, there have been 140 intimate partner homicides and 110 family homicides.16 Due to the statistically low numbers of incidents, small changes in the numbers of deaths can result in apparent fluctuations therefore, caution must be taken when trying to identify trends.

Figure 1: Domestic and family homicides, Queensland, 2006-07 to 2016-17

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Of the 263 homicides in this period, a history of domestic and family violence has been established in 165 cases (61.6%).

A history of violence was identified in greater proportions of intimate partner homicides (70.7%) and collateral homicides (77.8%), in comparison to family homicides (47.3%).

Figure 2: Homicides with a history of domestic and family violence, Queensland, 2006-07 to 2016-17

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Females were significantly over-represented as victims in intimate partner homicides, with 81.8% of victims being female (Figure 3). In contrast, there was little variation by gender with respect to family homicide victims.

Collateral homicide victims were almost exclusively male, as most of these deaths involve the former partner of a female victim murdering her new partner.

Figure 3: Domestic and family homicides by relationship type and gender, 2006 – June 2017

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Among intimate partner homicides, where a history of domestic and family violence was able to be established, the vast majority (97.6%) of female deceased were identified as the primary victim of violence.17 In contrast, in cases where the deceased was male, the deceased was identified as the perpetrator in the majority of cases (89.5%) where there was a known history of violence.18

The ages of homicide victims ranged from less than one day to 92 years. Figure 4 shows the majority of intimate partner homicides involved victims aged 25 to 34 years and 35 to 44 years. Children aged less than five years represented the highest number of deaths in family relationships.

Figure 4: Domestic and family deaths by relationship type and age group, 2006 to June 2017

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17 This included two cases where the female was identified as a victim and perpetrator. 18 This included eight cases where the male was identified as a victim and perpetrator.

Death Review and Advisory Board | Annual Report 2016–17 37

More than half (54.2%) of the victims of family homicides were children aged under 18 years (Figure 5).

Figure 5: Family homicides by age group, 2006 to June 2017

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Aboriginal and Torres Strait Islander people were over-represented among domestic and family homicide victims. Almost one-fifth (18.1%) of homicide victims identified as Aboriginal or Torres Strait Islander, compared with approximately 3.6% of the Queensland population.

As shown in Figure 6, while the absolute numbers of deaths among non-Indigenous people were generally higher, in some financial years the number of deaths of Aboriginal and Torres Strait Islander people approached those of the much larger non-Indigenous population.

Figure 6: Aboriginal and Torres Strait Islander status of domestic and family homicide victims, 2006 to June 2017

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35 to 44 years

45 to 54 years

55 to 64 years

Over 65 years

Intimate Partner Family Collateral

0

5

10

15

20

25

2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Aboriginal and Torres Strait Islander Non-Indigenous

55 65

0

10

20

30

40

50

60

70

Adult Child

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Domestic and Family Violence Death Review and Advisory Board

Figure 7 shows the breakdown of domestic and family homicide death type by Aboriginal and Torres Strait Islander status.

Aboriginal and Torres Strait Islander persons represented 17.5% of intimate partner homicides, 19.2% of family homicides, and 15.8% of collateral homicides.

Figure 7: Domestic and family homicides by relationship and Aboriginal and Torres Strait Islander status, 2006 to June 2017

25 23

3

118

97

16

0

20

40

60

80

100

120

140

In.mate partner Family Collateral

Aboriginal and Torres Strait Islander Non-Indigenous

Domestic and family violence homicides occur across Queensland.

Between 2006 and June 2017, homicides in an intimate partner or family relationship were recorded in each police district throughout Queensland (Table 1).

Table 1: Domestic and family homicides, by Queensland police district, 2006 to June 2017

Intimate Partner Family Collateral Total

Brisbane region 23 19 7 49

North Brisbane 10 10 1 21

South Brisbane 13 9 6 28

South Eastern region 26 20 3 49

Logan 3 9 0 12

Gold Coast 23 11 3 37

Southern region 30 24 5 59

Ipswich 10 6 0 16

Darling Downs 9 7 2 18

South West 3 4 0 7

Moreton 8 7 3 18

Central region 29 20 3 52

Sunshine Coast 6 4 1 11

Wide Bay Burnett 7 6 2 15

Death Review and Advisory Board | Annual Report 2016–17 39

Table 1 continued Intimate Partner Family Collateral Total

Capricornia 9 8 0 17

Mackay 7 2 0 9

Northern region 35 37 1 73

Townsville 13 14 1 28

Mount Isa 1 4 0 5

Far North Queensland 21 19 0 40

Queensland 143 120 19 282

Aboriginal and Torres Strait Islander people were represented among the homicide statistics in all regions of Queensland between 2006 and June 2017.

Due to the statistically low numbers in most regions, a breakdown of these numbers is not reported here for each location. However, due to the elevated numbers and proportions of homicides in the Northern region, this data is presented in Table 2 below. Almost one-half (47.9%) of people who died by homicide in the Northern region identified as Aboriginal and Torres Strait Islander.

This far exceeded the percentage of the population that identify as Aboriginal and Torres Strait Islander more broadly.19

Table 2: Aboriginal and Torres Strait Islander homicides in the Northern region, 2006 to June 2017

Indigenous homicides Percentage Percentage of population

Northern region 35 47.9% 12.1%

Townsville 7 25.0% 15.2%

Mount Isa 1 20.0% 23.0%

Far North Queensland 27 67.5% 7.1%

Queensland 51 18.1% 3.6%

Stab wounds were the most prevalent cause of death from intimate partner homicides and collateral homicides, and second most prevalent for family homicides.

Fatal assaults were the most common cause of death in family homicides and the second leading cause of death among intimate partner and collateral homicides.

Of note, strangulation, asphyxiation and suffocation was the cause of death for twelve intimate partner homicides, and six family homicides during this period.

19 Population figures sourced from Queensland Police Service Northern Police Region Resident Profile (August 2016). Population estimates are attributed to ABS, Census of Population and Housing, 2011, Indigenous Profile – IO2 (usual residence) and Queensland Treasury concordance-based estimated. https://www.police.qld.gov.au/rti/published/about/orgStrct/Documents/Northern%20 Police%20Region%20Profile%20-%20CC.pdf

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Domestic and Family Violence Death Review and Advisory Board

A significant proportion of intimate partner homicides occurred in the context of relationship separation. Over one-quarter (27.3%) of homicides occurred after a couple had separated, with this number increasing (31.7%) where there was an identifiable history of domestic and family violence in the relationship (Table 3).

Of note, even where there is no prior recorded history of violence, separation was a characteristic in over one-quarter (28.6%) of intimate partner homicides.

Among intimate partner homicides, where there was a history of domestic and family violence, children had been exposed to this violence in 30.7% of cases; at times this included being witness to, or present during, the actual fatality.

Table 3: Prevalence of separation among intimate partner homicides, 2006 to June 2017

All intimate partner homicides History of DFV* No recorded history of DFV*

Number Percentage Number Percentage Number Percentage

Actual separation 39 27.3% 32 31.7% 7 16.7%

Intent to separate 21 14.7% 16 15.8% 5 11.9%

No separation 73 51.0% 47 46.5% 26 61.9%

Unknown 10 7.0% 6 5.9% 4 9.5%

Total 143 100.0% 101 100.0% 42 100.0% *Domestic and family violence

Physical violence was the most commonly reported form of violence in intimate partner relationships with a known history of violence (Figure 8).

Psychological or emotional abuse was recognised in over one-half (55.1%) of such cases. However, these should not be seen to be in isolation of each other, as multiple types of abuse are characteristic of domestic and family violence relationships.

It is also important to note that as this data is predominantly sourced from agencies’ records, or statements, it is unlikely to encompass the

full spectrum of abusive behaviours the victim may have experienced.

Figure 8: Forms of domestic violence, intimate partner homicide cases, 2006 to June 2017

25.0%

9.6%

17.3%

9.6%

11.5%

21.2%

19.2%

13.5% 15.4%

19.2%

17.3%

5.8%

21.2%

9.6%

7.7%

11.5%

Hospital (incl. ED)

Mental Health

Relationship service

Psychologist, counsellor

GP

Specialist DV services

Child safety services

Other services

Legal services (e.g. Family Court)

Perpetrator Victim

84.1%

55.1%

4.3%

5.8%

18.8%

1.4%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Physical

Psychological

Economic

Sexual

Verbal

Pet abuse

28.8%

7.7%

9.6%

9.6% 51.9% 51.9%

Corrective Services

Magistrates Court issued DVO

Police 86.5%

73.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Where information from existing records was available, it was identified that the abuse escalated prior to the death in over one-half (52.0%) of intimate partner homicides. Stalking was identified in one-fifth (19.8%) of cases. The perpetrator was reported to be obsessive or jealous (56.0%) and controlling (57.6%) in over half of all the intimate partner homicide cases.

A domestic violence protection order was in place at the time of death in 41.6% of intimate partner homicides where a history of domestic and family violence was established. The deceased was recorded as the aggrieved on three-quarters (78.6%) of these orders, with cross

Death Review and Advisory Board | Annual Report 2016–17 41

orders in place in 11.9% of cases. The deceased was recorded as the respondent only on protection orders in 9.5% of intimate partner homicides.

Approximately one-quarter of intimate partner (23.1%) and family (28.3%) homicide offenders had symptoms or a diagnosis of mental illness. This was in comparison to lower reported rates among the deceased (12.6% and 8.3% respectively). Similarly, a history of substance abuse was more common among homicide offenders (26.2%) than deceased (18.1%).

Service system contact

Records were reviewed to establish service system contact20 between the parties involved in the homicide cases. To optimise the reliability and completeness of service system contact records, this was restricted to cases between 2011 and 2015. During this period there were a total of 124 domestic and family violence homicides, including 78 cases where there was a known history of domestic and family violence.

A reported history of service system contact was recorded in two-thirds (66.7%) of cases.

As shown in Figure 9, the most prevalent service contact identified was police, particularly for perpetrators. Contact with Magistrates Court (in relation to domestic violence protection orders) was also common for both victims and perpetrators. Victims were more likely to have contact with specialist services, child safety services and hospitals, whereas perpetrators had more identifiable contact with corrective services and mental health services.

Figure 9: Service system contact, domestic and family violence homicides, victims and perpetrators, 2011 to 2015

25.0%

9.6%

17.3%

9.6%

11.5%

21.2%

19.2%

13.5% 15.4%

19.2%

17.3%

5.8%

21.2%

9.6%

7.7%

11.5%

Hospital (incl. ED)

Mental Health

Relationship service

Psychologist, counsellor

GP

Specialist DV services

Child safety services

Other services

Legal services (e.g. Family Court)

Perpetrator Victim

84.1%

55.1%

4.3%

5.8%

18.8%

1.4%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Physical

Psychological

Economic

Sexual

Verbal

Pet abuse

28.8%

7.7%

9.6%

9.6% 51.9% 51.9%

Corrective Services

Magistrates Court issued DVO

Police 86.5%

73.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

With respect to intimate partner homicides cases, there was a total of 50 cases recorded between 2011 and 2015 where there was an established history of domestic and family violence. A reported history of service system contact was recorded for the victims in 43 cases (86.0%) and perpetrators in 38 cases (76.0%).21

As shown in Figure 10, the most prevalent service contacted for both victims (79.1%) and perpetrators (86.8%) was with the police. In over one-half of cases, the victim and perpetrator had been issued a civil domestic violence protection order through a Magistrates Court in Queensland.

Victims were more likely to be in contact with specialist domestic violence services and hospitals although it is not established if this was specifically for injuries sustained as a result of domestic and family violence. In contrast, perpetrators had higher rates of contact with corrective services and mental health services.

20 Service system contact is defined as contact with relevant service systems within the current or former relationships but may not relate specifically to presentations for domestic and family violence related issues.

21 This section defines the following roles: victims as the primary victim of domestic and family violence and person most in need of protection; perpetrators to describe the person identified as the primary abuser, and person most likely to inflict harm; the deceased is the person who died; and, offender is the person that caused the death.

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Domestic and Family Violence Death Review and Advisory Board

Figure 10: Service system contact, intimate partner homicides, victims and perpetrators, 2011 to 2015

27.9%

11.6%

20.9%

11.6%

14.0%

26.3%

23.7%

15.8% 18.6%

21.1%

18.4%

7.9%

10.5%

7.9%

10.5%

Mental Health

Corrective Services

Magistrates Court issued DVO

Police

Hospital (incl. ED)

GP

Psychologist, counsellor

Specialist DV services

Child safety services

Relationship service

Other services

Legal services (e.g. Family Court)

Perpetrator Victim

18.4% 18.6%

9.3%

11.6%

11.6% 57.9%

53.5%

86.8% 79.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Service system contact data for homicides in a family relationship are less well established. Improvements in data collection will remain a priority for the Board in 2017-18 to enhance reporting in this area.

Irrespective of these limitations, the patterns of service system contact demonstrate the ongoing need for service integration and robust information sharing across sectors, given the multiple generalist services that both victims and perpetrators are presenting to.

Death Review and Advisory Board | Annual Report 2016–17 43

Apparent suicides

As outlined within s.91B of the Act, a domestic and family violence death also includes a suicide or suspected suicide if the person was or had been in a relevant relationship with another person that involved domestic and family violence.

In practice, this includes perpetrator suicides, suicides of victims of domestic and family violence, and child suicides where there has been a previous history of domestic and family violence between parents or primary caregivers.

It is important to note at the outset that establishing a causal or proximate link between the deceased’s experience of domestic and family violence and their suicide is not always possible, and the relationship between the two is highly complex.

Consideration must therefore be given to the circumstances leading up to the death, whether there was a recent episode of domestic and family violence with reasonable proximity to the death, or there were other more salient stressors leading up to the death.22

Data is presented for the period 1 July 2015 to 30 June 2017 but should not be considered as representative of all deaths that may have occurred within this reporting period, potentially associated with domestic and family violence.

Data from the 2015-16 period consists of cases referred to the Unit for review, prior to the establishment of a revised surveillance and monitoring system for these types of deaths in early 2016.

As such, data from 2015-16 only represents a subsection of all domestic and family violence related suicides in Queensland where there was an identified nexus between the death and domestic and family violence. Data from 2016-17 is likely to be a more accurate reflection of the prevalence of these types of deaths in Queensland.

Processes supporting this monitoring function have improved over time, which is reflected in an increase in the number of recorded deaths during this period. This should not be interpreted as a definitive increase in the number of domestic and family violence related suicides but rather a change in methodology in surveillance processes. Ongoing enhancement of data in relation to domestic and family violence suicides will be a focus in 2017-18 and beyond.

From 1 July 2015 to 30 June 2017, a total of 66 apparent suicides were recorded where a clear history of domestic and family violence was established. This included 25 recorded deaths in 2015-16 and 41 recorded deaths in 2016-17.

The vast majority of these apparent suicide deaths involved males as the deceased (93.9%). This is reflective of the over-representation of males as victims of suicide in the general population, although the gender ratio is higher than is usually seen.23

The vast majority of apparent suicides also involved the deceased as the perpetrator of domestic and family violence in the relationship. (Figure 11)

Figure 11: Domestic and family violence role of apparent suicide victims, 2015-16 to 2016-17

4.5% 7.6%

3.0%

Victim

84.8%

Perpetrator & victim Perpetrator Child victim

4.5%

16.7%

22.7%

27.3%

21.2%

4.5% 3.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

12 - 17 years 18 - 24 years 25 - 34 years 35 - 44 years 45 - 54 years 55 - 64 years 65 years +

22 The case categorisation and review process for domestic and family violence suicides is available in the Board’s Procedural Guidelines that are available here: http://www.courts.qld.gov.au/__data/assets/pdf_file/0007/489175/ccq-dfv-board-procedural-guidelines.pdf

23 Potts, B., Kolves, K., O’Gorman, J., & De Leo, D. (2016). Suicide in Queensland: Mortality rates and related data 2011-2013. Brisbane: Griffith University.

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Figure 12. Age distribution of apparent suicides, Queensland, 2015-16 to 2016-17

4.5% 7.6%

3.0%

Victim

84.8%

Perpetrator & victim Perpetrator Child victim

4.5%

16.7%

22.7%

27.3%

21.2%

4.5% 3.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

12 - 17 years 18 - 24 years 25 - 34 years 35 - 44 years 45 - 54 years 55 - 64 years 65 years +

Apparent suicides occurred throughout Queensland. Table 4 outlines the distribution of deaths by Queensland Police District.

Table 4. Apparent suicides by location, Queensland, 2015-16 to 2016-17

Region Number Percent

Brisbane region 13 19.7%

North Brisbane 6 9.1%

South Brisbane 7 10.6%

South Eastern region 13 19.7%

Logan 4 6.1%

Gold Coast 9 13.6%

Southern region 13 19.7%

Ipswich 3 4.5%

Darling Downs 5 7.6%

South West 1 1.5%

Moreton 4 6.1%

Central region 11 16.7%

Sunshine Coast 1 1.5%

Wide Bay Burnett 3 4.5%

Capricornia 6 9.1%

Mackay 1 1.5%

Northern region 16 24.2%

Townsville 7 10.6%

Mount Isa 1 1.5%

Far North Queensland 8 12.1%

Queensland 66 100.0%

24 Queensland Government Statistician’s Office. (2017). A Changing Queensland, Census 2016 Snapshot). Brisbane: Author. http://www.qgso.qld.gov.au/products/reports/changing-qld-c16/ changing-qld-c16.pdf

25 Potts, B., Kolves, K., O’Gorman, J., & De Leo, D. (2016). Suicide in Queensland: Mortality rates and related data 2011-2013. Brisbane: Griffith University.

Nine of the apparent suicide victims (13.6%) identified as Aboriginal and Torres Strait Islander. This is over-representative of the proportion of the general population that identifies as Aboriginal and Torres Strait Islander (4.0%).24 The proportion of apparent suicides of Aboriginal and Torres Strait Islander people in a domestic and family violence context was markedly higher than has recently been reported for the general Queensland population (6.5%).25

Information obtained from available files has been explored to identify other relevant factors relating to these domestic and family violence related apparent suicides.

» Separation was a key feature in the majority of apparent suicide cases. Actual separation was reported in 59.1% of cases, with impending separation reported in an additional 12.1% of cases.

» Mental health concerns were reported in about three-quarters of cases. A diagnosed mental health disorder was reported in 34.8% of cases, while symptoms of mental illness were reported by families and friends in 37.9% of cases.

» Almost one-third (30.3%) of cases were known to have been subject to involuntary treatment orders for a mental health condition at some point in the past.

» A history of suicidal ideation (72.7%) and previous suicide attempts (47.0%) were prevalent in the apparent suicide cases.

» Nearly two-thirds (65.2%) of deceased were known to have a history of problematic substance use.

Physical violence was the most commonly recorded form of domestic and family violence among the cases of apparent suicide. Figure 13 shows the prevalence of the different forms of violence recorded in coronial files.

Episodes of domestic and family violence were reported to be escalating in the period leading up to the death in 60.6% of cases, with the level being reported as constant in an additional 9.1% of cases.

Children were known to be exposed to domestic and family violence in 43.9% of suspected suicide cases. This was inclusive of both adult and child suicide deaths.

Death Review and Advisory Board | Annual Report 2016–17 45

Figure 13: Forms of domestic and family violence, apparent suicide cases, 2015-16 to 2016-17

68.2%

47.0%

31.8%

24.2%

7.6%

7.6%

4.5%

3.0%

3.0%

3.0%

9.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Pet abuse

Abuse towards children

Suicide threats

Economic

Controlling

Property damage

Psychological / emotional

Verbal

Physical

Sexual assault

Unknown

84.6%

73.8%

52.3%

52.3%

38.5%

23.1%

18.5%

15.4%

6.2%

4.6%

1.5%

12.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Other

Legal services

Specialist DV service

Relationship service

Child Safety Services

Psychologist / counsellor

Corrective Services

GP

Hospital / ED

Mental Health

Magistrates Court issued DVO

Police

Domestic violence protection orders were current in 47 cases (71.2%). Of these cases, the deceased was recorded as the respondent in the vast majority of cases (87.2%). Cross-orders were in place in two cases (4.3%), while the deceased was recorded as the aggrieved in four cases (8.5%).26

A breach of protection order was recorded in 53.2% of cases where an order was in place.

An analysis of contact the deceased had with services was conducted. It must be noted this information is preliminary in nature as many cases are still subject to open coronial investigation, and further information may come to light that identifies additional service system contact.

A history of service system contact was recorded in the vast majority of apparent suicide cases (90.9%). As shown in Figure 14, contact with police was most prevalent, followed by mental health and hospital/emergency department services. Due to a high prevalence of domestic violence protection orders, there was also a high rate of contact with Magistrates Courts regarding the issuing of these civil orders.

This contrasts with the pattern of service system contact identified in intimate partner homicide cases, where mental health and other health services were accessed at far lower rates.

Figure 14. Service system contact, apparent suicides, 2015-16 to 2016-17

68.2%

47.0%

31.8%

24.2%

7.6%

7.6%

4.5%

3.0%

3.0%

3.0%

9.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Pet abuse

Abuse towards children

Suicide threats

Economic

Controlling

Property damage

Psychological / emotional

Verbal

Physical

Sexual assault

Unknown

84.6%

73.8%

52.3%

52.3%

38.5%

23.1%

18.5%

15.4%

6.2%

4.6%

1.5%

12.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Other

Legal services

Specialist DV service

Relationship service

Child Safety Services

Psychologist / counsellor

Corrective Services

GP

Hospital / ED

Mental Health

Magistrates Court issued DVO

Police

26 This included two cases where the deceased was also known to use violence, but this was not recognised in formal civil protection orders.

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Domestic and Family Violence Death Review and Advisory Board

Risk indicators

The Ontario Domestic Violence Death Review Committee, through the review of over 200 cases of intimate partner homicide and extensive research, has created a list of 39 risk factors that indicate the potential for lethality within an intimate partner relationship (Appendix A).

As they have been developed specifically through a targeted death review process, the Board utilises the coding system of the Ontario Committee to identify and record the presence of any risk indicators prior to the death.

A review of full coronial files from 201127 onwards was conducted to identify the prevalence of these lethality risk factors. As the more recent deaths may still be subject to an open coronial investigation, full coronial records have not yet been obtained for all cases from 2016 onwards.

As such, to allow a comprehensive analysis of any potential risk indicators prior to the deaths, an analysis of 61 of the 6428 intimate partner homicide deaths between 2011 and 2015 was conducted. The assessment of risk is based on the victim/perpetrator relationship prior to the death, and not on the deceased/offender relationship, which accounts for those circumstances in which a female primary victim of violence may kill their abuser.

As this coding form was specifically developed on reviews of intimate partner homicides, the applicability to homicides in a family relationship is yet to be tested. These deaths have been excluded from this analysis however will be a focus in the 2017-18 reporting period to better understand what risk indicators may have been present prior to the death.

Of the 61 homicide victims, four-fifths (80.3%) were female. Of the 12 male deceased, eight were identified as perpetrators of violence in the relationship, and the homicide offender was the primary victim of violence prior to the death.

Of the remaining four cases, there were two homosexual relationships featuring male partners (including one where there was no recorded history of violence prior to the death). In addition, there were two other cases where there was no recorded history of domestic and family violence in the intimate partner relationship prior to the actual homicide of the male deceased.

Of the 49 cases where a female died, the female was the primary victim in 38 cases (77.6%). There were two cases where the deceased female was identified as the primary perpetrator of violence. In the remaining nine cases, there was no recorded history of domestic and family violence prior to the homicide event.

As depicted in Figure 15 and Table 5, a history of domestic violence (80.3%) was the most commonly identified risk factor, followed by actual or pending separation (57.4%) and victim and perpetrator living in common-law (55.7%). This was followed by sexual jealousy (54.1%) and excessive alcohol and/or drug use by the perpetrator (52.5%).

Risk factors less commonly identified included: perpetrator exposed to suicidal behaviour in family of origin (3.3%); youth of couple (4.9%); misogynistic attitudes (8.2%); access to victim after risk assessment (8.2%); perpetrator abused/witnessed domestic violence as a child (9.8%); age disparity of couple (13.1%); and, prior forced sexual acts and/or assaults during sex (13.1%).

Research demonstrates that a past history of domestic and family violence is a strong predictor of future fatalities within intimate partner and family relationships, and this is reflected in the analysis. This highlights the need for routine risk screening, assessment and identification across the service system, and a move away from an incident based response system to one that better addresses the underlying patterns of harm.

While some factors may be associated with potentially fatal outcomes in intimate partner relationships, caution should be used when interpreting information drawn from this preliminary analysis. For example, living in a de-facto relationship (3rd rank) and the perpetrator being unemployed (9th rank) are less likely to be predictive of outcomes and may be just a reflection of general demographics of the broader population, and as such, should not be the focus of prevention or intervention activities.

27 This date accords with the establishment of the Domestic and Family Violence Death Review process in Queensland, and as such more records are available since this process has been implemented than was previously available.

28 Three cases were excluded due to limited coronial information being available at the time

Death Review and Advisory Board | Annual Report 2016–17 47

Table 5: Prevalence of lethality risk factors among intimate partner homicides, 2011-2015

Risk factors Number Percent

History of domestic violence 49 80.3%

Actual or pending separation 35 57.4%

Victim and perpetrator living common-law 34 55.7%

Sexual jealousy 33 54.1%

Excessive alcohol and/or drug use by perpetrator 32 52.5%

Victim’s intuitive sense of fear of perpetrator 31 50.8%

History of violence outside of the family by perpetrator 28 45.9%

Controlled most or all of victim’s daily activities 28 45.9%

Perpetrator unemployed 26 42.6%

Prior attempts to isolate the victim 25 41.0%

Prior threats to kill victim 24 39.3%

Obsessive behaviour displayed by perpetrator 24 39.3%

Failure to comply with authority 24 39.3%

Escalation of violence 21 34.4%

Prior threats to commit suicide by perpetrator 18 29.5%

Other mental health or psychiatric problems – perpetrator 18 29.5%

New partner in victim’s life 16 26.2%

Prior suicide attempts by perpetrator 15 24.6%

Prior destruction or deprivation of victim’s property 15 24.6%

Choked/strangled victim in past 15 24.6%

Extreme minimisation and/or denial of spousal assault history 14 23.0%

Prior assault with a weapon 13 21.3%

Perpetrator threatened and/or harmed children 13 21.3%

Prior threats with a weapon 12 19.7%

Prior hostage-taking and/or forcible confinement 12 19.7%

Presence of step children in the home 12 19.7%

Depression – in the opinion of family/friend/acquaintance 12 19.7%

Depression – professionally diagnosed 12 19.7%

Child custody or access disputes 10 16.4%

Prior assault on victim while pregnant 10 16.4%

Prior violence against family pets 9 14.8%

Access to or possession of any firearms 9 14.8%

Prior forced sexual acts and/or assaults during sex 8 13.1%

Age disparity of couple 8 13.1%

Perpetrator was abused and/or witnessed DV as a child 6 9.8%

After risk assessment, perpetrator had access to victim 5 8.2%

Misogynistic attitudes – perpetrator 5 8.2%

Youth of couple 3 4.9%

Perpetrator exposed to/witnessed suicidal behaviour in family of origin 2 3.3%

61 100.0%

Death Review and Advisory Board | Annual Report 2016–1748

Domestic and Family Violence Death Review and Advisory Board

Figure 15: Prevalence of common risk factors, intimate partner homicides, 2011 to 2015

Risk factors less commonly identified included: perpetrator exposed to suicidal behaviour in family of origin (3.3%); youth of couple (4.9%); misogynistic attitudes (8.2%); access to victim after risk assessment (8.2%); perpetrator abused/witnessed domestic violence as a child (9.8%); age disparity of couple (13.1%); and, prior forced sexual acts and/or assaults during sex (13.1%).

Research demonstrates that a past history of domestic and family violence is a strong predictor of future fatalities within intimate partner relationships and this is reflected in this analysis. This highlights the need for routine risk screening, assessment and identification across the service system, and a move away from an incident based response system to one that better addresses the underlying patterns of harm.

While some factors may be associated with potentially fatal outcomes in intimate partner relationships, caution should be used when interpreting information drawn from this preliminary analysis. For example, living in a de-facto relationship (3rd rank) and the perpetrator being unemployed (9th rank) are less likely to be predictive of outcomes and may be just a reflection of general demographics of the broader population, and as such, should not be the focus of prevention or intervention activities.

Figure 15: Prevalence of common risk factors, intimate partner homicides, 2011 to 2015

80.3%

57.4%

55.7%

54.1%

52.5%

50.8%

45.9%

45.9%

42.6%

41.0%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

History of domestic violence

Actual or pending separation

Victim and perpetrator living common-law

Sexual jealousy

Excessive alcohol and/or drug use by perpetrator

Victim’s intuitive sense of fear of perpetrator

History of violence outside of the family by perpetrator

Controlled most or all of victim’s daily activities

Perpetrator unemployed

Prior attempts to isolate the victim

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Multiple lethality factors were identified in the vast majority of cases. On average, 11.2 risk factors were recorded in each intimate partner homicide case between 2011 and 2015. Of the cases in Queensland, 72.1% had seven or more lethality risk factors potentially indicating that multiple risk factors may lead to a heightened risk of harm.29

The Ontario Domestic Violence Death Review Committee reports that between 2003 and 2014, 80% of total cases had seven or more factors present.30

The figure ranged from one factor to 27 (of a possible 39) with Table 6 below showing the breakdown of the number of factors reported:

Table 6: Number of lethality risk factors per case, 2011 to 2015

Number of cases Percentage

Nil 0 0.0%

1 to 3 factors 8 13.1%

4 to 6 factors 9 14.8%

7 to 10 factors 11 18.0%

11 to 19 factors 26 42.6%

20 or more factors 7 11.5%

Notably, the Lethality Risk Factors were developed in Canada, so caution needs to also be applied when adopting a tool that has not been specifically developed or tested on the population of interest.

A key characteristic which highlights the uniqueness of the Queensland population is the disproportionate number of Aboriginal and Torres Strait Islander intimate partner or family homicides. Table 7 shows the prevalence of risk factors for Aboriginal and Torres Strait Islander people, in comparison with people from a Culturally and Linguistically Diverse (CALD) background and non-Indigenous, non-CALD people who died by homicide, within an intimate partner relationship.31

Strikingly, risk factors that appear far more common among Aboriginal and Torres Strait Islander victims of intimate partner homicide include: history of violence outside the family by perpetrator (92.3%); prior threats (53.8%) and assaults with a weapon (61.5%); excessive alcohol and/or drug use by perpetrator (92.3%); sexual jealousy (both victim and perpetrator) (84.6%); and failure to comply with authority (84.6%).

29 Risk assessment processes within the context of domestic and family violence are still relatively unsophisticated and caution must be applied when drawing conclusions on raw data. It may be the case that certain factors should be weighted more heavily than others (such as non-lethal strangulation) or that certain risk factors clustered together have greater significance (such as obsessive behaviour displayed by a perpetrator, actual or pending separation and threats to kill)

30 Domestic Violence Death Review Committee. (2015). Domestic Violence Death Review Committee 2013-14 Annual Report. Ontario: Office of the Chief Coroner. 31 The number of cases where a victim was known to be Aboriginal and Torres Strait Islander, or culturally and linguistically diverse was relatively statistically low (13 and 12 cases respectively). As

such, caution must be taken when considering the findings with respect to these cohorts.

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By contrast, just 7.7% of Aboriginal and Torres Strait Islander intimate partner homicides involved actual or pending separation, compared with 66.7% of CALD cases and 72.2% of the non-Indigenous, non-CALD cases.

For cases involving CALD victims, there was an elevated presence of prior attempts to isolate the victim (66.7%); victim’s intuitive sense of fear (66.7%); prior destruction or deprivation of victim’s property (41.7%); child custody or access disputes (33.3%); and assault while pregnant (25.0%)

Table 7: Prevalence of risk factors, Aboriginal and Torres Strait Islander, Culturally and Linguistically Diverse, and other intimate partner homicides, 2011-2015

Aboriginal and Torres Strait Islander

Culturally and Linguistically Diverse

Other

History of violence outside of the family by perpetrator 92.3% 25.0% 36.1%

History of domestic violence* 84.6% 75.0% 80.6%

Prior threats to kill victim 46.2% 33.3% 38.9%

Prior threats with a weapon 53.8% 16.7% 8.3%

Prior assault with a weapon 61.5% 8.3% 11.1%

Prior threats to commit suicide by perpetrator 23.1% 25.0% 33.3%

Prior suicide attempts by perpetrator 23.1% 16.7% 27.8%

Prior attempts to isolate the victim 30.8% 66.7% 36.1%

Controlled most or all of victim’s daily activities 53.8% 50.0% 41.7%

Prior hostage-taking and/or forcible confinement 38.5% 8.3% 16.7%

Prior forced sexual acts and/or assaults during sex 23.1% 8.3% 11.1%

Child custody or access disputes 0.0% 33.3% 16.7%

Prior destruction or deprivation of victim’s property 15.4% 41.7% 22.2%

Prior violence against family pets 7.7% 8.3% 19.4%

Prior assault on victim while pregnant 15.4% 25.0% 13.9%

Choked/strangled victim in past 38.5% 16.7% 22.2%

Perpetrator was abused and/or witnessed DV as a child 15.4% 8.3% 8.3%

Escalation of violence 46.2% 25.0% 33.3%

Obsessive behaviour displayed by perpetrator 30.8% 50.0% 38.9%

Perpetrator unemployed 84.6% 16.7% 36.1%

Victim and perpetrator living common-law 84.6% 50.0% 47.2%

Presence of step children in the home 38.5% 0.0% 19.4%

Extreme minimisation and/or denial of spousal assault history by the perpetrator

30.8% 33.3% 16.7%

Actual or pending separation 7.7% 66.7% 72.2%

Excessive alcohol and/or drug use by perpetrator 92.3% 16.7% 50.0%

Depression – in the opinion of family/friend/acquaintance 0.0% 25.0% 25.0%

Depression – professionally diagnosed 15.4% 8.3% 25.0%

Other mental health or psychiatric problems – perpetrator 38.5% 33.3% 25.0%

Access to or possession of any firearms 7.7% 8.3% 19.4%

New partner in victim’s life 15.4% 25.0% 30.6%

Failure to comply with authority 84.6% 16.7% 30.6%

*Given the often hidden nature of domestic and family violence, the Board recognises there may be other cases in which a history of domestic and family violence was unreported.

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Table 7 continued Aboriginal and Torres Strait Islander

Culturally and Linguistically Diverse

Other

Perpetrator exposed to/witnessed suicidal behaviour in family of origin 0.0% 0.0% 5.6%

After risk assessment, perpetrator had access to victim 15.4% 0.0% 8.3%

Youth of couple 0.0% 8.3% 5.6%

Sexual jealousy 84.6% 41.7% 47.2%

Misogynistic attitudes – perpetrator 7.7% 16.7% 5.6%

Age disparity of couple 15.4% 8.3% 13.9%

Victim’s intuitive sense of fear of perpetrator 53.8% 66.7% 44.4%

Perpetrator threatened and/or harmed children 30.8% 16.7% 19.4%

With respect to risk factors, there were several differences between cases where the male died by homicide compared with the female. For instance:

» a prior threat to kill the victim was more common (49.0%) in female victims than male victims (0%)

» extreme minimisation or denial of spousal assault history was more prevalent in cases where a male died (58.3%) than a female (14.3%)

» compared with male victims, cases involving a deceased female featured a higher prevalence of: attempts to isolate (46.9% vs 16.7%); controlling most or all of the victim’s daily activities (53.1% vs 16.7%); prior forced sexual acts and/or assaults during sex (16.3% vs 0%); sexual jealousy (61.2% vs 25.0%)

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Chapter 4: Unravelling patterns of abuse, risk, and harm

32 This includes two homicide-suicides, nine intimate partner homicides (inclusive of five Aboriginal and Torres Strait islander victims) and one bystander homicide where the new partner of a domestic violence victim was murdered by her abusive former partner.

33 Under s91D of the Act the Board is only empowered to review cases where there is a history of domestic and family violence. 34 Fisher, S. (2011). From Violence to Coercive Control: Renaming Men’s Abuse of Women. White Ribbon Policy Research Series No.3. 35 Glaser, D. (2002). Emotional abuse and neglect psychological maltreatment: A conceptual framework. Child Abuse and Neglect. Vol 26:697. 36 McKinnon, L. (2008). Hurting without hitting: non-physical contact forms of abuse. Australian Domestic and Family Violence Clearinghouse, Stakeholder paper 4. February 2008. 37 Marshall, LL. (1996). Psychological abuse of women: Six distinct clusters. Journal of Family Violence. Vol 11:379. 38 Sackett, LA., & Saunders, DG. (1999). The impact of different forms of psychological abuse on battered women. Violence and victims, Vol. 14:105. 39 Follinstad, DR., & Dehart, DD. (2000) Defining psychological abuse of husbands towards wives: Contexts, behaviours and typologies. Journal of Interpersonal Violence. Vol 10:891. 40 This includes a sense of fear of the perpetrator, their partner’s intent to harm and their own self blame for the abuse. 41 Morgan, A., & Chadwick, H. (2009). Key Issues in Domestic Violence. Research in Practice (7) Canberra: Australian Institute of Criminology. 42 The presence of this type of abuse may occur within the context of physical abuse, so they should not be considered in isolation, or mutually exclusive, of each other.

Flowing on from the quantitative analysis in the previous chapter, this section seeks to explore key risk indicators, such as non-lethal strangulation or sexual (morbid) jealousy, identified by the Board throughout the review process during this reporting period.

In many of these cases, the significance of these risk indicators was not recognised by services or other informal supports, and therefore not responded to.

Episodes of violence or abusive tactics, where they were reported, were also often not considered within the context of previous reports or other concerning behaviours, thereby further limiting the provision of effective supports or assistance.

In this regard, this chapter highlights the need for services and the community to better understand the underlying patterns of risk and harm that are reflective of the coercive controlling abuse that characterises domestic and family violence.

With respect to the 12 intimate partner homicides32 considered by the Board in the 2016–17 financial year, a history of domestic violence was noted in all cases. Other commonly identified risk factors included:

» history of violence outside the family by perpetrator (91.7%)

» failure to comply with authority (91.7%)

» sexual jealousy (91.7%)

» victim’s intuitive sense of fear of perpetrator (83.3%)

An average of 18.8 risk factors were identified in each of these cases, which is somewhat higher than was observed among the larger cohort of homicides during the 2011–2015 period.

This is largely related to selection bias, as the cases reviewed by the Board in this reporting period had high levels of service system contact and recorded histories of domestic and family violence.33 It may be the case that where there are a greater number of risk indicators, there may be more service system contact and increased reporting. This requires further research and analysis prior to drawing any definitive conclusions.

The Board also considered the presence or absence of these factors within the other types of deaths, such as suicides and filicides (within the parental relationship) given they are generally characteristic of domestic and family violence relationships more broadly.

These case characteristics identified within each review meeting are outlined within more detail in Appendix B of this report.

Coercive controlling violence

Coercive control describes an ongoing and often relentless pattern of behaviour asserted by a perpetrator which is designed to induce various degrees of fear, intimidation and submission in a victim. This includes the use of tactics such as social isolation, belittling, humiliation, threatening behaviour, restricting resources (i.e. financial) and abuse of children, pets, and relatives,34 many of which are non-physical in nature.

Non-physical abuse can be difficult to identify because it leaves no visible injury35 and because some victims may not recognise they are a victim of abuse or seek help.36 Overt acts of non-physical abuse, such as stalking or verbal violence including threats, can be easier to identify. Covert forms of this abuse are more subtle and insidious.37

For example, the abuser may deny hostile intent with certain behaviours, while ignoring and discounting the target person’s needs, feelings or opinions.

Through repeated episodes over time, the perpetrator undermines the target person’s sense of self through emotional abuse strategies which:

» attack their target’s personhood by ignoring, demeaning, belittling, undermining their self-worth, ridiculing traits and criticising behaviour38

» defines their reality by making them question their own perceptions and judgment

» isolates them by controlling their contact with the outside world and support systems.39

While many people recognise physical abuse as domestic violence, fewer people consider social, emotional and psychological abuse constitutes domestic and family violence. This is despite research which indicates many victims perceive the emotional impacts of domestic violence40 as more significant than any physical injuries inflicted upon them.41

A consistent theme identified by the Board in the review of cases was a lack of detection and response to underlying indicators of abuse, particularly when they were not associated with reports of direct physical abuse.42

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For victims, the impact of this was devastating, as it meant there was often a limited service response to their disclosures of abuse and harm such as a perpetrator harassing or bombarding the victim with excessive texts and calls, making multiple threats to kill, or when they reported their own intuitive sense of fear of the perpetrator.

Explored in further detail within this chapter, are those (predominantly) non-physical indicators that were the focus of multiple discussions by the Board throughout the reviews of cases in this reporting period, specifically: sexual or morbid jealousy; post-separation violence; non-lethal strangulation; technology- facilitated abuse and ‘systems abuse’ within the context of child safety services interventions.

Extreme proprietariness, possessiveness and morbid jealousy

Sexual jealousy or obsessive possessiveness is a type of jealousy evoked in response to an actual or perceived threat of sexual infidelity43 with strong links to intimate partner homicide, predominantly in the context of male perpetrated violence.

It is a factor that has been consistently linked to domestic homicides internationally,44 with some putting it into one of the top five risk factors for homicide, increasing lethal risk by almost 10 times than for those cases where jealousy is not present.45

Extreme sexual suspicion, as opposed to jealousy or relationship insecurity has also been found to be associated with an increased risk of violence post-separation.46

The spectrum of behaviours which are commonly defined as ‘sexual jealousy’ were identified in 11 of the 12 (91.7%) intimate partner homicide cases47 reviewed by the Board.

Within the Aboriginal and Torres Strait Islander intimate partner homicides, these behaviours were prevalent and exhibited by both parties.

Sexual jealousy was commonly a precursor to acts of physical violence, including at times, prolonged assaults over many hours and/or hostage taking. Records indicate that a number of the victims were assaulted in the context of repetitive and intense accusations of infidelity, often during periods of separation.

In one case reviewed by the Board, the perpetrator used overt behaviours to investigate suspicions of infidelity, both during the course of the relationship and after separation, including but not limited to:

» interrogating the victim around allegations of perceived unfaithfulness which were recorded and posted online

» making incessant telephone calls to the victim when she was away and socialising with her friends or at work

43 Buss, D.M. (2012). Evolutionary Psychology: The new science of the mind. (4th ed.) Boston: Pearson. 22(2), 155-182. 44 Websdale, N. (2000). Lethality Assessment Tools: A Critical Analysis. National Online Resource Centre on Violence Against Women. 45 Specifically 9.9 times, Women’s Justice Centre Domestic Violence Homicide Risk Assessment http://justicewomen.com/tips_dv_assment.html . Notably threats to kill or injure increases risk by 14.9

times and prior strangulation by 9.9 times. 46 Fleury, R.E., Sullivan, C.M., & Bybee, D.I. (2000). When ending the Relationship does not End the Violence: Women’s Experience of Violence by Former Partners, Violence against Women. 47 This included 5 out of 5 Indigenous intimate partner homicide cases, 4 out of 5 non-Indigenous intimate partner homicides, and 2 out of 2 homicide-suicides. 48 Harris, C.R. (2003). A Review of Sex Differences in Sexual Jealousy, Including Self-Report Data, Psychophysiological Responses, Interpersonal Violence and Morbid Jealousy, Personality and Social

Psychology Review, 7(2), 102-128. 49 Mullen, PE. (1995). Jealousy and violence. Hong Kong Journal of Psychiatry, 5, 18-24. 50 Weizman-Henelius, G., Gronroos, LM., Putkonen, H., Eronen, M., Lindberg, N. and Hakkanen-Nyholm, H. (2012). Gender specific risk factors for intimate partner homicide: A nationwide register-

based study. Journal of Interpersonal Violence, 27, 1519-39. 51 Wilson, M., & Daly, M. (1993). Spousal homicide risk and estrangement. Violence and victims, 8, 3-16. 52 Polk, K., & Ranson, D. (1991). The role of gender in intimate homicide. Australian and New Zealand Journal of Criminology, 24, 15-24.

» harassing her when she was at work functions, even though he may have earlier refused to attend, including insisting that she leave early or waiting outside for her for many hours

» perpetrating acts of physical violence when the victim refused to provide the perpetrator with access to her electronic communications

» Committing acts intended to socially isolate the victim from other men

These behaviours, viewed across a continuum, are indicative of extreme possessiveness and a sense of exclusive ownership of the victim. Indeed, in the lead up to the death, he repeatedly expressed a desire to make her pay for what she did as he attempted to hunt her down, going to extraordinary lengths to locate her.

Referring to these behaviours as jealousy minimises the sheer impact it has on a victim and its association with increased harm, or indeed in extreme cases, homicide.

While most research in this area substantively considers sexual jealousy or possessive behaviours exhibited by males as a risk factor associated with future harm, female jealousy is less well researched. This is because most studies with respect to jealousy and the role of jealousy in intimate partner homicides predominantly examine male perpetrated violence and female victimisation leading to an inherent gender bias.48

Research does indicate that the role played by jealousy in both initiating episodes of domestic violence and in attempts by perpetrators to justify their violence, cannot be overstated.49 In men, possessiveness, often within the context of separation and jealous behaviours, seem to be one of the most common motivational factors in femicide, whereas women demonstrate a higher propensity to kill their spouses in self-defence or after years of suffering physical violence.50

One common theory, the male sexual proprietary theory, suggests that unions must be understood as ultimately sexual and reproductive in nature,51 and proponents of this concept argue that major problems arise from men’s desire to control women and their reproductive capacities. Under this theory, it is suggested (some) men not only view their partners as their’s exclusively, they also experience feelings of entitlement.

Where this sense of entitlement is present, particularly during periods of actual or intended separation, a perpetrator may perceive they are losing control of their female partners and may use coercive controlling tactics to terrorise a victim and keep them under their control,52 perhaps best described as an attitude of if I can’t have her, no one can.

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The word ‘proprietariness’ is often used to describe these behaviours, as it implies a more encompassing mindset than the word ‘jealousy’.53

It is clear that there is a need to better understand the underlying intent associated with behaviours that are commonly defined as ‘jealousy’, which is recognised as a specific limitation of the aforementioned theories given it is difficult to measure qualitatively or quantitatively.

As such the extent to which ‘proprietariness’ or ‘jealousy’ is deemed to be a motivating force depends to a great extent on the interpretation of the investigator or researcher.54

These definitional limitations of the term ‘jealousy’ may impact on community or service provider understandings of the term and their subsequent response when these behaviours are disclosed.

At the extreme end of the continuum, this construct may be better understood as ‘extreme possessiveness’ to reflect the increased risk of harm of this characteristic; particularly where there are other indicators of coercive controlling violence present in a relationship.

Within the cases subject to review by the Board, arguments about ‘alleged infidelity’ were noted by responding police officers or other parties on several occasions. At times the minimisation of these behaviours precluded a full investigation or exploration of other potential abuse indicators.

Similarly, where sexual jealousy, proprietary attitudes or possessiveness were disclosed in counselling sessions, it was often dismissed or not explored in further detail as a potential indicator of greater harm. Within this clinical context, traits of sexual jealousy and a subsequent risk of extreme physical violence or aggression, through the harbouring of hostile or homicidal ideation, were overlooked.

Consequently, the service system as well as informal supports, needs to be better equipped to understand, detect, and respond to this indicator, and ensure it is not dismissed or ‘accepted’ as an excuse for a perpetrator’s abusive or controlling acts.

While jealousy can manifest as a rational emotive response to feelings of rejection, insecurity or resentment in the context of rivalry within any given relationship setting, those that experience jealousy within normal parameters can modify their beliefs and reactions as new information becomes available.55

In contrast, those behaviours symptomatic of morbid jealousy are based on irrational thoughts and emotions constructed around a preoccupation with a partner’s sexual unfaithfulness, whereby ‘individuals interpret conclusive evidence of infidelity from irrelevant occurrences and refuse to change their beliefs even in the face of conflicting information’.56 Morbid jealousy, in this regard, should be considered as descriptive of ‘a number of psychopathologies within separate psychiatric diagnoses’.57

53 Serran, G., & Firestone, P. (2004). Intimate partner homicide: A review of the male sexual proprietariness and the self-defense theories. Aggression and violent behaviour, 9, 1-15. 54 Ibid. 55 Kingham, M. & Gordon, H. (2004). Aspects of morbid jealousy, Advances in Psychiatric Treatment, 10, 207-215. 56 Ibid. 57 Shepherd, M. (1961). Morbid jealousy: some clinical and social aspects of a psychiatric symptom. Journal of Mental Science, 107, 688-704. 58 Kingham, M. & Gordon, H. (2004). Aspects of morbid jealousy, Advances in Psychiatric Treatment, 10, 207-215. 59 Hotton, T. (2001). Spousal Violence after Marital Separation. Canadian Centre for Justice Statistics. 21 (7). Cat. No. 85-002. 60 Anderson, D.K. & Saunders, D.G. (2003). Leaving an Abusive Partner: an empirical review of predictors, the process of leaving and psychological well-being. Trauma, Violence and Abuse 4(2), 163-

191. 61 Fleury, R.E., Sullivan, C.M. & Bybee, D.I. (2000). When Ending the Relationship does not End the Violence: Women’s Experiences of Violence by Former Partners. Violence Against Women, 12, 1363-

83. 62 Johnson, H. & Hotton, T. (2003). Losing Control: Homicide Risk in Estranged and Intact Intimate Relationships. Homicide Studies, 7, 58-84. 63 Serran, G. and Firestone, P. (2004). Intimate partner homicide: A review of the male sexual proprietariness and the self-defense theories. Aggression and violent behaviour, 9, 1-15. 64 This includes the homicide of Joshua, who died in the context of being killed by his partner’s former husband, whereby significant fear was expressed by both Joshua and his partner, and repeat

calls for assistance to police were made, in the lead up to the fatal event.

As the nature of morbid jealousy is often equated to a delusional state in the sense that irrational preoccupations cannot be refuted rationally once suspicions of a partner’s infidelity are established,58 repeat denials, or even false confessions of infidelity by a partner are often futile and may even provoke anger or violence in the jealous individual. In this regard, the importance of appropriately defining and assessing this characteristic along with other potential indictors of harm, across the service system should not be discounted; particularly for frontline and generalist services that may not be in a position to conduct an in-depth risk assessment, or develop an ongoing management plan.

Caution may be required in appropriately defining these behaviours with respect to Aboriginal and Torres Strait Islander victims of violence, as these cases highlighted that both parties may express sexual jealousy within their intimate partner relationships; including the person most in need of protection.

Post-separation violence, and ‘contact abuse’

Relationship separation at the time of death was prevalent in 17 cases (63%). All of the homicide suicides and four of the perpetrator suicides considered by the Board within this reporting period occurred within the context of relationship separation. Seven of the intimate partner homicides and three of the suicides of victims of domestic and family violence also occurred within the context of separation, which allowed the Board to consider this period of heightened risk in great depth.

While leaving a relationship characterised by domestic violence may seem the obvious solution to prevent further abuse, in many cases the risk of being hurt or killed is greatly increased when women make a decision to leave.59,60 When a perpetrator senses they may be losing control over their partner, an escalation in abuse may occur in an attempt to regain or maintain this control, or to punish their partner for leaving.61

Post-separation violence tends to be more serious, more obsessive, more likely to involve stalking, to involve female victims and most importantly, more likely to lead to homicide than violence which occurs within an intact relationship.62 This behaviour has been associated with a perpetrator’s need for control in the relationship, which is attained through the use of violence, with sub-lethal assaults and threats of homicide being utilised by them as effective control mechanisms.63

Importantly, with respect to some of these cases, when separating from an abusive partner there is a recognisable risk of physical violence irrespective of whether it happened previously in the relationship, particularly when emotional abuse is present.

This risk was most evident within the intimate partner homicides, particularly in circumstances where the women were killed as they were attempting to separate from their abusive partner. All expressed significant terror and fear prior to the death of the potential consequences of this course of action,64 and all sought

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help from services in an attempt to secure their own safety and protection, and that of their loved ones.

In discussions regarding these cases, Board members considered the service system response was inadequate during this period particularly when children became involved, as abuse was often attributed by services to ‘child custody issues’ as opposed to domestic and family violence.

Where children were present in the relationship, and the couple had separated or were separating, there was evidence that the children were used as a means of control by the primary perpetrator in nine of the 13 cases (69.2%) reviewed by the Board.

Such behaviour is typical of the underlying power and control dynamics that characterise these types of relationships. It has substantial negative and enduring consequences for both victims and their children.

In several cases, a perpetrator took a child from the mother’s care during an argument which was then reported to police. These occurrences went unrecognised as an act of domestic and family violence, demonstrating a lack of understanding of the fear such behaviours can elicit in a victim, and that it can be a powerful means through which a perpetrator retains control over an aggrieved party.

In such circumstances when ongoing contact with the abusive partner is necessary to facilitate child custody arrangements, the continuation of control and abuse of women and children by men may be extended.

Inherent in the concept of contact abuse is the notion that, in negotiating and implementing child custody arrangements, women are largely unable to minimise contact with their perpetrator and, as such, are incapable of securing their safety. This means the abusive partner is able to use their role as a parent to facilitate continued abuse, whereby the child(ren) are used as weapons against the victim. In this sense, the women’s safety is diminished as a consequence of the presumption of contact.

Research suggests it is also common for perpetrators of family violence to hurt children as a means to harm their mother65 and that children are more vulnerable to abuse after separation.66 Perpetrators may also seek to undermine the mother-child relationship, involve children in violence and make threats to harm the children.67 A reluctance to acknowledge that (some) men can be dangerous to their children in certain circumstances, particularly post separation, may inadvertently validate or elevate the position of abusive fathers.68

Many women manage to parent effectively despite experiencing even severe violence and go to great lengths to counteract its effect on their parenting despite the often significant personal toll.69 It is also the case that the level of violence may impede the mother’s emotional or physical capacity to parent their child/ren effectively. There is also evidence that suggests some mothers are more likely to act in a punitive way towards their

65 Fish, E., McKenzie, M., & MacDonald, H. (2009) ‘Bad mothers and invisible fathers’. Parenting in the context of domestic violence. Discussion Paper, no.7, Domestic Violence Resource Centre Victoria. 66 Bagshaw, D., Brown, T., Wendt, S., Campbell, A., et al (2010). Family violence and family law in Australia: The experiences and views of children and adults from families who separated post-1995 and

post-2006. Attorney-General’s Department: Canberra. 67 Australian Domestic and Family Violence Clearinghouse. (2011). The impact of domestic violence on children: A literature review. Australian Domestic and Family Violence Clearinghouse for the

Benevolent Society: Sydney. 68 Morris, A. (2008). Gendered dynamics of abuse and violence in families: considering the abusive household gender regime, Child Abuse Review, 18, 414-427. 69 Levendosky, AA et al. (2000), ‘Mothers’ perceptions of the impact of woman abuse on their parenting’, Violence against Women, vol 6, no 3. Cited in Fish, E., Mackenzie, M. and MacDonald, H.

(2009). Bad Mothers and invisible fathers. Discussion Paper No. 7, 2009. Domestic Violence Resource Centre: Victoria. 70 Holden, G. & Richie, K. (1991). ‘Linking extreme marital discord, child rearing and child behaviour problems: Evidence from battered women’, Child Development, vol 62 Cited in Fish, E., Mackenzie,

M. and MacDonald, H. (2009) Bad Mothers and invisible fathers. Discussion Paper No. 7, 2009. Domestic Violence Resource Centre: Victoria. 71 Domestic Violence Resource Centre. (2009). Bad Mothers and Invisible Fathers: Parenting in the Context of Domestic Violence, Discussion Paper No. 7, Victoria. 72 Ibid.

children when in the presence of the violent man;70 which may be indicative of an attempt to avoid triggering further violence from their abusive partner.

Emotional abuse, name-calling, ridiculing and intimidation are strategies designed to undermine a mother’s authority, with the perpetrator deliberately using these and other tactics to control their child/ren’s perceptions of their mother.71 This may include over-riding the mother’s decision-making, or post-separation, it may entail the perpetrator creating a home environment which is lacking in discipline, allowing the children to do whatever they like. When they return to their mother’s home, they are likely to be resistant to any structure she may try to impose.72

For example, in a private application for a protection order made by a homicide victim shortly before the death, she stated her ex-partner was constantly abusive and would call her a fucking mole, dumb bitch and pathetic excuse for a mother. She stated further that her eldest son would take their younger child to his paternal family whenever he pleased and the father’s family would allow this. She expressed that it was very hard for her to teach the children what was right when the father and his family continually reinforced their misbehaviour. She stated further that the respondent father seemed to delight in encouraging the boys to misbehave.

Although this couple had been separated for six years prior to the death, there were multiple altercations post-separation regarding the child custody arrangements put in place by the Family Law Court. Indeed, on the day of her death, the deceased had arranged to meet up with the offender to negotiate a working shared parenting arrangement and had expressed an intention to seek formal mediation to assist.

This case highlighted the sustained risk of harm for victims of domestic and family violence even years after separation; and the importance of ensuring that the Family Law Court and the broader family law system are alert to these dangers.

Pursuing matters through the family court system can cause added emotional, financial and personal distress to victims of domestic and family violence. In this case, the victim was not only required to navigate the judicial system to stabilise custody arrangements; she was made subject of a number of claims and affidavits regarding her ability to parent her children by both the perpetrator and his family.

In another case, complex arrangements for visitations were put in place with other family members in an attempt to keep an intimate partner homicide victim safe from further harm.

For another mother, child visitation handovers would occur in the police station car parking area because of the perpetrator’s escalating abuse. He was also known to use his children to try and track her movements.

While separated parents are required to maintain a respectful relationship with both the child/ren and the other parent, this is not always feasible when violence has, or is, occurring in

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that relationship. After a relationship separation, domestic violence can continue in a range of different forms with respect to the family court system, including through continued litigation against a victim by their partner that may lead to emotional and financial duress.

A recent Australian study suggested that the more issues present during a relationship, the greater likelihood there was of difficulties up to five years after separation, including highly conflicted or fearful inter-parental relationships, safety concerns for themselves or their children and diminished personal and child well-being.73

A recent study commissioned and led by the Australian Institute of Family Studies74 (AIFS), examined the impact of inter-parental conflict and domestic and family violence on parenting and parent- child relationships.75

The key findings of this report indicate that the magnitude of these problems are significant and widespread:

» The experience of inter-parental conflict is common among Australian families, with both mothers and fathers reporting experiencing physical abuse prior to separation (although mothers reported abuse at higher frequency).

» Emotional abuse was a serious issue with two-thirds of mothers and half of fathers reporting experiences of at least one form of emotional abuse by their former partners; which continued for long periods – even up to five years after separation for significant numbers of people.

» Women at the more extreme end of family violence were subjected to multiple types of abuse including emotional abuse, physical harm, sexual abuse and financial abuse.

» In the qualitative sample of 50 women, they experienced highly controlling behaviour by their former partners, including: unreasonable expectations around housework and their children’s behaviour; psychological and verbal abuse, frequently including threats to kill; stalking and vexatious litigation, post separation.

» Inter-parental conflict and domestic and family violence have serious, negative impacts on parents and children.

» Mothers who experience family violence were more likely to suffer psychological distress and to have less confidence as mothers and to be facing financial hardship than mothers who did not have this experience.

ANROWS also recently published their findings of a study into the impact of inter-parental conflict and domestic and family violence on parenting and parent-child relationships.76 The research findings have significant policy and practice implications at a range of levels, including:

» Women who engage with services against a background of domestic and family violence have a number of complex material and psychosocial needs.

73 Moloney, L., Weston, R. & Qu, L. (2015). Attitudes to post-separation care arrangements in the face of current parental violence. Melbourne: Australian Institute of Family Studies. 74 The study was led by the AIFS and drew on data from: over 6000 families in the Longitudinal Study of Australian children; 16,000 separated families in the Family Pathways Studies; and 50 in-depth

interviews with women across Australia who had personal experience of family violence (and used services in the family violence, child protection and family law sectors). 75 Kaspiew, R., Horsfall, B., Qu, L., Nicholson, J. M., Humphreys, C., Diemer, K., & Dunstan, J. (2017). Domestic and family violence and parenting: Mixed method insights into impact and support needs:

Final report (ANROWS Horizons 04/2017). Sydney: ANROWS. Refer to: https://aifs.gov.au/publications/domestic-and-family-violence-and-parenting-0 76 Kaspiew, R., et al. (2017) Domestic and family violence and parenting: Mixed method insights into impact and support needs: Key findings and future directions. ANROWS Compass series. Issue

04/2017. Available online at: https://d2c0ikyv46o3b1.cloudfront.net/anrows.org.au/Parenting_Compass.pdf 77 In one case orders were negotiated by the victim and offender’s lawyers, in the other, family court orders were in place although the perpetrator was known to be non-compliant with these.

» If women are not already engaged with a specialist domestic and family violence service, then such a referral is usually necessary.

» It is likely that women and their children are experiencing ongoing abuse unless contact with the perpetrator has ceased and other safety measures to prevent abuse are available (e.g. being legally permitted to live at an undisclosed address to prevent stalking).

» Women may need assistance and referral in relation to financial and housing needs, including being informed about the availability of financial wellbeing and capability services and financial counselling.

» Women and their children may be experiencing physical and emotional consequences from domestic and family violence and abuse and may need long-term therapeutic assistance.

» Mothers may need referrals to programs and services that will support the restoration of parenting capacity from a perspective of understanding the dynamics of domestic and family violence, including programs that offer services to mothers and children together. Children may also need assistance separately.

» Where relationships between fathers and children are being maintained, fathers may need referral to services in relation to parenting. Where this is occurring, the wellbeing and safety of children need to be monitored.

» Service providers should be alert to the fact that their services and other types of services and agencies may be used in a pattern of systems abuse. Staff, including legal professionals, should be trained to recognise this and provide appropriate advice and referrals where this is occurring.

Despite the prevalence of post-separation conflict, most parents seek to establish informal custody arrangements, which was reflected in the cases reviewed by the Board. There were formal parenting orders in place in only two cases77 and in five cases there were voluntary agreements in place (although the perpetrator was noted as being non-compliant with these arrangements in all of these cases).

Substantial dilemmas may be faced by victims of domestic violence who are seeking Family Court orders to protect them and their children from further abuse. This may deter individuals from accessing this option. For example:

» The need to provide evidence of abuse and future risk of harm, which is required to be sufficiently detailed so the context and significance of specific acts can be understood by the courts.

» Seeking such an order and articulating the reasons regarding the potential risk can be seen as vindictive or punitive, and dwelling on old grievances or as a means of alienating the child/ren from the other parent.

» If the court considers the evidence to be insufficient, or protective orders are not necessary, there may be an adverse view of the victim, with the unintended consequence of

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increased access to the offending parent as a means to protect them from the ‘hostile’ parent.78

While it is well recognised that most episodes of domestic and family violence go unreported to formal services and that this violence is characterised by a pattern of coercive control over time, the credibility of a victim’s allegations of abuse may be brought into question when there is limited evidence of abuse known to services (i.e. such as police or hospital reports) in Family Court proceedings.

It can be even more difficult to present documented evidence when it comes to non-physical acts of domestic and family violence such as stalking, threats to harm or kill and other controlling behaviour, despite its links to increased danger post-separation. From an evidentiary perspective, this type of violence is often the hardest to define as abuse, and the hardest for a victim to prove as the impact on the victim is cumulative in which relatively ‘minor’ or ‘innocuous’ acts may reinforce a sense of victimisation and trauma.

Further, there is a significant psychological and emotional impact of domestic and family violence on victims which may be heightened when they are attempting to separate from an abusive partner. As such, they may present to the court as disorganised, anxious or depressed, and/or be considered an ‘unimpressive’ witness.79 This subsequently impacts the credibility of their accounts of violence.

While it is also the case that some people misrepresent matters in court proceedings and indeed lie, the perception that victims of domestic and family violence lie, or misrepresent their experiences of abuse is problematic and misleading, particularly with respect to the wealth of research that demonstrates significant and sustained underreporting of these types of events.80

An Evaluation of the 2012 Family Violence Amendments (2015) provides an overview of the effects of amendments to the Family Law Act 1975 (Cth) that were intended to improve the family law system’s responses to matters involving family violence and safety concerns.81 While the findings showed some positive aspects of the amendments, the report identified concerns regarding the capacity of the family law system to deal with the increased scrutiny of parenting matters where concerns about family violence and child abuse are raised.

Concerns were also raised regarding the complexity of the family law system and the legislation, and the need for more effective education and training in the areas of family violence and child abuse.

The Federal Attorney-General recently announced the Federal Government’s commitment to establishing a comprehensive review of the family law system.82 The Terms of Reference for this review are not yet publicly available, however, the Attorney- General indicated that the Australian Family Law Reform Commission would be tasked with conducting the review ‘with a view to making necessary reforms to ensure the family law system meets the contemporary needs of families and effectively

78 Chisholm, R. (2009). Family Courts Violence Review, Attorney-General’s Department (Australia).A report by Professor Richard Chisholm. Available at: http://apo.org.au/node/20315. online: https:// www.ag.gov.au/FamiliesAndMarriage/Families/FamilyViolence/Documents/Family%20Courts%20Violence%20Review.pdf

79 Ibid. 80 For example, see Gracia, E. (2004). Unreported Cases of Domestic Violence against Women: towards an epidemiology of social silence, tolerance and inhibition, Journal of Epidemiological

Community Health, 58. 537-537. 81 The full report can be found here https://aifs.gov.au/publications/evaluation-2012-family-violence-amendments 82 The media release is available online at: https://www.attorneygeneral.gov.au/Mediareleases/Pages/2017/SecondQuarter/Transforming-the-Family-Law-System.aspx 83 Refer to exposure draft – Family Law Amendment (Family violence and cross-examination of parties) Bill 2017. https://www.ag.gov.au/Consultations/Pages/Family-violence-cross-examination-

amendments.aspx 84 Available online at: http://www.qls.com.au/For_the_profession/Advocacy/Domestic_and_Family_Violence_Best_Practice_Guidelines 85 The order had a number of extra conditions including that: The respondent is prohibited from locating, attempting to locate or asking someone else to locate the aggrieved and the child.

addresses family violence and child abuse’. The review will report on its findings by 2018 with interim reports to be delivered on key issues.

Legislative reform has also been introduced to amend the Family Law Act 1975 (Cth) to ensure that victims of domestic and family violence are not able to be cross-examined by perpetrators or be required to cross-examine their alleged perpetrator.83 This is a critical step in reducing opportunities by the perpetrator to control and intimidate their former partner during such proceedings.

At a state level, the Queensland Law Society (QLS) has recently released Domestic and Family Violence Best Practice Guidelines84 to assist practitioners in dealing with legal matters for those that are impacted by domestic and family violence, as part of the current reform agenda.

The primary principle of the guidelines prioritises safety, which is an underlying tenet of the document. With respect to the issue of risk, the guidelines outline strategies to prioritise the safety of victims and their children but caution that lawyers should recognise their limitations in assessing risk and consider whether referral to another service should be made.

At the outset, the guidelines note that when dealing with perpetrators of domestic and family violence, practitioners must not give advice that may compromise the safety of the client, other party or any children of the relationship. It further articulates that lawyers should ‘be aware of perpetrators’ potential to manipulate and exert control’ and ‘do not allow yourself to be drawn into or act in furtherance of such behaviour’.

This is particularly salient with respect to the death of Gabby, in which lawyers for both parties negotiated orders regarding the care and custody of the child. While ostensibly it appeared that the lawyers were working towards a unified position that enabled both parents reasonable access to the couple’s child, the respondent’s lawyer on several occasions attempted to obtain information, seemingly for the purposes of locating Gabby, specifically contravening a condition of that order.85

The guidelines also suggest practitioners consider information pertaining to mental health. For example, they suggest that where information is received that a perpetrator has experienced mental health or substance use issues, the lawyer should consider this when referring their client to a perpetrator intervention program, and where possible provide referrals to support programs addressing all of these issues in a holistic manner.

Information for further training, resources and other support options are also listed within the guidelines.

With respect to training, the QLS notes that the Queensland Centre for Domestic and Family Violence Research offers regular video link seminars to keep practitioners current in their knowledge and understanding of domestic and family violence; and that Central Queensland University also offers specific postgraduate training in domestic and family violence.

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Non-lethal strangulation

A history of non-lethal strangulation86 was evident in six of the homicide cases, two of the homicide-suicides, two of the perpetrator suicides, three of the victim suicides and two of the filicide cases considered by the Board.

Strangulation is a particularly gendered form of violence in which most perpetrators are men, and nearly all victims are female. Despite its strong association with increased lethality and harm, it was often misidentified or minimised by victims, police and the courts in the cases subject to review.87

While recent legislative amendments have occurred to improve system responses to acts of non-lethal strangulation,88 it is important to note the prevalence of non-lethal strangulation within these case reviews, the need to ensure it is appropriately identified and recorded, and the importance of providing early intervention where this type of violence is detected.

In some cases, offenders had a history of perpetrating non-lethal strangulation against multiple former partners which was most often recorded in police files. This information was not, however, easily accessible to officers responding to future reported episodes of violence.

Investigating officers at times also did not record acts of non-lethal strangulation clearly, resulting in a lack of identification of, and corresponding response to, this behaviour.

On occasions where prior acts of non-lethal strangulation were identified in police records, these were recorded as clinching her by the throat, grabbed the victim by the throat or as placing his hand around her neck and pinching her throat with his fingers. Naming this behaviour as an act of non-lethal strangulation is critical in ensuring this risk indicator is easily identifiable and to ensure the seriousness of this behaviour is detected and responded to.

The Queensland Police Service (QPS) Protective Assessment Framework89 which aims to assist officers to better respond to domestic and family violence includes prior episodes of non-lethal strangulation as a Category 1 Risk Factor.

In one particular case reviewed by the Board that occurred more than two years after the implementation of this Framework, police responded to a domestic violence related occurrence but do not appear to have taken into account an act of non-lethal strangulation by the primary perpetrator just a few days earlier, with the subsequent assessment of risk based solely on this perpetrator’s account of events.

The QPS subsequently identified the victim as a respondent on this occasion prior to locating and interviewing her, even though just a few days earlier she had begged police for assistance as she feared for her life.

86 Both current and former partners 87 Douglas, H. & Fitzgerald, R. (2014). Strangulation, Domestic Violence and the legal response, Sydney Law Review, 36, 231-254. 88 The addition of s315A to the Criminal Code 1899 (Qld) prescribes offences relating to the unlawful choking, suffocating, or strangling of an individual in a domestic setting. 89 Implemented in 2012, the QPS Protective Assessment Framework is a decision making framework designed to assist officers in assessing the protective needs of an aggrieved person by identifying

the presence of risk factors and assessing the aggrieved individual’s level of fear. 90 The QPS Vulnerable Persons Training Package is a two day, face to face training session which equips police with the knowledge and skills to work within the new legislative frameworks for domestic

and family violence and mental health. The QPS intend rolling out training to 11,500 officers across the state. The first day of training focuses on policing responses to people with mental illness and mental health issues with a focus on suicide prevention working in conjunction with partner agencies. The second day focuses on the challenges of responding to and investigating incidents of domestic and family violence. Officers are provided with a greater understanding of the dynamics of domestic and family violence.

91 Section 9.6.2 Investigating domestic violence – Choking, suffocation or strangulation in a domestic setting 92 Kranz, A., & Nakamura, K. (2002). Helpful or harmful? How innovative communication technology affects survivors of intimate violence. MINCAVA Clearinghouse, Minnesota Centre against Violence

and Abuse. Available at: http://www.mincava.umn.edu/documents/5survivortech/5survivortech.html 93 Kee, J. (2005). Cultivating violence through technology? Exploring the connections between information communication technologies and violence against women. Association for Progressive

Communications. Available at: http://www.apc.org/en/system/files/VAW_ICT_EN.pdf 94 Hopkins, S. & Ostini, J. (2015).. Domestic violence and Facebook: harassment takes new forms in the social media age. The Conversation. 30 November 2015. Available at: http://theconversation.

com/domestic-violence-and-facebook-harassment-takes-new-forms-in-the-social-media-age-50855

This demonstrates the limitations of an incident based tool and systems in which officers may encounter difficulties in easily and adequately taking into account past patterns of violence and harm to inform future responses.

While recognising legislative amendments in this area, the Board identified that it would be important to roll-out comprehensive and appropriate training for first-responders or other specialist services, to identify the signs of non-lethal strangulation, and ensure referral for appropriate medical treatment where this type of violence is identified.

Police have already undertaken such training as part of the state- wide roll out of their Vulnerable Persons training package,90 with the implementation of supporting investigation guidelines within their Operational Procedures Manual.91

Legal practitioner training may be required to improve the successful prosecution of such matters through court.

There may also be a need for increased community awareness about the dangers of non-lethal strangulation as victims may not understand its associated links with lethality, or the need to seek medical treatment after such an act occurs.

Technology facilitated abuse

An emerging trend throughout these cases was the prevalence of technology facilitated abuse and harassment via text, email and social media. In several cases this was used as a means by which to publicly shame a victim when the perpetrator posted intimate pictures, videos or abusive messages to Facebook or other social media sites for the victim’s family and friends to see.

The internet can be beneficial for victims of domestic and family violence in providing them with increased access to information and support, and by allowing service providers and advocates to reach out.92 At the same time, evidence continues to demonstrate that technology is progressively being used as a new avenue for perpetrators to abuse their victims including by stalking, monitoring and harassing them.93 There are challenges in restricting this type of behaviour. Although numbers or user profiles can be blocked, harassment can still continue through mutual friends’ accounts or by a perpetrator changing numbers. Online harassment is pervasive and can further isolate victims from their social network and supports94 and damage their personal and professional reputations.

Existing legislation may restrict the capacity for police or other agencies to swiftly respond.

For example, in one case, police failed to detect that a perpetrator who had sent hundreds of messages in the space of a few hours was in fact harassing the victim and causing her significant fear and distress, regardless of the content of the messages.

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Despite the reported increase in technology facilitated abuse, recognition of the seriousness of this behaviour and its corresponding effect is lagging behind.95 Physical harm, or threats of physical harm, continue to be taken more seriously and by extension, victims are generally better protected against this type of violence.96

Victims are also less likely to recognise this form of abuse as a potential indicator of heightened risk or danger to themselves. In a number of the cases reviewed by the Board, victims stated they were not fearful of the respondent because of the continued harassment via social media and text, but primarily concerned about their partner’s risk of self-harm and mental health.

While these technologies can be a quick and accessible medium through which to stalk and harass a victim, they can also be effective evidence. Victims should be encouraged to retain this evidence for the purposes of pursuing criminal charges.

In one case, police successfully prosecuted a respondent for breaches to a protection order with no contact provisions, after he posted derogatory messages to the aggrieved individual’s social media accounts.

The link between domestic violence and technology facilitated abuse is well established by a growing body of evidence. Most significantly, in 2015, the Recharge: Women’s Technology Safety project97 released findings of a national survey of over 546 domestic violence service practitioners with almost all survey respondents (98%) stating they had clients who had experienced technology facilitated abuse and stalking.

This issue is a priority for all levels of government and has been a specific focus of the Council of Australian Governments (COAG) Advisory Panel on Reducing Violence against Women and their Children. In recognition of the rising prevalence and significant harm caused by this type of abuse, funding has been dedicated to research, policy and collaborative solutions as part of the Australian Government’s Women’s Safety Package to Stop the Violence.

As part of this work, the Office of the Children’s eSafety Commissioner has implemented the eSafety Women’s Project; an online resource designed to empower women to take control of their online experience and manage technology risks and abuse. Free resources are provided to support women and services to address issues such as online abuse; cyber stalking; eSafety planning; keeping children safe; safe engagement with social media; and tips to understanding and using devices safely.

The WESNET Safety Net Australia Project, established in 2011, is another key initiative seeking to examine the intersection of violence against women, and technology. WESNET provides research and policy advice; advocacy; and delivers technology safety training based on a best-practice model developed by the National Network to End Domestic Violence (NNEDV) in America.

This training has been delivered throughout Australia to a range of stakeholders including domestic and family violence practitioners; sexual assault crisis services; health professionals; magistrates; police, youth and disability services; alcohol and other drug workers; and Aboriginal and Torres Strait Islander services.

95 Sun, C. (2015). Technology-facilitated stalking and abuse: Putting our legal framework to the test. Law Society Journal, 78-79. Available at: http://www.wlsnsw.org.au/wp-content/uploads/LSJ- Article-Charissa-Sun-June-2015-LSJ.pdf

96 Ibid. 97 A collaboration between the Women’s Legal Service NSW, the Domestic Violence Resource Centre Victoria (DVRCV) and WESNET which was funded by the Australian Communications Consumer

Action Network. 98 Available online at: https://www.communities.qld.gov.au/communityservices/women/queensland-violence-against-women-prevention-plan-2016-22

WESNET also provides free access to research and resources designed to support women experiencing technology-facilitated abuse and those agencies working with them.

The Board notes that the Queensland Government has reaffirmed their continued commitment to working with other jurisdictions and the Commonwealth to take action to limit technology- facilitated abuse as part of the Queensland Violence against Women Prevention Plan 2016–2022.98

Accordingly, the Department of Community Child Safety and Disability Services (DCCSDS) reports that it is trialling new technologies as part of safety upgrades to keep women safe in their homes, in four locations around the state.

Systems abuse

Systems abuse, or the abuse of processes in the course of domestic and family violence related proceedings, is a tactic used by perpetrators to gain an advantage over, or to harass, intimidate, discredit, or otherwise control victims as a means of reasserting power over them. In this sense, the role of protective systems may unintentionally facilitate coercive controlling behaviours which trivialise or silence a victim’s experiences of abuse or dissuade help-seeking attempts.

Within the Board’s review of cases this included:

» threats to call police by the perpetrator to get their victim in trouble, particularly in those cases where cross-protection orders were in place

» attempts to discredit their current or former partner’s capacity to care for their child/ren to services

» alleging their partner had a mental illness in an attempt to discredit them to responding services.

While these types of behaviours were present in a range of cases reviewed by the Board, the impact of this was tragically most evident in the filicide cases.

In the majority of the filicide cases, investigations identified that the deceased infant had multiple injuries with signs of healing, indicative of multiple assaults over time or that the (ultimately) fatal assault occurred sometime before the actual death. In all cases, there is a significant likelihood that had medical intervention been sought at an early point, the deaths could have been prevented, or at the very least, the suffering of the infants could have been minimised.

Three of the mothers within these cases told police after the death that they had attempted on multiple occasions to seek medical treatment for their child, but were prevented from doing so by their partner. In the other case, the perpetrator was known to be highly controlling and the victim expressed that she complied with the perpetrator out of fear of future assaults or an escalation in his abusive behaviours.

In these cases, the perpetrator reportedly silenced the mother/s with threats that Child Safety Services would remove the child/ren if medical treatment was sought for the injured infant.

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Even after the deaths, some of the mothers took steps to protect their abusive partner throughout the police investigation.

Mandatory reporting laws have been in place across Australian jurisdictions for suspected cases of child abuse and maltreatment for decades, which specify the persons who have a mandated obligation to report; what types of abuse and neglect must be reported; and outlines confidentiality protections for the notifier.99

Concerns regarding mandatory reporting laws have primarily focused on the issue of overburdening child protection systems with cases, in recognition that the degree of risk and harm to a child is dependent on a range of personal, familial and situational characteristics. It has been suggested that the intention of mandatory reporting laws should be to primarily capture severe cases of abuse and neglect requiring state intervention, while having concurrent processes in place to ensure appropriate referral to, and deployment of, supportive community agencies for situations of less severity.100

While mandatory reporting laws are a critical component of holistic community responses to child abuse and neglect, similar to mandatory reporting laws for domestic and family violence, there may be unintended consequences that can compromise a victim’s safety or that of their children.

Applicable to these cases, an unintended consequence of mandatory reporting is that the prospects for help-seeking are likely to decrease as parental fears of statutory child protection intervention heighten. The fear of statutory intervention and child removal may be a driving force influencing a parent’s decision to postpone, or entirely withhold, access to appropriate medical attention for a child.

To avoid detection, high risk perpetrators and families, may become increasingly avoidant and transitory in their relationships with support services,101 which will ultimately render service systems incapable of ongoing surveillance and oversight, and in turn, increases the risk of harm to the child.

99 Australian Institute of Family Studies. (2014). Families, policy and the law: selected essays on contemporary issues for Australia, Australian Government, https://aifs.gov.au/publications/families- policy-and-law/14-mandatory-reporting-laws

100 Ibid. 101 Mathews, B. (2014). Mandatory Reporting Laws and Identification of Child Abuse and Neglect: Consideration of Differential Maltreatment Types, and a Cross-Jurisdictional Analysis of Child Sexual

Abuse Report, Social Sciences, 3, 460-482. 102 Queensland Family and Child Commission have recently launched a campaign to promote help seeking behaviours among families: https://www.talkingfamilies.qld.gov.au/

It is well-established that a fear of child removal by statutory services is a factor that prohibits disclosure by domestic and family violence victims (particularly those who identify as Aboriginal and Torres Strait Islander) but what appears to be less well understood is the use and impact of this threat as a coercive controlling tactic by perpetrators on victims, and their children, to the extent it precludes vital treatment or intervention.

This type of behaviour represents a form of systems abuse, and as demonstrated in these cases, can have tragic outcomes.

The question becomes how can the service system respond to counteract the impact of such threats and ensure that during situations of significant harm, victims have confidence that as much as possible, the service system will work with them and not against them to improve protective outcomes for themselves and their children.

In recent years, Child Safety Services has moved towards a practice approach that seeks to hold perpetrators of domestic and family violence accountable for their actions rather than holding mothers to account for a failure to protect their child(ren).

To that end, the cultural paradigm driving child safety responses has shifted to recognise that the safety of women and their children is paramount and that partnership with mothers is the foundation from which to plan family safety and effectively intervene with fathers.

This is a positive step towards fairer and safer outcomes for families affected by domestic and family violence. It will require sustained efforts to embed cultural change and practice among child safety workers. It also requires a ‘whole of systems’ approach that requires child protection workers be better equipped to be supportive of mothers in their decision making where harm associated with domestic and family violence has been substantiated, and ongoing community awareness that aims to promote help-seeking behaviours among at risk families.102

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Chapter 5: Strengthening our systems

103 For the purposes of the death review process, the following definitions apply: Deceased: the person/s who died; Offender: the person whose actions, or inaction, caused the person (the deceased) to die; Victim: the person who was the primary victim of the domestic and family violence in the relationship and the person most in need of protection; Perpetrator: the person who was the primary aggressor in the relationship prior to the death and who used violence within the relationship to control the victim.

104 Meyer, S. (2011). Seeking Help for Intimate Partner Violence: Victims’ Experiences When Approaching the Criminal Justice System for IPV-Related Support and Protection in an Australian Jurisdiction. Feminist Criminology, 6, 268-290.

105 Willis, M. (2011). Non-disclosure of violence in Indigenous communities, Trends and Issues in Crime and Criminal Justice, no. 405, Australian Institute of Criminology, Canberra.

In the reviews of domestic and family violence deaths, the Board is required to consider the events leading up to the death; any interaction with and the effectiveness of any support or other services provided to the deceased person, and the person who caused the death; the general availability of these services; and any failures in systems or services that may have contributed to, or failed to prevent, the death.

This chapter provides a broad summary of the discussions regarding the service response prior to the death/s in the cases reviewed by the Board during this reporting period.

While it is not possible to capture the full extent of the state and national reforms applicable to the circumstances of these cases, this chapter also broadly recognises and acknowledges the positive reforms underway across Queensland that aim to improve responses to victims and perpetrators of domestic and family violence; as well as address broader issues around mental illness, child protection and probation and parole.

In all but one case considered by the Board during the 2016–17 reporting period, the victims and perpetrators had contact with a variety of generalist and specialist services prior to their deaths.103

This included:

» Nineteen cases (70.4%) where the victim and/or perpetrator had contact with health services including presentations for assault-related injuries, mental health or alcohol and other drug treatment, and/or suicidal self-harm. This was inclusive of 13 cases (48.1%) where the victim and/or perpetrator had contact with mental health services.

» Twenty three cases (85.2%) where the victim and/or perpetrator had contact with police in relation to domestic and family violence and/or other offences in either their current or a former relationship, prior to the death.

» Six cases (22.2%) where the victim had contact with specialist domestic and family violence services, including women’s refuges. There were also three cases where a perpetrator had contact with a specialist domestic violence service for a perpetrator intervention program.

This chapter focuses on those ‘generalist’ services that are regularly required to respond to domestic and family violence. While it is separated into sections focused on health, criminal justice and child safety for the convenience of the reader, it is important to recognise a person’s journey through the system and across the different agencies is not linear.

In recognition of the inherent complexities in responding to domestic and family violence, a collaborative and complementary combination of legal and psychosocial support is demonstrated to be the most effective in addressing victims’ needs for support, protection and recovery from violence.104

While each agency has a critical role in keeping victims and their children safe, and holding perpetrators to account, all agencies

must be consistent in their responses to both perpetrators and victims to ensure a robust and comprehensive service response that aims to reduce both current and future risk of harm.

For the sake of brevity, specialist domestic and family violence services are considered within Chapter 1 of this report, as the Board made specific recommendations regarding these services to the Attorney-General in June 2017. Perpetrator intervention programs are covered in Chapter 5.

Service engagement and response

Across different services a reluctance to engage by victims and perpetrators was noted in 16 cases reviewed by the Board.

In some cases, this appeared to be taken as implicit justification by agencies for the lack of service provision, even in circumstances of extreme violence or frequent system contact. In discussions regarding this issue, the Board acknowledged that services are not only for those who are actively willing to engage. Agencies must be responsive to individual needs and conscious of identifying and addressing any barriers to help-seeking as soon as possible to achieve optimal outcomes.

Across the service system, the Board observed that:

» There was a disproportionate focus on reactive responses in the majority of cases, often when the situation had escalated to crisis, with limited evidence of services working with clients at an earlier point or over the longer term.

» Some service responses were marred by an undercurrent or tone of judgement that the victims didn’t remove themselves from the violent situation. Indeed, in one case, a specialist domestic violence worker told a victim who had recently given birth that Child Safety Services would not hesitate to remove the child if the violence continued, with the victim ceasing contact with that agency shortly afterwards.

» There was a pronounced reluctance by Aboriginal and Torres Strait Islander women to engage with services in the cases reviewed. This is, in part, indicative of an ongoing fear and distrust of police, the justice system and other government agencies105 as well as a fear of reprisal from the perpetrator, and/or respective families.

» There was evidence that when perpetrators did seek support, particularly from mental health services, the responses were generalist in nature and did not consider their specific or underlying needs or self-disclosed abuse indicators.

» A lack of service choice, or consideration of the appropriateness of referrals, was also noted as a barrier to engagement in some of the cases. For example, a perpetrator with substance use issues who identified as Aboriginal was referred repeatedly for alcohol and drug treatment with an Aboriginal and Torres Strait Islander service, however, he did not engage with the agency because of a previous

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negative experience which was not identified at the initial referral point.

» In several matters, individuals and families were closed to services as they had been unable to contact them or because they had not engaged with practitioners when required.

The Board identified that vulnerable families or high-risk perpetrators may go to great lengths to remain ‘invisible’ from services, and will actively avoid contact with these services, as was evidenced in several of the filicide cases. In this regard, failing to attend a service should, in certain circumstances, trigger a warning to increase efforts rather than withdraw services. For families experiencing unstable accommodation or other complex risk factors, there is a corresponding need for services to be proactive and persistent in attempting to locate and engage with individuals.

The Board also acknowledged that the majority of cases involved multiple, complex and co-occurring issues highlighting the importance of integrated service responses and the challenges associated with their application.106

The vital importance of ensuring services were responsive and cognisant of the nature and dynamics of domestic and family violence was also clear; whether services were providing brief interventions, specialist support or a referral to another agency.

Being cognisant that one size does not fit all and tailoring interventions to meet an individual’s needs can be an effective mechanism for change with respect to domestic and family violence, child welfare concerns, substance use and mental health problems.

The Board noted ongoing work at a national and state level to address barriers across sectors and improve service integration and collaboration, however, the sectors required to respond to these (often) interrelated issues have all evolved separately over time and while reforms may occur concurrently, they may not always take into account co-occurring issues in a holistic way.

Notwithstanding these challenges, positive practice and opportunities to enhance responses were identified in the Board’s review of these cases, which represent critical learnings to continue driving the significant reform agenda in Queensland.

The Board also acknowledges that the Department of Community, Child Safety and Disability Services (DCCSDS) is currently leading a ‘Domestic and Family Violence Support Services Practice Standards Development’ project. The department has contracted Encompass Family and Community and consortium partners to review the current practice standards for working with victims and perpetrators, and to develop a suite of evidence-based minimum standards and guides.

The standards will apply to all service types funded under the domestic violence funding area (including local service systems, women’s and children’s services, counselling, court services, Aboriginal and Torres Strait Islander services and perpetrator intervention programs.

106 For example, a recent study by ANROWS, identified some of the challenges associated with implementing an integrated service response to domestic and family violence, including: Power imbalances between agencies; Lack of common ground between perspectives and disciplines; Individual (client) perceptions of cross-agency control; Communication problems between and across services as a cause of frustration for clients and staff; Unsustainability due to resource limitations; and Loss of specialisation and tailored responses. They suggest, that overall, the anecdotally and empirically-derived potential benefits of integration appear on face value to outweigh the challenges. The evidence base on the effectiveness of integration is limited and therefore restricts definitive conclusions being drawn. Breckenridge, J., Rees, S., Valentine, K. and Murray, S. (2016). Meta-evaluation of existing inter-agency partnerships, collaboration, coordination and/or integrated interventions and service responses to violence against women. Key findings and future directions. ANROWS Compass series, Research to policy and practice. Issue 05: July 2016.

107 Hovane, V. & Cox, D. (2011). Closing the Gap on Family Violence: Driving Prevention and Intervention through Health Policy. Australian Domestic and Family Violence Clearinghouse. Issues Paper 21 108 Plichta, SB. (1997). Violence, health and the use of health services. In: Women’s Health: health and care seeking behaviour. Baltimore: John Hopkins University Press.

In addition to new practice standards, the project also aims to develop: a role description and guidance for court support workers; a tool to assist with monitoring compliance with perpetrator intervention standards; and a training package to assist service providers embed the new standards in practice.

Health service system contact

The health impacts of domestic and family violence are substantial, extending beyond just physical injuries and include a range of ongoing mental health problems, and substance use issues.

Research has shown that the negative health impacts for victims not only occur while they are experiencing abuse, but may persist for years following the cessation of violence as victims try to cope with any ongoing injuries, trauma and other mental health or substance misuse concerns.107

Abused women also often describe their physical and mental health as fair or poor and are more likely to see a general practitioner than non-abused women.108 It is also the case that female victims of domestic and family violence may minimise or fail to recognise they are victims of violence, particularly in cases where the violence is predominantly non-physical in nature, or the effect of the abuse is masked by co-occurring issues such as mental illness and problematic substance use.

Further, perpetrators of violence may also come into contact with health services for a range of related concerns, and as such, health settings represent an opportunity for intervention and response to both victims and perpetrators of domestic and family violence.

A large proportion (70.4%) of both victims and perpetrators in the cases reviewed by the Board had a previous history of contact with health services. This included contact with a range of clinical and non-clinical staff within hospital and health services, paramedics, general practitioners, counsellors, social workers, psychologists and psychiatrists; in the private and community sectors as well as the public health system.

This contact was predominantly due to:

» assault related injuries requiring medical intervention and treatment

» maternity related admissions

» presentations associated with mental health problems, problematic substance use, suicidal self-harm or for relationship counselling and therapeutic support.

Common themes, issues and patterns identified with respect to health system contact across the cases included:

» Domestic and family violence was rarely identified or meaningfully responded to, even in circumstances where there were compelling indicators, or on some occasions open disclosures of abuse. This subsequently precluded the provision of effective support, interventions or referrals to specialist services, and also impacted on treatment outcomes

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» in instances where the focus remained predominantly on the presenting issue and not underlying contributing factors.

» The presence or quality of policies, procedures and training on domestic and family violence across services was inconsistent. While significant work has been undertaken as part of the current reform agenda to provide consistent and standardised training for all staff across both public and private hospital and health services,109 it must be recognised that training programs are not currently mandatory.

» A significant barrier to the provision of effective support was the capacity of perpetrators to strategically and favourably alter their presentation to others, thereby masking or minimising the impact of their abusive behaviours. Perpetrators who presented with suicidal ideation or attempts also used this as an opportunity to portray themselves as the victim requiring attention and sympathy; with their distress being attributed to relationship issues, conflict or marital disharmony as opposed to abusive tactics. In some cases, this translated to practitioners inadvertently colluding with or supporting a perpetrator’s ongoing abuse of their partner.

» A number of victims were conveyed to emergency departments with assault-related injuries and in some cases, a history of violence was known to staff (either through information sharing by frontline services or via historical patient records) with limited follow-up or investigation of these issues. Although the extent to which health practitioners are able to address underlying psychosocial issues is somewhat limited in acute or crisis-focused settings, there are still avenues for referral as well as social workers attached to emergency departments or other services (although they may not operate on a 24 hour basis).

» Victims were occasionally noted as being reluctant to engage, or to disclose their experiences of domestic and family violence, particularly in emergency department settings. The involvement of social workers elevated the likelihood the violence was identified and maximised the potential for follow up contact.

» Where routine domestic and family violence screening existed, such as within a maternity health care setting, the use of the tool was sporadic and not always completed, or there were no self-disclosed or identified indicators of domestic and family violence (even where corresponding records indicated abuse had occurred previously).

» Formal risk assessments were often incomplete or not undertaken. In a number of cases where perpetrators were subject to a risk assessment, the focus was almost universally on whether or not they themselves were at risk of (commonly, self) harm, rather than identifying the risk of harm they potentially posed to others.

» In some cases, engagement with a health practitioner was short-term or sporadic, which also impeded the development of effective rapport and treatment. Sometimes the provision of effective supports was inhibited by the transient lifestyle of the couple and where attempts were made to follow up, they could not be located, or contact details had not been sought or were incorrect. For example, Alcohol, Tobacco and Other Drug Services (ATODS) staff worked tirelessly to find short-term accommodation for one chronically disadvantaged victim, only to find she could not be located for transport

109 Queensland Health have developed a toolkit of resources and an online training package to help health practitioners respond appropriately if they become aware of an incident or disclosure of domestic and family violence. Refer to: https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/patient-safety/duty-of-care/domestic-family-violence/healthcare-workers.

to the residence. The victim later lost her place at the designated accommodation.

» There was limited evidence of comprehensive discharge planning or referrals, particularly in relation to suicidal behaviour or admissions associated with assault- related injury. Where discharge planning occurred, it tended not to take into account prior recent admissions to inform the development of a more tailored treatment or discharge plan.

The stature and profession of one particular perpetrator was considered to have potentially influenced staff perceptions as he was healthy, athletic, and presented as remorseful.

In another case a perpetrator was described as politely declining a referral indicative of a perception that the staff were dealing with a ‘nice guy’ with limited consideration of broader context of his disclosed behaviours or their impact on his family and friends. The same perpetrator had disposed of all of his former spouse’s possessions, had attempted suicide on multiple occasions, subjected her to months of harassment and stalking and broken into her house and tried to attack her.

Perpetrators who presented with suicidal ideation or attempts also appeared to use this as a means to portray themselves as the victims requiring attention and sympathy. There are obvious difficulties for services in effectively addressing this type of abuse, where the underlying causal factors may not be immediately recognisable; and the challenges with relying on self-reporting when working with perpetrators of domestic and family violence should not be underestimated.

Recommendation 2

That the Department of Health introduce mandatory training for staff who may come into contact with victims and their children, or perpetrators, of domestic and family violence. The training should be delivered to a standard (or level) that proficiency can be measured. This should cover:

(a) risk screening, assessment and management processes

(b) enhancing understanding of risk factors;

(c) comprehensive discharge planning and follow-up care that takes into account the safety of both self and others, including appropriate referrals

(d) appropriate safe information sharing in accordance with Queensland Health guidelines

(e) specialist non-lethal strangulation training for accident and emergency departments that aims to assist in recognition of the signs of this type of violence, but also in the collation of forensic information to inform the prosecution of any related criminal charges.

Maternity and ante-natal care

Maternity admission assessments have been introduced in many jurisdictions, including Queensland, to screen for domestic and family violence during pregnancy in recognition that there is an increased risk of harm during this time. Routine screening for domestic and family violence in health care settings may also reach many victims who have not previously disclosed abuse,

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and assist a proportion of these victims to address the traumatic impacts of abuse.

There is evidence that the Queensland Health Safe Start Psychosocial Assessment was administered to several of the mothers but the presence of domestic and family violence were not disclosed to practitioners in any of the cases reviewed by the Board. On some occasions the screening was not completed which may have been due to the presence of the abusive partner at the appointment (although this cannot be confirmed) or due to a lack of training and awareness by practitioners. There was also limited evidence of attempts to re-administer the screening tool as part of ongoing prenatal care.

In cases where shared care arrangements were present, there was no evidence of screening by general practitioners for domestic and family violence; or communication regarding this in hospital records.

In accordance with recommendation 54 of the Special Taskforce on Domestic and Family Violence Final Report,110 Queensland Health commissioned an evaluation of the frequency and efficacy of antenatal screening for domestic and family violence which has been recently completed but is not yet publicly available. An expert working group has been convened to develop a new screening tool which is expected to be available for consultation by the end of 2017. The Board is eager to see how this will be rolled out in private obstetrics and health facilities, in addition to publicly operated antenatal care facilities.

Where concerns of potential risk of harm to infants were identified, hospital staff was vital in ensuring referrals were made to child safety services, including raising significant concerns about one infant they suspected had been abandoned by the parents shortly after birth.

There was also evidence of hospital staff dismissing concerns about the abusive perpetrator being present at the birth of a couple’s child in one case, despite being aware of the history of domestic violence and being advised that there was a current protection order prohibiting contact with the victim.111 The response from the hospital staff at that time was reportedly he is the father and he has a right to be here even after security intervened because he was verbally abusive to a family member of the victim, who was a named person on the order. Staff subsequently put plans in place to minimise the contact between him and other family members, but did not make any reports to police of the threats and the apparent breach of the no contact conditions on this order.

Further, in the review of the filicide cases by the Board, there was limited evidence of maternity and post-natal support by health practitioners who may have been in a position to detect and respond to indicators of abuse.

In one case an expectant father who had a significant prior history of child abuse and maltreatment, presented to the service just prior to the birth, expressing concerns about his capacity to cope with a new-born child. While he was referred to alcohol and drug treatment services because of disclosed substance use issues, his parenting concerns were not explored in any further detail and no

110 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 111 An application had been made but the order had not been issued at the time as the respondent had not been able to be located by police. The aggrieved, and her family member who was a named

person, were of the belief that they were being protected by the order. Regardless, hospital staff understood that a protection order was in place at the time of service delivery. 112 Recommendation 53. 113 Australian Institute of Health and Welfare 2015. Screening for domestic violence during pregnancy: options for future reporting in the National Perinatal Data Collection. Cat. no. PER 71. Canberra:

AIHW. Available online at: https://www.aihw.gov.au/getmedia/62dfd6f0-a69a-4806-bf13-bf86a3c99583/19298.pdf.aspx?inline=true 114 Refer to: https://www.ranzcog.edu.au/news/RANZCOG-welcomes-Medicare-funded-mental-health-sup 115 Refer to: http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-ObstetricsServices

supports or referrals were offered to him to help him cope with the stressors associated with parenting.

In this respect, the Board identified that there may be opportunities to improve the supports available for families, including fathers, during this critical high-risk period, with the aim of facilitating earlier access to potentially beneficial services that may be able to address their broader support needs.

Upon discharge there was limited evidence of any post-natal support or follow up occurring in the cases, and where this did occur, there was a noted lack of engagement by the victims.

There may be myriad reasons why women choose not to engage with antenatal care or postnatal support services. A failure to engage should be considered as a potential warning sign particularly in cases where there is a known or suspected history of domestic and family violence or child abuse and maltreatment.

There is also a need for care to be tailored to suit the individual where possible through out-reach or other proactive approaches, as some women may not attend hospitals as they do not feel comfortable in these environments.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has a comprehensive training and development program for medical practitioners which was recognised by the Special Taskforce in their final report. The Special Taskforce also identified that once practitioners achieved registration there was no ongoing efforts to ensure that they use the available resources and screen their patients as a matter of routine.

Accordingly, the Special Taskforce recommended that the RANZCOG continue to expand the resources available to trainees and practitioners, and develop a strategy to actively engage with Fellows to encourage ongoing use of the resource.112 The Queensland Government supported the intent of this recommendation and the Minister for Health wrote to the college to provide access to the Queensland Health training resources for clinicians and health workers.

The Australian Institute for Health and Welfare (AIHW) recently released a report113 outlining the opportunities and barriers for the collection of data on screening for domestic and family violence during pregnancy. It identified a lack of consistency and routine screening tools across the country as a significant barrier.

In Queensland, a risk assessment and screening tool has been recently trialled in the Royal Brisbane and Women’s Hospital and it is intended that this will be used for routine screening although this has not yet been rolled out.

Imminent amendments to the Medicare Benefits Schedule (MBS) have been welcomed by the RANZCOG114 and are likely to have a positive influence in increasing screening for domestic and family violence amongst private practitioners. Subject to the passage of legislation, from November 2017 changes to obstetrics items and the introduction of new items will occur.115 Mental health screening of mothers will be Medicare funded for women during pregnancy

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and up to two months after the birth. A new obstetric MBS item will also be introduced to cover mental health assessment, screening for drug and alcohol use and domestic violence during the postnatal period.

The Board considers there is still a need to embed screening for domestic and family violence as routine practice amongst all practitioners including private obstetricians and gynaecologists.

Recommendation 3

That the Department of Health consider ways to enhance the delivery of post-natal care for all families with a focus on equipping them with the requisite skills to care for a newborn infant. The Department should consider and incorporate intensive and robust maternity and post-natal support models of care for all high-risk and vulnerable families with a focus on continuity of care options (including midwives), the use of multidisciplinary teams to address broader support needs, and specific interventions and support for fathers.

Recommendation 4

That the Department of Health consider ways to ensure culturally appropriate maternity and post-natal care for Aboriginal and Torres Strait Islander families are available. This should include a focus on increasing and supporting a specialist workforce in this area, and the provision of outreach support services that aim to engage with hard to reach families.

Recommendation 5

That the Department of Health liaise with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to promote routine screening for domestic and family violence, and enhanced responses to high-risk and vulnerable families in private obstetrics and health facilities.

Mental health, alcohol and other drug services

In the cases reviewed by the Board, 11 victims116 had contact with mental health services prior to the deaths and 19 perpetrators had contact with mental health services, most commonly in the context of relationship separation or ‘conflict’ and as a result of expressed suicidal ideation or attempts.

This is unsurprising given the known correlation between domestic and family violence and mental health concerns. It also highlights the critical importance of a well-trained, resourced and connected mental health system with cross-agency and community partnerships which address the needs of clients presenting with multiple and complex psychosocial factors in the context of domestic and family violence.

Common themes and issues with respect to mental health treatment in these cases include:

» Inconsistent screening and limited apparent response to disclosures of behaviour consistent with domestic and family violence, or potential indicators of risk.

116 This included cases of victim suicide, intimate partner homicide and filicide, where the victim was the biological mother of the child who was killed.

» Responses were largely focused on addressing immediate presenting issues with limited attention afforded to underlying determinants of mental health; a core tenet of an evidence-based recovery oriented approach.

» Perpetrators were frequently adept at manipulating perceptions of themselves and minimising their abusive behaviour which significantly limited comprehensive risk assessment and treatment approaches in those cases where screening was completed. Screening tools used which did assess for domestic and family violence, were predominantly focused on detecting victimisation, as opposed to perpetration of violence.

» Evidence that practitioners actively sought relevant collateral information was limited and in some cases potential sources of information were closed due to perceived confidentiality conflicts (even in cases where third parties sought to provide information only and in circumstances where the safety of others was an imminent concern). In other cases, family and friends were interviewed in front of the patient which precluded an open disclosure of the concerns they held for that person’s welfare.

» Significant issues were identified with discharge planning immediately prior to the death in three cases, including a perceived overreliance on family members, and even the victim themselves, to care for the suicidal person, in circumstances where they were noted to be an abusive person.

» Problematic substance use was a common co-occurring issue although there was limited evidence of dual diagnosis or an integrated approach to treatment strategies.

In 24 cases (88.9%) problematic substance use issues were identified for the perpetrator, the victim or both parties. Of this cohort, there was evidence to suggest engagement with treatment services for three of the victims and one perpetrator, within reasonable proximity to the death.

With respect to contact with alcohol and other drug services in the cases subject to review by the Board, the following observations were made:

» Several of the victims and perpetrators experienced drug and/or alcohol use issues with the severity occurring along a continuum of problematic use to dependence or addiction.

» This drug use was a noted barrier to the provision of services in some cases and impeded the provision of primary care as well as referrals to relevant support services.

» There was limited evidence that domestic and family violence was screened or considered by treating health practitioners despite disclosures or indicators.

» There was limited evidence that domestic and family violence was screened or considered by treating health practitioners despite disclosures or indicators.

The challenges associated with responding to the co-occurrence of substance use, mental illness and domestic and family violence victimisation was explored in further depth within the Systemic Review Report of the Domestic and Family Violence Death of Tricia, released by the Board in June 2017.

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This report highlighted the significant relationship between substance use and trauma exposure among women with up to 80% of treatment seeking women reporting a lifetime history of sexual or physical abuse.117 This is proposed to be in part because traumatised women often engage in substance abuse, or ‘self- medication’, as a maladaptive coping mechanism.

Further, as highlighted above, while co-occurring mental health and substance use problems were identified by practitioners, there was limited evidence of an integrated response to these co-morbidities.

Unfortunately, the presence of these issues often masked abuse and on some occasions, intoxication was a barrier to service and treatment provision. Conversely, there were two examples where couples were excluded from participating in rehabilitation programs because they were in a relationship and both concurrently seeking treatment, and/or there was some knowledge of ‘relationship conflict’ or violence by that service. This happened within relative proximity to the deaths which indicates the importance of capitalising on opportunities to intervene or support individuals who might otherwise be reluctant to engage with services.

The Board highlighted research that suggests, due to the strong association between substance use and domestic and family violence, all patients attending substance abuse treatment should be screened for intimate partner violence (victimisation and perpetration).118

It further considered research that suggests there could also be potential benefits for substance use treatment programs/ facilities to concurrently provide interventions to address domestic violence.119

What is also clear, is that across a range of mental health, drug and alcohol treatment and other general health services, practitioners should be better equipped to consider, assess and respond to a perpetrator’s use of violence in relationships. This includes the capacity to routinely screen for both victims and perpetrators of domestic and family violence, being mindful of the potential impact on children as well as victims; to refer to specialist services; and to engage meaningfully with those who use violence, or who are at risk of using violence in their intimate partner or family relationships where it is appropriate to do so.

Recommendation 6

That the Queensland Government consider ways to improve access to, and availability of, priority alcohol and other drug treatment places for high risk or vulnerable parents, who may have contact with the child protection system or be experiencing domestic and family violence. This should also take into account the practical supports that parents may need, such as free access to child-care, to encourage uptake with treatment services, and aim to

117 Cited in Cohen, L.R., & Hien, D.A. (2006). Treatment outcomes for women with substance abuse and PTSD who have experienced complex trauma. Psychiatric Services, 57, 100-106. 118 Kraanen, F.L., Vedel, E., Scholing, A., & Emmelkamp, P.M.G. (2013). Screening on perpetration and victimization of intimate partner violence (IPV): Two studies on the validity of an IPV screening

instrument in patients in substance abuse treatment. PLoS ONE, 8, e63681, doi:10.1371/journal.pone.0063681 Accessed on 16 June 2016 119 Capezza, N.M., Schumacher, E.C., & Brady, B.C. (2015). Trends in intimate partner violence services provided by substance abuse treatment facilities: Findings from a national sample. Journal of

Family Violence, 30, 85-91. 120 The Sentinel Event report is the final report of the Mental Health Sentinel Events Review Committee and was published in April 2016. The Review Committee was established to review recent fatal

events involving people with mental health issues in Queensland. The report is available online at: https://www.health.qld.gov.au/.../0026/443735/sentinel-events-2016.pdf 121 Recommendation 10, Mental Health Sentinel Events Review Committee. (2016). When Mental Health Care Meets Risk: A Queensland sentinel events review into homicide and public sector mental

health services. Brisbane: Queensland Health. 122 Recommendation 11, Mental Health Sentinel Events Review Committee. (2016). When Mental Health Care Meets Risk: A Queensland sentinel events review into homicide and public sector mental

health services. Brisbane: Queensland Health. 123 Recommendation 12, Mental Health Sentinel Events Review Committee. (2016). When Mental Health Care Meets Risk: A Queensland sentinel events review into homicide and public sector mental

health services. Brisbane: Queensland Health.

ensure that services are informed around the intersection between domestic and family violence, trauma and substance use.

Recommendation 7

That the Department of Health implement processes for routine mandatory screening for domestic and family violence victimisation and perpetration within all Queensland Health, and government funded, mental health, and alcohol and other drug services. These should be supported by clear local pathways to specialist support services, and appropriate training on the intersection between domestic and family violence, mental health and substance use, which accords with the National Outcome Standards for Perpetrator Interventions.

Recommendation 8

That the Queensland Government fund and facilitate cross professional training and relationship building between mental health, drug and alcohol and specialist domestic and family violence services to enhance collaboration, shared understandings and information sharing.

Opportunities also exist to enhance the detection and assessment of risk for domestic and family violence when perpetrators present to mental health services disclosing a range of potentially interrelated issues, such as relationship conflict and separation, substance use concerns, child custody disputes or other legal matters.

This issue was explored in detail within the recently released When mental health care meets risk: A Queensland sentinel events review into homicide and public sector mental health services, Final Report (April 2016) (the Sentinel Event report120) which found that despite evidence of a previous history of domestic violence or threats to intimate partners, family members, children and parents, these risks were either not identified from collateral information provided by the family, or if known, strategies to manage them were not shared with the family, and often not specifically noted in clinical file material.

The Sentinel Event report identified that people at risk of violence by consumers of mental health services tend to minimise, deny or be naive about the risks they may face even when they may have been threatened. It further noted that clinicians need to be aware of this and specifically address these matters.

A suite of recommendations were made within this report to enhance clinical assessments by ensuring collateral information is obtained from families or carers121 engagement with families is initiated early and maintained throughout the episode of care;122 and, that families are advised of potential risks to their safety and provided with appropriate information and support to ensure their safety.123 Further, it was recommended that prompts are

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included in clinical tools and training to ensure clinicians ask difficult questions about safety and risk.124

The legislation underscoring the service system response to individuals with apparent mental illness, who are patients of authorised mental health services, was also recently subject to significant review.

The Mental Health Act 2016 was introduced in March 2017 after an extensive review of Queensland’s mental health system. The new Act included amendments designed to better align with good clinical practice by strengthening responses to those people experiencing a mental illness in accordance with a recovery- oriented approach.125

Captured in this Act are those persons who have a mental illness characterised by a clinically significant disturbance of thought, mood, perception or memory, in accordance with internationally accepted medical standards, and are subject to examination, assessment, treatment, care and, if necessary, detention, in an authorised mental health service.

The intent of the new Act is to enhance mechanisms which aim to balance the rights of the consumer with appropriate risk assessment and management.

The new Act realised positive changes with respect to patient rights and strengthens the role of family and support persons. The three main objects of the Mental Health Act 2016 are:

» to improve and maintain the health and wellbeing of persons who have a mental illness and do not have the capacity to consent to be treated

» to enable persons to be diverted from the criminal justice system if found to have been of unsound mind at the time of committing an unlawful act or to be unfit for trial

» to protect the community if persons diverted from the criminal justice system may be at risk of harming others.

Among the changes, greater recognition has been given to the importance of evidence-informed assessments and this is reflected in the legislation, and Queensland Health’s updated policies, clinical guidelines and practice standards.126

A key issue within the cases reviewed by the Board throughout this reporting period was a lack of collateral information gathering and verification, which impeded services in making informed assessments of the risk that someone posed to themselves, or to others.

Subsequent to these deaths, in accordance with new legislative provisions under the Mental Health Act 2016, the Chief Psychiatrist established a policy, ‘Treatment capacity and Assessment of Capacity’, which acknowledges that collateral information forms a crucial component of a mental health assessment and, as such, must now be sought from relevant others. This includes from other health professionals and in documents such as the person’s medical record, when a clinical formulation around capacity is made. It is also stipulates that information from carers and family members should be sought where available.

124 Recommendation 13, Mental Health Sentinel Events Review Committee. (2016). When Mental Health Care Meets Risk: A Queensland sentinel events review into homicide and public sector mental health services. Brisbane: Queensland Health.

125 Recovery-oriented approaches to mental health focus on the individual’s experience of their mental health with a focus on hope, self-determination, self-management, empowerment and advocacy. Key to the concept is a person’s right to full inclusion and to a meaningful life of their own choosing, free of stigma and discrimination. Refer to the National Framework for recovery-oriented mental health services: guide for practitioners and providers, http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-recovgde.

126 Refer to Mental Health Act 2016, Chief Psychiatrist Policy, ‘Treatment criteria and assessment capacity’. https://www.health.qld.gov.au/__data/assets/pdf_file/0018/465210/cpp-treatment- criteria-capacity.pdf

127 Refer to Queensland Health Guideline, ‘The use of the standard suite of clinical documentation’. https://www.health.qld.gov.au/__data/assets/pdf_file/0030/368454/qh-gdl-365-1.pdf

In addition to this overarching policy, Queensland Health has also now:

» undertaken a review of the core documents within the state- wide standardised suite of clinical documentation127 and added instructions to guide information gathering;

» developed a user guide to inform clinicians on how these revised documents can be used as tools to assist with comprehensive assessments and treatment planning; and

» amended the Guideline on the use of state-wide standardised suite of clinical documentation to detail how Hospital and Health Services collect and document collateral information, and undertake quality assurance processes (such as auditing).

An eLearning package has been developed to help authorised doctors, psychiatrists and mental health practitioners comply with their obligations under the Mental Health Act 2016.

The training is also mandatory; all authorised doctors/ psychiatrists and mental health practitioners must complete the training to be authorised under the Act to provide care.

Private Practitioners

Evidence of contact with other health practitioners within the community was also identified in some of the cases, although this was largely ancillary to the main points of contact within hospital and health settings.

General practitioners (GPs) had some contact although this was not a significant focus of the Board in their discussions as for the most part, GPs in the reviewed cases made appropriate referrals to specialist services where required and played a valuable role in providing support to victims when abuse was disclosed to them.

Some of the perpetrators and victims were engaged with private psychologists and/or psychiatrists at the time of the death with only minimal detection of domestic and family violence, and indicators of collusion with the perpetrator in some cases.

For example, in one case, although the psychologist knew about a protection order and subsequent breach of this order, he did not undertake any risk or safety screening with the perpetrator. Indeed, the practitioner wrote a letter to the court dismissing the perpetrator’s actions as a momentary act due to distress over the breakdown of the relationship, failing to recognise the underlying pattern of coercive control in this relationship, thereby minimising the impact of the abuse and colluding with the perpetrator.

In another case, the perpetrator admitted to attempting to seriously harm and/or kill his former wife while the couple were separating. The practitioner dismissed this behaviour, attributing it to the perpetrator’s mental health problems with no further action taken.

Best practice standards for working with perpetrators clearly highlight the need to ensure that practitioners are mindful not to dismiss or minimise a person’s use of violence within

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relationships and to ensure that they are held to account for their actions.

Collusion with a perpetrator’s deflections, minimisations or victim blaming contributes to inconsistent, incoherent and ineffective responses to men who use violence in their intimate partner or family relationships.128

In one particular case, the perpetrator’s prevailing discourse was one in which the relationship conflict was attributed solely to the deceased’s behaviour with enduring allegations that she was a drug user, a bad mother, that she partied all the time, left him and took all his money and didn’t provide for her children. This discourse was never challenged by the practitioners working with him, even when he repeatedly expressed homicidal intent towards his ex-partner (which prompted a service intervention, but no referral to police regarding this stated (and ultimately fulfilled) intent).

A significant barrier to the provision of effective support in these cases was the capacity of perpetrators to be skilled and strategic in altering their presentation to others, and dismissing or minimising the impact of their own abusive behaviours.

Relationship counsellors

Records indicate that relationship counselling was undertaken in the context of ongoing and often escalating violence during periods of actual or pending separation, in a number of the cases reviewed by the Board. Despite this, there was a lack of detection or response to these abusive behaviours, and in some cases, this further exacerbated the situation by continuing to facilitate contact between the victim and perpetrator.

One study has suggested that the prevalence of violence among couples seeking relationship counselling is high, with estimates of up to one-half to two-thirds of all couples129 in violent relationships participating in this type of service. Despite its high incidence, domestic violence may be under-identified by relationship therapists and there is limited research to validate the use of couple counselling as an appropriate intervention in cases where domestic and family violence is present.130

Consideration as to whether this treatment modality is appropriate is firstly dependent upon thorough screening processes and requires awareness of relevant clinical guidelines and practices among therapists and counsellors.

While this is a potential area for improvement within certain professions, for others (e.g. counsellors) there are currently no regulatory bodies that require registration or mandate minimum practice standards131 so they are not bound by the same regulatory framework as other professions.

As such it would be difficult to monitor all practitioners who come into contact with victims or perpetrators, or ensure they were compliant with practice standards or training requirements that aim to improve responses to domestic and family violence. This should not preclude us from encouraging peak bodies to lead the

128 Department for Child Protection and Family Support. (2015). Practice Standards for Perpetrator Intervention: Engaging and Responding to Men who are Perpetrators of Family and Domestic Violence, Perth Western Australia: Western Australian Government

129 Schacht, R et al. (2009). Domestic violence assessment procedures among couple therapists. Journal of Marital and Family Therapy, 35, 1. 130 Brown, T. & Hampson, R. (2009). An Evaluation of Interventions with Domestic Violence Perpetrators. Monash University: Victoria. 131 For example the Australian Health Practitioner Regulatory Agency is responsible for the implementation of the National Registration and Accreditation Scheme across Australia; and works with the

14 National Health Practitioner Boards. Further information is available at: http://www.ahpra.gov.au/About-AHPRA.aspx 132 This may be an under representation as records from QCS were not requested in all cases. 133 This included four out of five intimate partner homicides, four out of five Indigenous intimate partner homicides, three out of four adult victim suicides, two child suicides, and four out of seven

perpetrator suicides.

way in ensuring appropriate training and supporting guidelines applicable to relevant professions are available.

Recommendation 9

That the Queensland Government liaise with peak professional bodies to recommend all registered practitioners who may come into contact with victims and their children, or perpetrators of domestic and family violence, complete specialist domestic and family violence awareness training within one year of obtaining registration or membership and be required to complete ongoing refresher training to maintain their registration or membership. Training should include specific information pertaining to working with perpetrators in accordance with the National Outcome Standards for Perpetrator Interventions, as well as responding to victims of domestic and family violence.

Peak professional bodies may include, but not be limited to, practitioners registered with the Australian Counselling Association, Australian Association of Psychologists, Australian Association of Social Workers, Royal Australian and New Zealand College of Psychiatrists and accredited relationship counsellors and mediators.

Criminal justice system contact

This section discusses issues identified with the responses of different agencies that form part of the broader criminal justice system.

In the cases reviewed by the Board during this reporting period:

» Contact with the criminal justice system was evident in 26 of the 27 (96.3%) cases prior to the death. This was inclusive of domestic and family violence related offences, other offending behaviour as well as contact because of a range of other presenting issues requiring a police response, such as an acute mental health episode, a situational crisis or threatened or attempted suicide or self-harm.

» These behaviours triggered contact with police (96.3%), the courts (70.4%) and corrective services132 (33.3%).

» At the time of the deaths, domestic violence protection orders were in place in 17 out of 27 cases (63.0%).133 (This constituted twelve orders which police had applied for, and five which were privately applied for by the aggrieved).

» Where there was a protection order in place at the time of death, breaches of the current order were identified in eight cases (47.1%). Outcomes of these breaches included imprisonment (two cases), suspended sentences (one case), fines (one case), and no action completed prior to the death (four cases).

» In seven cases, there had been a protection order involving the respondent and aggrieved that had previously lapsed, with breaches identified in six of these cases.

» Further, protection orders had been issued in former relationships for the victim and/or perpetrator in 18 cases

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(66.7%), with (at times multiple) breaches recorded in 12 (66.7%) of these cases.

» Criminal charges (excluding breaches) for domestic and family violence related offending were reported in six cases (22.2%). The majority (22; 81.5%) of perpetrators also had a history of non-domestic and family violence related offending. Among domestic and family violence victims, 10 (37.0%) had a history of non-domestic and family violence related offending.

Police

Police play a critical role in responding to domestic and family violence and this issue encompasses a substantial proportion of the calls for service they are required to respond to. It has been estimated that the Queensland Police Service (QPS) responds to approximately 238 domestic and family violence matters each day.134

Domestic and family violence related calls for service also take a substantial proportion of time to resolve, with it being further estimated that each domestic and family violence related call for service takes approximately two and a half hours in response time.135

In the cases subject to review by the Board, contact with police included:

» Calls for service by victims, other family members or witnesses, to report episodes of domestic and family violence that were occurring or had recently occurred.

» Requests for information, advice or assistance from police officers, predominantly through presentations at police stations, where an episode of violence may have recently occurred.

» Calls for service regarding a range of other related issues in which there were underlying indicators of domestic and family violence including: welfare checks, or acts of suicidal self-harm which resulted in police making an application for an Emergency Examination Order or taking other action.

» Action pertaining to other offence categories which were not identified as domestic and family violence related, and while noted by the Board, were not considered any further.

For some cases the history of domestic and family violence as recorded by police was extensive, spanning over a decade and occurring across multiple relationships. This information was invaluable in establishing patterns of violence perpetration, and victimisation over time, and to allow the Board to identify opportunities for earlier intervention when cases may not have been considered ‘high risk’.

In those instances, the benefits of proactive referrals to appropriate services should not be underestimated and the QPS has invested much time over recent years to encourage third-party referrals for vulnerable persons by frontline officers. This includes originally through ‘faxback referrals’ to specialist service providers; the implementation of mandatory referrals to Child Safety Services where officers responded to domestic and family violence

134 Queensland Police Service. (2016). Annual Statistical Review 2015/2016. Brisbane: 135 Police and Community Safety Review. (2013). Sustaining the Unsustainable: Police and Community Service Review, final report. Brisbane: Author. 136 Though this has now been removed following the Child Protection Commission of Inquiry (2013), it is noteworthy as there was evidence of multiple such referrals in the cases subject to review;

which brought a vulnerable family to the attention of those services who may have been in a position to detect, and respond, to the domestic and family violence, and other related issues, that occurred within the immediate familial network.

137 Legislative Council Standing Committee on Social Issues. (2012). Domestic Violence trends and issues in NSW. 88-89 Retrieved from New South Wales Parliamentary Library cataloguing-in- publication data

occurrences and children were known to be present;136 and in ensuring police officers provide third-party referrals to agencies for vulnerable persons both through Supportlink, and a new QPS referral system.

In the review of cases there were instances of proactive enforcement by police including: refusing to withdraw charges where a victim requested that this occur; the issuing of a station wide alert advising other officers that a high risk couple were believed to be residing together in breach of the no-contact conditions on their order; requesting extra conditions on protection orders or release conditions; or making application to the court for a revocation of bail.

Further, particularly in regional locations and remote Indigenous communities, it was evident that police were a primary source of assistance for victims of domestic and family violence and they were often required to respond to frequent and repeat calls for service involving the couple with very limited resources.

A sustained focus on increased perpetrator accountability by police, relieves victims from having to take their own protective measures, and continued improvements in policing domestic and family violence also serves to enhance victims’ trust in police, and therefore their rates of reporting.137

In other cases, potential areas for improvement were also identified by the Board where a different response by police may have enhanced protective outcomes for a victim, or assisted in holding the perpetrator to greater account for their abusive actions.

There were also identified discrepancies in practice between individual officers. For example in one case reviewed by the Board where it was identified the offender was in breach of his bail conditions, one officer charged him with a contravention of the bail conditions which prohibited contact between the couple. Although it was known that this couple continued residing together in breach of these conditions, and the perpetrator was reporting regularly to the police station as per his bail conditions for a prior domestic assault, no further action was taken by other officers who had contact with him regarding this apparent contravention.

Broadly speaking, the issues identified with the police responses in cases reviewed by the Board, included:

» Poor triaging and prioritisation of calls for service in two cases where an episode of domestic and family violence was reported, resulting in delays in attendance on the night of the death. In a third, substantial issues were identified with the response by call centre staff (both 000 and Policelink) to multiple reports by a victim, and her new partner, that her former husband was harassing and threatening to kill them. This contributed to deficiencies in the overall policing response, as it appears that not all of this information was known to other officers who responded to future reports of continued abuse.

» Challenges in recognising non-physical forms of domestic and family violence were evident in 15 cases, such as acts of coercive controlling violence, including suicidal

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threats or attempts;138 arguments over alleged infidelity; one partner refusing to return the children in accordance with mutually agreed custody arrangements; threats to kill or harm; and a victim’s sense of fear. Notably, the detection of these underlying characteristics may be difficult for junior officers who may not understand their underlying significance with respect to the potential for future harm. This extended to a lack of identification of acts of associated domestic and family violence where the threat or abuse may have been targeted at a third party, as a means to control the primary victim.

» Respondents may have presented as charming and calm when engaging with police (or other service providers), while the victim appeared distressed, hostile or agitated, limiting an effective response. As such, service providers and police need to be better equipped to recognise this agitation as potentially a physiological response to ongoing intimate partner terrorism, particularly where victims are fearful of immediate or future acts of domestic and family violence.

» Instances in which there were disclosures of domestic and family violence which were not responded to by police officers. This included occurrences involving altercations between intimate partners or family members, and reports of domestic and family violence which were recorded as intelligence submissions or welfare checks. On occasion, no further action was taken by police with respect to these allegations of violence including where victims openly expressed being fearful of future harm by their family member or partner. Notably, oversight of these types of occurrences is the responsibility of specialist Domestic and Family Violence Coordinators, District Crime Coordinators as well as other supervising officers, so there are established processes for identifying matters which have been recorded incorrectly within the QPS systems. There is limited evidence in police records to suggest that, subsequent to a review by a supervising officer, these occurrences were ever identified as domestic and family violence related, and revised accordingly through these existing quality assurance processes. In some, but not all, of these situations, this may have been because the perpetrator was experiencing an acute mental health episode which was appropriately prioritised.

» In some cases, there appeared to have been a lack of consideration of previous recorded history of domestic and family violence to inform officer’s decision-making, even in those episodes of violence that had occurred over recent months. With the introduction of Q-LITE139 there is an increased capacity for investigating officers to check prior offending history in the car or on scene when they have a call for service. For some persons this history may be extensive and involve multiple parties (as either a witness, victim and an offender). These records are difficult to analyse and interpret quickly, as much of it is contained within the narrative of an individual occurrence. While people or addresses may be flagged as high risk, sometimes there may be multiple flags and the volume of information becomes meaningless as the flags may no longer be current (e.g. if an address has been flagged and the person of interest has moved). For this reason, there is a need for caution

138 The definition of domestic and family violence, as per Section 8 of the DFVP Act is inclusive of behaviour by a person (the first person) towards another person (the second person) with whom the first person is in a relevant relationship that is physically or sexually abusive; or is emotionally or psychologically abusive; or is economically abusive; or is threatening; or is coercive; or in any other way controls or dominates the second person and causes the second person to fear for the second person’s safety or wellbeing or that of someone else.

139 Which provides officers with access to QPRIME via mobile tablets and smart phones. 140 This included three intimate partner homicides and two Aboriginal and Torres Strait Islander intimate partner homicides 141 As per s.177 of the Domestic and Family Violence Protection Act 2012 although a court may not find a respondent contravened an order merely because a police officer told the respondent about the

existence of the order, unless the court is satisfied the police officer told the respondent about the condition that it is alleged the respondent contravened 142 Rule 15, Domestic and Family Violence Protection Rules 2014.

and for the information to be verified. The potential for this information to be more easily interrogated by responding officers was considered of benefit to allow them to have easier access to salient information and risk indicators to inform their decision making. This may be resource intensive and impractical given the volume of domestic and family violence related occurrences police respond to annually.

» Issues with the service of orders were seen in five cases,140 which diminished the capacity of police to take action with future reported breaches. This included difficulties in locating the respondent, delays in the service of a full protection order or in one case, no action taken by officers to serve an order as they were told the respondent had been emailed the order by the aggrieved’s lawyer. Notably, an order only becomes enforceable once a respondent is told about the order and the conditions of the order by any means,141 and as such delays in service may leave a victim unprotected from future acts of abuse and restricts police responses at future occurrences. Where police officers have difficulties in serving protection orders, there should be a dedicated focus on communicating to victims the status of serving the order, or the outcomes of any investigation where contraventions of an order have been reported. Notably, police already have the option to serve orders by telephone, or by other electronic means, if they are unable to locate a respondent in person.142

» Further, not taking out an application for a protection order where one may have been warranted was identified in four cases, or delays or failure to, pursue (at times multiple) breach charges were noted in at least ten cases. Police inaction or non-compliance with the requirement to proactively enforce breaches not only places victims at further risk of harm, it is likely to increase their risk of future victimisation from their partner; erode their faith that the police can and will protect them; and may reinforce a perpetrator’s ongoing abusive behaviours.

» While officers may have taken action with respect to making an application for a protection order, or charging offenders with breaches of the order in place at the time; there appeared to be limited consideration given to the pursuit of concurrent criminal charges in seven cases where records suggest there may have been sufficient evidence to do so.

» Barriers to information sharing between police and other agencies, which impacted on the officer’s ability to make an informed assessment of risk was noted in six cases, with other agencies holding knowledge with respect to the deceased’s experiences of domestic and family violence that may have led to more enhanced and proactive responses to reported acts of violence. For example, shortcomings in communication between police and mental health services were identified with respect to one case, despite the presence of enabling legislation and a shared memorandum of understanding designed to improve information exchange between these agencies. This was attributed in part to individual clinical perspectives which were focused on the need for client confidentiality and a desire to ensure an objective assessment of a patient’s risk of harm to self and

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others; and resulted in a missed opportunity to prevent a further escalation in harm, and the ultimate fatality.

» For those episodes of domestic and family violence that were recorded as occurring after the implementation of the QPS Protective Assessment Framework, deficiencies in the use of the framework were identified. These include that it was not completed as a matter of routine in accordance with existing procedures, or officers did not take into account previous assessments, even when they may have been completed within a few weeks of a subsequent event; although it is noted that these prior assessments are not easily accessible in the current police database. It was also identified by the Board that the capacity for junior constables to detect and respond to risk factors is quite challenging as they may themselves have limited experience to understand the patterns of abuse that underpin these types of relationships.

» In some cases, applicable criminal charges were withdrawn where a victim requested this occur even where there were independent witness statements of abusive acts and on one occasion, hostage taking and a concurrent assault against a 13-year-old child; or in circumstances where witnesses refused to make statements to police regarding the index event. There was also some indication that victims had limited confidence in the ability of police officers to protect them, and at times they openly expressed their frustrations about this, both to police and other parties.

» In one case, while the victim repeatedly sought assistance from police, by the time officers attended and the immediate conflict had de-escalated, they refused to provide further statements considered necessary for the successful pursuit of criminal charges. This reluctance hinders the capacity of police to successfully prosecute a perpetrator. Without the cooperation of the victim supported by a statement, particularly where there are conflicting versions of events and no other witnesses, it may be unlikely that this will be considered sufficient evidence to sustain prosecution.143

» Other avenues of providing evidence to the court were discussed by the Board, including the utilisation of video footage from body worn cameras. An evaluation of the use of body worn cameras is intended to be conducted by the QPS, but this will not have a specific focus on whether it improves the successful prosecution of domestic and family violence related offences. The use of expert witnesses, where a victim refuses to testify, has also been trialled internationally, with an apparent improvement in successful prosecutions. In such circumstances, the expert will speak in broad terms about why a victim may not willingly testify. The use of these types of witnesses only constitutes one element of evidence presented to the court emphasising the importance of comprehensive evidence gathering from investigating officers.

Despite governing legislation, policies and procedures to support police in proactively responding to domestic and family violence, research demonstrates, as does the circumstances of some of

143 It is noted that pursuant to section 245 of the Queensland Criminal Code, where assault is an element of an offence, police must prove that the assault took place without consent. This becomes problematic when witnesses recant their version of events or are unwilling to assist police with pursuing the assault charges.

144 Her Majesties Inspectorate of Constabulary. (2014). Everyone’s Business: Improving the police response to domestic abuse. Author: London. 145 Ibid. 146 Crime and Misconduct Commission. (2005). Policing Domestic Violence in Queensland: Meeting the challenges. Brisbane: Author. 147 Ibid. 148 The decision to discontinue or continue a prosecution is subject to the sufficiency of evidence, public interest and impartiality criteria. As most domestic and family violence proceedings are

summary offences these are predominantly managed by police prosecutions. 149 ODPP Directors Guidelines ‘The decision to prosecute’. Available online at: www.justice.qld.gov.au/.../0015/16701/directors-guidelines.pdf

these cases, that police responses to domestic and family violence can be varied.144 Inconsistencies in police practice, and a lack of adherence by police in following basic procedures, with associated attitudinal barriers that affected the provision of support to victims, were evident in some of the cases reviewed by the Board.

Police officers may experience frustration when they respond to an episode of domestic and family violence at the request of the victim, only to subsequently find the victim refuses to make a statement, denies anything has happened or objects to the point of verbally or physically assaulting officers when they try to detain the perpetrator.145,146 This may impact on policing attitudes to domestic and family violence more broadly, and affect the way in which officers respond to future reported episodes of violence.

While some police will enforce the law regardless of the victim’s willingness to cooperate or press charges, other police are reluctant to get involved in what they see as a private matter, because victims are uncooperative or they believe that they won’t pursue criminal charges, particularly after the situation has de-escalated.147

This issue was discussed in depth by the Board, with a consideration of strategies that aim to improve successful prosecutions for these types of offences, with some suggestion that there may be a need to consider whether existing guidelines discourage the robust prosecution of domestic and family violence related offences.

In accordance with the Office of the Director Public Prosecution (ODPP) Guidelines and Chapter 3 of the QPS Operational Procedures Manual, the prosecution process should be initiated or continued wherever it appears to be in the public interest and there is sufficient evidence.148 It is the independent duty and responsibility of police prosecutors and the ODPP not to proceed with matters where it is not in the interests of justice to do so. This recognises that the scarce resources available for prosecution (court availability, staffing, etc.) should be used to pursue cases worthy of prosecution and not ‘wasted’ in pursuing inappropriate cases.149

As the vast majority of domestic and family violence related charges are summary offences, they are mostly managed by police prosecutors and a senior officer is required to approve the decision not to prosecute. For the ODPP, decisions not to prosecute matters require the approval of at least a senior prosecutor (if not the Director) to discontinue proceedings. In the ODPP, legal officers and prosecutors are required to speak to the complainant about the reasons for the decision not to indict or to not pursue an indictment, so that they understand the rationale.

Within the case reviews, police often noted that they had insufficient evidence to proceed with the prosecution, or that the victim was uncooperative. Assessments as to the reliability and willingness of a complainant are something prosecutors (and police) have to undertake for each and every matter, and are certainly a relevant consideration in determining whether a prosecution should continue.

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The discretion to continue or discontinue a proceeding is necessary to ensure criminal prosecutions are just and not subject to abuse.

It is also imperative that front line officers gather sufficient evidence to sustain prosecution, in accordance with applicable provisions of the QPS Operational Procedures Manual. It is also the case that given the known reluctance of victims to testify for a myriad of reasons, the system needs to accept and adapt to this, and consider ways to ensure perpetrators are held to account even in the absence of a direct witness statement.

This may include a review of existing applicable guidelines to provide further advice in relation to prosecuting domestic and family violence offences specifically, in recognition of these underlying dynamics.

The perceived severity of episodes of domestic violence may also influence police attitudes and decisions. While many forms of domestic violence are criminal such as physical violence, sexual assault, stalking and property damage, threats and homicide, there are other forms of domestic violence that are not categorised as criminal offences but can be just as harmful to victims and their families; including the use of coercive controlling behaviours that may cause a person to live in fear, or to suffer emotional and psychological torment, financial hardship or social isolation.150

As outlined in Chapter 4 of this report, it is these types of behaviours that are often the hardest for police to detect and respond to. For police, a decision to charge and pursue a matter through court may be influenced by the severity of the offence, and the likelihood of a meaningful outcome, with more serious offences generally falling within the scope of detectives with specialist investigative skills, as opposed to being managed by general officers.

This may further influence the quality of investigations undertaken and whether the evidence gathered is likely to be sufficient to sustain a prosecution.

The standard mandatory condition on domestic violence protection orders in Queensland is that the respondent be of good behaviour towards the aggrieved and not commit domestic violence against the aggrieved. In some cases, this may be sufficient, but the vagueness may inhibit the effectiveness of enforcing the order, particularly for acts of non-physical abuse such as those that are technology facilitated. In this respect, individually tailored conditions on protection orders may assist police in pursuing contraventions against respondents, and enforcing orders, leading to enhanced protection for victims. The use of extra conditions can also counteract a lack of understanding in relation to acts of coercive controlling violence among less experienced police officers, as the court has specified in more explicit details what conditions they expect the perpetrator to adhere to (e.g. not being at a place the aggrieved lives or works or not attempting to locate the aggrieved).

The Board also recognised that frontline police officers are not necessarily best placed to respond to the complex social issues that encompass calls for service related to domestic and family violence, beyond a role in ensuring the immediate safety of all parties, the enforcement of any relevant legislation, and

150 NSW Police Force. (2012). Code of Practice: NSW Police Force Response to Domestic and Family Violence. 151 Project PRADO is a regional interagency partnership response to domestic violence which aims to deliver case management strategies in partnership with Probation, Child Safety Services and

the Caboolture Regional Domestic Violence Service (CRDVS). It includes a dedicated domestic violence caseworker employed by CRDVS to work alongside police, in partnership with the regional Domestic and Family Violence Coordinator, to maximise the safety of all families at risk by providing early intervention, safety skills and planning, and information and options to aggrieved persons; as well as improving information sharing, referral processes and criminal justice system responses to recidivist offenders.

participating in cross-agency partnerships to reduce harm over the longer term.

It was suggested in Board discussions that after police have de- escalated the immediate crisis, it may be more appropriate for senior human services professionals (such as a social worker) to subsequently intervene to address the needs of the victim and/or perpetrator over the longer term; with recent partnership policing or ‘co-responder’ models being trialled in Queensland.

In these trials, a specialist domestic and family violence staff member works concurrently with police to improve longer term outcomes after the initial police response. These models have been trialled in certain police districts and have generally evolved from identified local need, with no standard model of consistent practice.

The operation of this service delivery model was present in one case reviewed by the Board, whereby the victim was supported by a PRADO151 caseworker throughout the course of court proceedings and was provided advice around safety planning strategies and referral pathways in the context of her experiences of severe and ongoing domestic violence.

The significant reforms with respect to enhancing police responses to domestic and family violence subsequent to the release of the Special Taskforce Final Report should also be acknowledged, including the roll out of state-wide Vulnerable Persons training; implementing strategies to drive cultural change within the QPS; the re-establishment of a state-wide coordinator of domestic and family violence; and the designation of a Deputy Commissioner who has strategic oversight of domestic and family violence. This latter role in particular, is critical in ensuring appropriate governance and leadership, and in driving continuous improvement in policing responses by elevating the issue to one of prominence among senior officers in the police who have the authority to lead change in their districts.

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The QPS are also currently implementing and participating in a broad range of communication, training and change management strategies to assist frontline officers in identifying and responding to children who may be at risk of harm. This has arisen because of regional feedback about under-reporting of child harm concerns, and as a result of recommendations made by the Queensland Family and Child Commission in its supplementary review of information sharing legislation, policies and practices.152

Within their databases, the QPS holds a significant amount of information based on prior calls for service with respect to both victims and perpetrators of domestic and family violence. The Board acknowledges that there have been positive steps towards ensuring ease of access to this information in a timely manner including the introduction of Q-LITE devices which provide frontline officers with access to mobile applications to assist in their daily duties.

This commitment supports officers in responding to domestic and family violence related occurrences by providing real-time, in-the- field access to relevant information.

It was evident in the review process, that quick accessibility of some of this information may be limited, particularly when held across different databases (such as QPRIME, QCAD and ITAS) or when the history is extensive, which may impact on frontline officer’s ability to meaningfully and quickly identify any patterns of harm over time. The information may also be buried within an occurrence narrative, and therefore not quickly or easily accessible

Further, officers may not always understand the significance of the information held within the police databases in informing current or future policing responses to high risk or vulnerable individuals.

As such, the Board notes there may still be a need to ensure officers are conscious of the significance of historical events and offending behaviours with respect to domestic and family violence matters. Opportunities exist for staff embedded within the high risk teams and district vulnerable persons units, or specialist Domestic and Family Violence Coordinators, to bring this information together in a meaningful way to support frontline officers.

Learnings from the Gold Coast Police Taskforce may help in informing this body of work.

Finally, in the cases reviewed by the Board there were excellent examples of positive police action where officers were required to respond to people experiencing a mental health crisis or expressing suicidal self-harm; and there is potential for key learnings to be translated from such initiatives as the ‘Mental Health Intervention Project’,153 a dedicated and sustained tri- agency partnership that aims to improve responses to people with a mental health problem, to enhance policing responses to victims and perpetrators of domestic and family violence across relevant partner agencies.

152 The QFCC released a report on information sharing to enhance the safety of children in regulated home-based services in accordance with recommendation 28 of their report, ‘When a child is missing: Remembering Tialeigh – A report into Queensland’s children missing from out-of-home care. The supplementary report is available online at: http://www.qfcc.qld.gov.au/knowledge-and- resource-hub/recommendation-28-supplementary-review-report-information-sharing-enhance

153 The Mental Health Intervention Project is a longstanding partnership between the Queensland Police Service, Queensland Health and the Queensland Ambulance Service, which aims to prevent and safely resolve, mental health crisis situations to reduce the risk of injury to members of the community and agency staff. District Mental Health Intervention Coordinators from the three agencies work together at district level to find local solutions to local mental health issues, including the development of preventative interventions and identification of alternative referral pathways.

Spotlight on: Gold Coast Police Taskforce

The Gold Coast Domestic and Family Violence Taskforce was identified as an example of excellent police practice which is having positive outcomes. The Gold Coast Taskforce is working with other relevant stakeholders (including Child Safety Services, Corrective Services, specialist domestic and family violence service providers, and Mental Health), who work collaboratively and flag every single domestic and family violence case that police respond to in that District, to determine risk and how they will respond to each case.

The ‘House of Harm’ philosophy adopted by the Gold Coast Taskforce is based on the principle of ‘act fast, tread carefully, and prevent homicides’ in which they recognise, and aim to respond to the broader harm that may occur within vulnerable families or intimate partner relationships, through a collective consideration of any identified domestic and family violence, child abuse and maltreatment, problematic substance use and mental health concerns. The Taskforce have also established processes for identifying, and targeting high risk offenders, which is supported by the development of an intelligence network that is able to detect potential high risk indicators. Responses focus on robust enforcement activity, and partnership policing through an integrated service system response.

At any point in time, the Taskforce is staffed by 10 officers, including five Detectives (led by a Detective Inspector), with strong governance and support by the District Officer. To achieve their outcomes, the Taskforce adopt a ‘hub’ approach in which the officers audit relevant offence categories with a strong focus on reducing error rates within police systems and subsequently distribute tasks across the district (approximately 1000 officers).

Officers rotating through the Taskforce are trained relatively quickly, and are able to share their knowledge when they return to other duties, with the aim of leading to sustained change in the way in which the District responds to domestic and family violence. The Taskforce is currently undergoing an external evaluation by Griffith University, however, substantial benefits have been identified, both in terms of enhancing responses by police to domestic and family violence, improved protective outcomes for victims, and a greater accountability for perpetrators.

Recommendation 10

That the Queensland Police Service continue to develop operational communiques and training targeted at first responding officers to domestic and family violence related occurrences, which aim to enhance understanding of the broader dynamics of domestic and family violence and the significance of certain risk indicators that may lead to a heightened risk of harm, such as those identified within this report.

Recommendation 11

That the Queensland Police Service ensure that all first responding officers have timely access to electronically available, current, relevant and accurate information held across their data systems in relation to a prior history of domestic and family violence, for

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perpetrators and victims; in a format which aims to enhance, but not disrupt, an operational response. This should be supported by the implementation of strategies that emphasise the importance of this information to call takers and frontline officers, and how to better take this information into account, when responding to domestic and family violence related occurrences, particularly repeat calls for service.

Courts

The court system plays a critical role in providing protection and support for victims of domestic and family violence.

Optimal responses hold perpetrators to account for their actions, acknowledge the harm and prioritise the safety of victims; and can provide opportunities for targeted support to victims and their families, and perpetrators.

Conversely, studies into the detrimental effects of negative court-related experiences for victims of domestic and family violence have found problems associated with minimisation of harm, exclusion, misrepresentation, isolation and disempowerment of women in the application of law to domestic violence matters;154 all of which serve to further traumatise or re-victimise complainants.

The importance of the court response cannot be overstated, including with respect to future policing responses. A proactive and timely response from the courts may reinforce a clear pathway for police officers’ efforts in responding to future episodes of violence.

A number of cases reviewed by the Board included judicial contact with victims and perpetrators with respect to:

» civil and administrative matters including protection orders and bail hearings

» criminal matters including domestic and family violence related assaults, protection order breaches, and charges related to drug use, property-related offending and other violent acts

» family law matters including child custody arrangements post-separation (discussed in Chapter 4).

Although noting the significant reform occurring in this area subsequent to most of these deaths, the Board was cognisant of key issues arising in these cases, including:

» the critical support needs of both victims and perpetrators of domestic and family violence navigating or in contact with the judicial system

» the impact of sentencing on the immediate and future safety of victims, and perpetrator recidivism.

154 Douglas, Heather. (2008). The Criminal Law’s Response to Domestic Violence: What’s going on? Sydney Law Review. Vol 30:439-469. 155 Recommendation 124 - Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane:

Author. 156 Recommendation 125 - Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane:

Author. 157 For example, the DCCSDS allocates funding to non-government organisations to provide court based support services to aggrieved attending court for domestic and family violence matters at most

Magistrates Courts in Queensland. In addition, the Department of Justice and Attorney-General, through Legal Aid Queensland, has contracted DV Connect to provide information and support to respondents in five Magistrates courts in south east Queensland. Court support is offered by the volunteer Court Network who currently operate in Brisbane, Cairns and Townsville. Victims may also receive support through the Victim Coordination Program run by Victim Assist Queensland; a service offered to victims of violent crime in Queensland that provides practical support and guidance through the court system; referrals; and, aid to apply for financial assistance.

With respect to support needs, the Board agreed that interaction with the court system presented an opportunity to ensure additional, specialist services were afforded to both victims and perpetrators; noting there were several examples throughout the cases where judicial contact was clearly a source of distress for both parties, with limited evidence of support being provided in this context.

For one victim suicide, in which cross-protection orders were in place, the victim had been coerced to attend the court with the perpetrator with respect to criminal proceedings associated with a breach of the protection order, listing him as the respondent and her as the aggrieved.

Stress about attending court was a significant concern for the victim in this case, who cited her unwillingness to participate in court proceedings against him in her suicide note. Records indicate that the respondent was drinking throughout the day at the court and after the proceedings were adjourned, he proceeded to verbally abuse her and make threats of further violence including that if he was going to prison anyway he was going to make her pay in the meantime.

He then forced her to leave with him, physically assaulting her while he was driving and causing a car accident. He subsequently attempted to make her attend the hospital with him, even after police had attended the scene of the accident. When she refused, he self-discharged from the hospital and attended her premises to locate her.

These events occurred just one week before her subsequent death.

It is salient to note that the Special Taskforce on Domestic and Family Violence specifically considered the need to increase access to court support services for victims and perpetrators, recommending that:

» the Queensland Government employs court support workers in all Magistrates Courts for domestic and family violence matters for all applicants; and information/liaison officers for all respondents155

» the Queensland Government develops formal position descriptions for these workers to increase uniformity in support.156

In the context of subsequent and ongoing reform, the Board recognised that court support options have increased in Queensland.

Although services are not always available in every location, additional funding has recently been allocated towards increasing the coverage and spread of services throughout the state, to complement those services already existing. These support services include court support and attendance with both victims and perpetrators; non-legal advice and information services; advocacy; and referrals to other support services where appropriate.157

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The Board also noted the recent launch of Family Advocacy and Support Services;158 a federal government initiative to assist families experiencing domestic and family violence as they navigate the family law system. This integrated service helps families navigate between the federal and state court systems and connects people with trauma-informed support, as well as risk assessments and safety planning. Lawyers and support workers collaborate to provide services that help to bridge the gap between state and Commonwealth legal systems and processes.

Although assistance is offered by specialist court support workers for civil proceedings, these same supports are not necessarily available during other related criminal proceedings.

For such proceedings, the Board considered that there may be a need for further exploration of alternative support models, similar to those provided by mental health services (e.g. a victim liaison service), to improve dedicated supports available for victims in court; and, the importance of robust implementation and monitoring of any new support initiatives.

Recommendation 12

That a program for specialised and consistent court support for victims of domestic and family violence in criminal proceedings be developed and funded by the Queensland Government.

Although it is not within the Board’s scope or mandate to comment on individual sentencing decisions, there were some issues identified with respect to the perceived ‘severity’ of sentencing commensurate with harm and in ensuring victim safety remains a paramount consideration in sentencing and bail considerations.

With respect to the perceived ‘severity’ of sentencing, the Board identified issues particularly in circumstances where convicted perpetrators had inflicted significant physical injuries on their partners, and received short or suspended sentences. This observation was extended to the actual homicide events themselves, where offenders may have pleaded guilty to manslaughter and received relatively short custodial sentences even though they had an extensive history of violence perpetration recorded prior to the death.

In some cases, the offenders also received relatively short custodial sentences for prior assault-related charges, despite extensive histories of violence, often against the deceased victim, and within notable proximity to the death.

For instance, in one victim suicide, a perpetrator who inflicted life-threatening injuries during an assault of his partner was given a 12 month imprisonment sentence for obstructing and assaulting police when he was arrested, but was convicted for common assault (without further punishment) and ordered to pay restitution for property damage.

This episode of violence occurred the day after he was released from jail for previously slashing his female victim with a knife.

Another offender had criminal convictions recorded almost every year, yet he had been incarcerated for relatively minimal periods

158 In Queensland, Family Advocacy and Support Services operate from the Brisbane, Cairns and Townsville Family Law Courts Registries. 159 Refer to the Criminal Law (Domestic Violence) Amendment Act (No 2) 2015. 160 Including contravention of the order and assault occasioning bodily harm against the female deceased. 161 Refer to: http://www.courts.qld.gov.au/__data/assets/pdf_file/0019/512425/ccq-rpt-intimate-partner-homicide-of-kelly.pdf 162 Refer to the Bail (Domestic Violence) and Another Act Amendment Act 2017. 163 The National Domestic and Family Violence Bench Book was developed to compliment the work being undertaken by The National Plan to Reduce Violence against Women and their Children

2010-2022 by assisting the education and training of judicial officers so as to promote best practice and improve consistency in judicial decision-making and court experiences for victims in cases involving domestic and family violence across Australia. It is also intended to serve as a resource accessible to other legal professionals and service providers who are working with victims and perpetrators of domestic and family violence. Refer to: http://dfvbenchbook.aija.org.au/

of time. This included a previous conviction for manslaughter (non- domestic and family violence related).

The Board considered that lenient sentencing may reinforce the perception that future offences may also attract minimal consequences, and therefore have limited impact as a deterrent or in reducing recidivist behaviour.

In this regard, the Board welcomed recent legislative reform159 which has seen the introduction of a circumstance of aggravation of domestic and family violence to be applied to all applicable criminal offences with the intent of increasing penalties for offences occurring in this context.

Although imprisonment alone may not be sufficient to break the cycle of domestic and family violence perpetration, it does remove the offender for a fixed period of time. This increases opportunities for victims to access relevant supports and services in the absence of intense and pervasive acts of coercive control by an abusive perpetrator. Furthermore, the Board recognised that for incarceration to be effective for perpetrators it must be accompanied by intensive evidence-based behavioural change interventions delivered by professionals.

Another issue identified by the Board within cases reviewed in this reporting period related to delays between when an offender was charged and subsequently appeared before a court. In one case, the offender was on bail for previous charges for a domestic assault160 of his intimate partner at the time of her fatal assault. There were eight months between that charge being laid, and the date of death, just three days before the proceedings were due to be heard.

This not only highlights the importance of swift accountability and justice; but also, the need for robust judicial consideration as to the safety of victims in determining bail; an issue which the Board referred directly to the Attorney-General by way of a systemic report into the Intimate Partner Homicide of ‘Kelly’ in February 2017.161

The Board acknowledges and welcomes the subsequent legislative reform162 that has occurred to reverse the presumption in favour of bail in circumstances where relevant domestic violence offences have occurred; and the introduction of optional additional measures designed to enhance victim safety through more rigorous monitoring of offenders who are granted bail.

The Board also recognised the continued efforts to increase judicial awareness and understanding of the dynamics of domestic and family violence as a vital and complementary component of overall enhancements to the court system response.

With respect to judicial education regarding domestic and family violence, there are several resources and initiatives seeking to improve court responses to domestic and family violence, such as the:

» National Domestic and Family Violence Bench Book163

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» Domestic and Family Violence Protection Act 2012 – Bench Book164 (currently under revision)

» Family Violence Best Practice Principles165 (Edition 4, December 2016).

Finally, the Board welcomed positive findings from an evaluation of the trial specialist domestic and family violence court in Southport which was established on 1 September 2015, noting that a number of the issues identified in their review of applicable cases may be better addressed through this model.

Components of the specialist court includes specialist magistrates who hear all civil domestic violence and related criminal proceedings; dedicated and specialist staff to coordinate and operate the court registry including support workers, duty lawyers and police prosecutors; and support services for respondents and aggrieved parties.

A recently released independent evaluation166 by Griffith University found that the trial was, overall, tracking well against its objectives and made a series of recommendations to improve linkages, refine processes and support staff working in the court.

The Board welcomes the Queensland Government’s commitment to further roll-out and evaluation of specialist domestic and family violence court approaches throughout 2017 to 2020 in Beenleigh, Townsville, Mount Isa and Palm Island while noting the importance of ensuring robust measures are made to enhance generalist responses until these specialist courts become available across the state.

Child Safety Services

In the review of cases where children were present in the relationship, or indeed for the deaths of children and young people, where applicable, the Board considered interventions and contact with child safety services noting that:

» Children were present in the home while episodes of domestic and family violence occurred in 13 cases (48.1% of all cases reviewed) and contact with child safety services was recorded in eight of these cases (29.6%).167

» In five cases (18.5%), one or both parents had a prior history of contact with child safety services as a subject child themselves; and there were indicators of abuse or neglect within the childhood of three other adult victims.

The Board identified a number of themes, issues and patterns with respect to child safety system contact in these cases, noting that:

164 The Domestic and Family Violence Protection Act – Bench Book was developed in response to recommendations of the Special Taskforce on Domestic and Family Violence and outlines the relevant laws and suggested procedures for judicial officers working within the Queensland jurisdiction when dealing with domestic violence issues. Refer to: http://www.courts.qld.gov.au/court-users/ practitioners/benchbooks

165 The Family Violence Best Practice Principles was developed by the Family Court of Australia and the Federal Circuit Court of Australia as a valuable tool in providing background information for decision makers, legal practitioners and other individuals involved in cases in which allegations of family violence, or risk of family violence, are raised. Refer to: http://www.familycourt.gov.au/ wps/wcm/connect/fcoaweb/family-law-matters/family-violence/family-violence-best-practice-principles/

166 Available online at: http://www.courts.qld.gov.au/__data/assets/pdf_file/0007/515428/dfv-rpt-evaluation-dfv-court-southport- 167 In total, contact with DCCSDS was reviewed in nine cases. This included: three filicide cases (two involving the deceased as a subject child and one where child protection concerns had been raised

about the parents with respect to their capacity to care for other children); two children and young people who died from apparent suicide who were known as subject children; one young adult suicide victim who had a long history of contact with child safety when she was a subject child; two intimate partner homicides where the parents had involvement regarding children in their care; and one Aboriginal intimate partner homicide where the homicide offender had a history of contact with child safety services as a subject child and as a parent. Some of the other adult deceased and/or offenders had contact with child safety services but this did not form the focus of the review as it wasn’t proximate to the death. Contact was recorded across cases from 1995 to 2015, including in many cases within days and weeks of the deaths, and often repeat notifications pertaining to suspected harm. While much of the practice issues identified in these cases occurred prior to ongoing practice improvement activities within the child protection sector, some of the issues continue to be observed (which accords with the most recent findings of the Queensland Child Death Review Process).

168 While the Child Protection Act 1999 provides the legislative framework which authorises DCCSDS officers to investigate allegations of harm against children (s14), inform parents / guardians of allegations of harm and outcomes of investigations (s15), allow contact with a child believed to be at immediate risk of harm in certain circumstances (s16), and enable officers to have contact with a child at school (s17), there is limited guidance for officers in relation to interviewing children separate from parents who are alleged to be responsible for the harm. The Child Safety Practice Manual outlines that officers should consider whether section 17 provisions should be utilised when planning their investigation although there is limited guidance about scenarios in which this might be appropriate.

» There were several cases in which child safety officers appeared to minimise the potential impact of cumulative and emotional harm caused by childhood exposure to domestic and family violence. For example, in one case child safety services were made aware by police and other informants that a child had witnessed violence between her parents from as young as five. In the weeks before her death, concerns were again raised about the subject child’s suicidal ideation and behaviour in the context of the parent’s separation and escalating violence. This included allegations that the parents had verbally abused the child. On the day prior to the death, the child safety officer interviewed the subject child in the presence of her parents, resulting in minimal disclosures by her. Such a process may have prohibited a more open disclosure of her experiences of violence within the immediate familial network (or suicidal behaviours).168

» Non-physical abusive acts were less likely to be recognised as domestic and family violence by child safety officers. For example, in one case it was identified that the child safety officer did not afford sufficient consideration of evidence of controlling and socially isolating behaviours by the perpetrator father. In the course of their assessment the mother’s access to familial supports was identified as a protective factor and this informed the decision to return the infant to the care of the parents. In the course of these assessments however, the father also expressed an intention to move the family to get away from familial conflicts and was known to be socially isolating. He also spoke for the mother in the assessment.

» Child safety officers also identified separation as a reason for closing a case with no ongoing intervention in three cases, even when harm was substantiated. In circumstances where the couple were known to cycle in and out of periods of separation, there was limited evidence that the likelihood of reconciliation was accounted for in safety or intervention planning and decision making.

» Early opportunities to improve parental capacity were often missed, and responsibility for protecting the child devolved to the female victim of violence with limited or no attempt to address the identified perpetrator’s violent behaviour or ability to effectively parent his child. For example, in one case it was assessed that the father posed a risk to children and pets as early as four years prior to the fatality. Because the couple had separated and the father was known to have limited, supervised visits, no intervention appears to have been offered to address his abusive behaviours or parental capacity to care. Visits were supervised by the mother at the time, who was also the primary victim of violence, although she advised officers that her lawyers had told her not to continue these visits.

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» In cases where one or both of the parents had experienced abuse or harm in their own childhood, there was no identifiable records that indicated they had received support to develop necessary life and parenting skills; although this cannot be definitively excluded.

» One mother was held responsible for failing to comply with the protection order conditions listing her as an aggrieved party, when further episodes of domestic and family violence came to the attention of Child Safety Services. This occurred in one of the youth suicide cases, where an assessment was delayed by 16 months due to a backlog of files, after it was reported that the child witnessed their father brutally assaulting his girlfriend with a baseball bat. While harm was substantiated on this occasion, with cumulative harm also noted, child safety officers considered that there was no requirement for further intervention as the father and his partner had separated and the risk of exposure to violence had apparently diminished. Notably during the intervening period between the notification and assessment with respect to the paternal household, another Child Safety Service centre received a notification of harm to the children regarding domestic and family violence within the maternal household. There was no indication in the available records of any consideration of the other notification, in the respective assessments.

» Where referrals were made, participation was largely not mandatory; and there was no recourse or reassessment of risk in the absence of service engagement, even in cases where there was a repeated lack of engagement in suggested programs. Similarly, families were continuously referred to the same service, even though they had previously failed to engage, with limited exploration of whether they were the right fit for the service. For example, one child’s father and his new partner were referred to a Family Support Service after an episode of domestic and family violence involving an act of non-lethal strangulation about three months before the infant’s death. Their participation was voluntary and they consequently refused to engage with the service. The matter was subsequently closed although the assessed risk remained and no intervention had been delivered to minimise it.

» There was limited evidence that child safety officers referred to relevant practice papers including ‘Domestic and Family Violence and its Relationship to Child Protection’ which are intended to guide decision-making in particular circumstances. This remains an ongoing issue with the Queensland Child Death Case Review Panel Annual Report 2015-16 identifying a need for greater understanding of the dynamics and nature of domestic violence in order to assess and intervene with families and better protect children.169

» While information suggests that Recognised Entities (RE)170 were consulted regarding departmental decision making as required across cases, in reality, the actual contact that RE’s had with families appeared to be minimal. The involvement of RE’s did not appear to result in increased engagement between vulnerable families and culturally appropriate services, or an improved understanding of cultural needs among generalist staff. This finding was also reflected in

169 Queensland Child Death Case Review Panel. (2017). Annual Report on the Queensland Child Death Case Review Panels, 2015-16. DCCSDS: Brisbane. https://www.communities.qld.gov.au/ resources/childsafety/child-protection/queensland-child-death-case-review-panels-annual-report-2015-16.pdf

170 A Recognised Entity is an individual or organisation that the DCCSDS is required to work with under the Child Protection Act 1999 (s6) when making decisions about Aboriginal or Torres Strait Islander children, to ensure the cultural and identity needs of Indigenous children are being met. The DCCSDS is required to provide the recognised entity with an opportunity to participate in the decision-making, where the decision is significant, and to consult with the recognised entity on all other decisions.

171 Queensland Child Death Case Review Panel. (2017). Annual Report on the Queensland Child Death Case Review Panels, 2015-16. DCCSDS: Brisbane.

the most recent Queensland Child Death Case Review Panel Annual Report.171

Spotlight on: Walking with Dads (WWD)

Walking with Dads (WWD) is equipping those working in child protection with the tools to better address cases where harm is caused primarily by fathers who abuse their partners and children. Developed by the DCCSDS, this intervention also helps those fathers to take responsibility for the harm their violence causes.

A four year trial strategy, WWD has its genesis in both the child protection reforms to better engage fathers and the domestic and family violence reforms to hold perpetrators to account for their use of violence. It places a specialist worker in Child Safety Service Centres and has been operating in Caboolture, Caloundra and Gympie since October 2016, and Mount Isa since February 2017. WWD draws on David Mendel’s Safe and Together approach to bring a domestic violence informed lens to child protection casework. WWD workers are experienced child safety staff who have undergone specialist training and in Mount Isa’s case, a respected local Kalkadoon father who will bring additional cultural competency to the role. WWD practice is founded upon two principles: the safety of mothers and children is paramount; and partnerships with mothers is the foundation from which to plan family safety and effectively intervene with fathers. An independent three year evaluation has commenced which will include a strong Aboriginal and Torres Strait Islander perspective focused on the Mount Isa trial.

The evaluation will capture men’s engagement as well as the impact WWD has on changing Child Safety’s approach to partnering with mothers and non-offending parents. WWD will also benefit from being part of the Australian National Research Organisation on Women’s Safety (ANROWS) Invisible Practice project which is establishing communities of practice across the country to support quality practice in addressing domestic and family violence in child protection.

Recommendation 13

That the Department of Communities, Child Safety and Disability Services, in investigating alleged harm to a child and assessing whether the child is in need of protection, review the appropriateness of conducting interviews with children and young people in front of persons alleged to have caused harm, particularly in the context of domestic and family violence; with a view to strengthening guidelines within the context of statutory obligations as to when this should not occur.

High risk and vulnerable infants

The Board also gave considerable attention to the protection of high risk and vulnerable infants based on their review of the filicide cases. All four of the infants in these cases were killed in their first few months of life and in three cases there was a prior

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history of contact with child safety services for one or both parents.

Although in all of the filicide cases the actual fatal blow or act was occasioned by the paternal caregiver, the Board recognised that there were indicators of abuse or maltreatment by some of the mothers who were themselves victims of domestic and family violence. In this regard, it is important to note that research suggests that the effects of victimisation (such as pain, distress, anger or fear) may affect a mother’s parenting capacity, and conversely that perpetrators of domestic violence may deliberately interfere in the maternal/child relationship; impacting on the child’s attachment to the mother.

While most mothers strive to protect their children, some who are victims of domestic and family violence may experience psychological distress or disturbance to such an extent that their ability to protect their children is compromised. This may extend to a failure to protect their child from direct harm or witnessing violence; a failure to nurture their child; or, on occasion, involve physical abuse of the child by the victim parent.172 Women may also fail to recognise the impact of abuse on their children; or convince themselves that an abusive father loves the child/ren despite their behaviour.173

With respect to this cohort of vulnerable infants, the Board found that although the DCCSDS practice paper, ‘Child protection intervention with high-risk infants’ identifies that infancy is a particularly critical period in a child’s development and represents a period of heightened vulnerability, there was limited evidence that child safety officers referenced or were familiar with the tenets of this paper in these cases.

The Board acknowledged the current and ongoing reform agenda with respect to Child Safety Services following the Queensland Child Protection Commission of Inquiry in 2013, and that much of the contact reviewed in these cases occurred prior to this time.174

A greater emphasis on the referral of high-risk families to early intervention services before they enter the statutory child protection system is one strategy being implemented in a bid to strengthen family units, respond at an earlier point, and minimise formal engagement with the child protection system.

Although this has considerable merit and is a positive step towards early intervention and improving family functioning, it must be acknowledged that participation in these services remains voluntary in the absence of a formal intervention order; and that there is nothing to compel families to participate in any ongoing or meaningful way.

Therefore, it may be of limited benefit for those hard to reach, service resistant families who actively avoid such contacts, and because of this, are often the most vulnerable.

With respect to infants who experience greater vulnerability due to their total dependence on their parents; inability to communicate; restricted mobility; and ‘invisibility’ from services;175 the Board considered the importance of ensuring this approach did not inadvertently cause vulnerable families to ‘fall through the cracks’. The Board did acknowledge the complex nature of work for professionals working in child protection and the need for strong cross-agency partnerships; as well as the raft of reform initiatives

172 Kaufman Kantor, G., & Little, L. (2003). Defining the boundaries of child neglect: When does domestic violence equate with parental failure to protect? Journal of Interpersonal Violence. 18: 338-355. 173 Ibid. 174 Although there was one cases where there was contact 2014 and two cases in 2015 that were also considered. 175 Invisibility in this context refers to the increased likelihood that high-risk infants may have limited contact with services or be socially isolated. 176 Refer to: https://www.communities.qld.gov.au/childsafety/child-safety-practice-manual/framework-practice-maps

that aim to contribute to strengthening families and improving outcomes for individuals in contact with the child protection system including:

» Ongoing, collaborative efforts to address the over- representation of Aboriginal and Torres Strait Islander children in the child protection system by working with Aboriginal and Torres Strait Islander families, communities and services. This includes the development of Our Way: A generational strategy for Aboriginal and Torres Strait Islander children and families and Changing Tracks: An action plan for Aboriginal and Torres Strait Islander children and families that outlines action for 2017 to 2019.

» The DCCSDS, in partnership with the Queensland Aboriginal and Torres Strait Islander Child Protection Peak (QATSICPP), has undertaken a comprehensive review of the Recognised Entity program in response to recommendation 11.4 in the Queensland Child Protection Commission of Inquiry’s final report, in which the outcome of extensive consultations with key stakeholders has been to embed the Aboriginal and Torres Strait Islander Family Led Decision Making process that will strengthen the application of the Aboriginal and Torres Strait Islander Child Placement Principle for children and families in the statutory system.

» The Strengthening Families Protecting Children Framework for Practice176 which sets out a strengths based, safety oriented approach to enhancing Queensland’s child protection practice and delivering better outcomes for vulnerable children, young people and families.

» The DCCSDS has worked with the Safe and Together Institute to develop five foundational eLearning training resources to help staff identify, understand and assess domestic and family violence, and work with families, including Aboriginal and Torres Strait Islander children. More than 470 child safety staff and community domestic and family violence practitioners have also completed face-to-face training.

» Introduction of Family and Child Connect Services to support families who are at risk of entering or re-entering the child protection system by offering advice and referrals to a range of services.

» Significant new investment in Intensive Family Support services; funded services that provide family support delivered under a lead case management model to address multiple and/or complex needs and assist families to build their capacity to care for and protect their children.

Further initiatives that have sought to improve outcomes for children in out-of-home care include:

» Introduction of the Out-of-Home Care Outcomes Framework to build a more robust out-of-home care system that focuses on achieving meaningful outcomes for children and young people in care.

» A trial of specialist family carers as an alternative residential care option for children who have experienced, or are impacted by trauma, by providing therapeutic or specialist support within a family environment. This is expected to commence by the end of 2017.

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» Implementation of the newly developed, trauma-informed Hope and Healing Framework across the residential care sector which aims to improve the quality of residential care provided to children and young people by ensuring the support they receive has a strong therapeutic focus. This framework will be fully implemented by December 2018.

» Initiatives targeted to support children and young people transitioning from out-of-home care to independence by increasing funding, prioritising referrals and extending practical support options such as a telephone help-line and financial aid.

These major reforms require appropriate time for robust implementation before attempts are made to measure their effectiveness or otherwise, and the Board will continue to consider their progress in the course of the review process.

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Chapter 6: Earlier detection, and targeted intervention and support

177 While this report acknowledges that risk varies over time and that there is a need to better understand, and respond to these patterns of violence, acts of abuse are commonly considered across a spectrum of severity ranging from low to high, and at times, extreme risk. This report does not seek to quantify this terminology, and recognises that there is significant work that needs to be undertaken to improve responses to perceived or actual risk within the context of domestic and family violence relationships.

In reviewing these deaths, the Board gave consideration to opportunities for earlier intervention and prevention.

Currently the service system predominantly focuses on reacting to episodes of violence and dealing with presenting symptoms, instead of tackling the underlying drivers of such behaviours. As such, there is a need to focus on the broader system response at an earlier point, so that agencies are not only responding at a point of crises.

At the moment there is a lot of focus in jurisdictions, including Queensland, on high risk interventions. In the cases subject to review by the Board there were also many missed opportunities at the low or medium risk level, where intervention may have been more effective at reducing the risk of future harm or death.

Based on discussions held throughout the review process, this chapter considers such interventions in further detail, including with victims and their children, with perpetrators, and with the community more broadly. It articulates the need for a range of strategies to address domestic and family violence at a population level, through community awareness activities and broad scale initiatives, as well as through targeted initiatives that aim to address the needs of specific population groups who may be at heightened risk or harm, such as victims who themselves may use violence, or families with multiple vulnerabilities.

Most significantly, this chapter discusses perpetrator intervention programs, and highlights that if we are to put an end to domestic and family violence in Queensland, we must focus our attentions on the individuals who are responsible for this type of violence, at an earlier point and over the longer term.

By no means exhaustive, this section also touches on some of the significant reforms currently underway across Queensland and nationally, that aim to improve interventions for victims, perpetrators and the community more generally in this area.

Early intervention and prevention

A consistent theme noted by the Board, particularly in the review of the filicide and homicide cases, arose in relation to missed opportunities for early intervention or prevention when perpetrators came in contact with the system for low or medium risk acts of abuse or other indicators of coercive control.177

In almost all (13 of 16; 81.3%) homicide cases discussed by the Board, the offenders had pervasive histories of anti-social, violent and offending behaviour. Although these offences may not have been solely domestic and family violence related, they were often indicative of the type of controlling behaviour that underpins domestic and family violence perpetration.

For example, one offender demonstrated jealous and controlling behaviours in his familial network and with an earlier girlfriend, from a young age. Despite appropriate detection through mental

health services of abusive behaviours, there was limited response. The offender, and his family, ultimately disengaged with the service.

This was a critical missed opportunity to potentially reduce an escalation in these problematic behaviours, as the development of misogynistic attitudes and controlling behaviours can become entrenched at an early age.

Early intervention can also be beneficial in reducing the impact of violence for victims as well any children who may witness or experience domestic and family violence in their home. It has positive immediate and long-term implications for not only these individuals, but also the broader community in terms of health, social and economic benefits.

The Board therefore acknowledged the need to focus on responses across a broader continuum of anti-social, violent and offending behaviour to maximise opportunities for early intervention and prevention of domestic and family violence perpetration.

The Board emphasised that these efforts should complement ongoing reform and continual improvement of crisis-focused responses; although acknowledged that these latter types of interventions can be resource intensive and are often less effective in behaviour change and reducing the future risk of harm or death.

This also highlights the need to consider all points of engagement and potential intervention as critical, in the prevention of future harm, irrespective of the perceived level of risk at any given time.

In this regard, the Board also noted that the youth justice sector undertakes behavioural and attitudinal screening. It was suggested that although youth justice workers only deal with a relatively small cohort, they could play an important role in identifying and responding to at risk individuals who could benefit from early intervention through screening for behaviours or indicators of coercive controlling violence.

There are also opportunities to learn from their approach and adapt it to different situations and settings.

Spotlight on: ReNew

ReNew is an Australian-first pilot program aimed at breaking the cycle of domestic violence by focusing on early intervention, and the renewal of healthy relationships for adolescent boys and mothers who have experienced domestic violence.

ReNew is focused on helping people overcome the trauma of domestic violence to re-establish strong family relationships. Sometimes, adolescent boys who have witnessed domestic violence find it particularly challenging to cope with, and sometimes go on to use abusive, controlling or coercive behaviour in their own family relationships. Repairing relationships and providing new ways to manage emotions can have significant

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positive impacts on families, and can help to prevent future domestic violence.

The program was developed by the Ipswich Domestic Violence Action Centre (DVAC) and Carinity Talera, a non-government organisation, and funded by the Queensland Government. The course runs over 20 weeks, and involves group therapy, individual counselling and joint mother and son counselling sessions. It has been delivered in Ipswich, Brisbane South and Brisbane West regions; and is currently being evaluated by Griffith University.

Information sharing to support earlier response

As has been demonstrated in some of the filicide cases, multiple services had information available in their records to suggest that the infant may have been at heightened risk of harm. However, this risk was not generally identified within the proximate period prior to the death/s where services may have been provided for a range of other presenting concerns.

For example, one abusive father with a significant history of assaults against multiple infants attended a hospital emergency department stating that he did not know how he would cope with the upcoming birth of the subject child. He was subsequently assessed and referred to alcohol and other drug treatment services with no parenting supports offered and limited indication of any identified risk to the highly vulnerable unborn child. On this occasion of service, health records held information to suggest that he was known to be abusive to his intimate partners and their children from previous presentations.

As such, the Board gave consideration to enhancing service system responses, so that when a vulnerable family or high-risk person re-presents to a service, underlying risks are identified and appropriate referrals are made; including a notification to child safety services where circumstances warrant such a course of action.

This may be of particular benefit in circumstances in which the family or persons are reluctant to engage, transient or seek to remain ‘invisible’ to the services required to assist.

Such monitoring processes do exist in certain circumstances already. For example, child safety services and Queensland Health, have established processes to ensure that child safety are notified immediately when a pregnant woman who has been assessed to be at high risk presents for delivery of an unborn child.178

178 If it has been assessed that an unborn child will be in need of protection after their birth and the pregnant woman does not consent to intervention with a support service case, no ongoing intervention can occur. Similarly, where a pregnant woman withdraws her consent to the support service case, during a period of ongoing intervention, ongoing intervention cannot continue. In both of these circumstances, child safety officers are to make every effort to alert the pregnant woman to the potential risks identified to her unborn child after birth; and, provide information about support services in the community to assist her family prior to the birth of her child. They are required to advise the pregnant woman that either a new notification or child protection order may be required when the child is born. This information is not to be provided to the pregnant woman when it is assessed that, by providing this information, the child may be placed at further risk after their birth. Child safety officers then record an ‘unborn child alert’ on the person records of the mother and unborn child. This form is forwarded to Queensland Health hospitals and/or the private or interstate hospital where the woman is likely to give birth. After this alert has been initiated, the child safety officer is required to consider whether a referral to the SCAN team is warranted and provide the Child Safety After Hours Service Centre with an after-hours referral form including the alert details. The child safety officer is then required to recontact the pregnant woman’s medical practitioner to discuss the concerns identified; request that the information be shared to relevant health professionals, such as midwives or social work services; and, ask that the department be advised of the birth of the child. They are also required to recontact any services previously involved in the provision of support services to the pregnant woman to inform them that the pregnant woman has withdrawn her consent to ongoing intervention.

179 Within the criminal justice system work is underway to progress the Single Person Identifier project to better track and monitor offenders across relevant agencies. The Single Person Identifier (SPI) is a unique person identification number recorded on QPRIME for an individual. This is used to identify a person linked to occurrences and is a unique number associated with that person, which aims to avoid duplication of person entries, and reduce confusion for officers when identifying a person. This system itself has not been without challenges and limitations. As highlighted in the Review of the Civil and Criminal Justice System in Queensland (2008) there were a number of issues with this process originally, as it was evident that a substantial proportion of people were referenced multiple times, resulting in one person having multiple SPI’s. In essence, the number of SPI’s at this time within the police system was found to greatly exceed the population of Queensland, meaning that the tracking of people, specific court cases and occurrences through the criminal justice system was highly problematic. It was within this report that, once sufficient focus had been placed on cleansing this data, it was recommended that the SPI could be utilised by separate agencies across the criminal justice system to allow data across the systems to be exchanged in a more seamless manner. In this regard, the SPI 2013-16 project was designed to enhance service delivery and improve criminal justice system responses, through allowing the unique identifier in QPRIME to be incorporated for use in other justice agency databases (courts and corrective services). It was intended that this could subsequently be used to manage, evaluate the effectiveness of, and improve, criminal justice interventions and services to offenders, and make it easier to monitor persons across the systems. In 2015, as part of a suite of recommendations that aimed to enhance the law and justice framework for domestic and family violence within the Special Taskforce on Domestic and Family Violence Final Report, it was recommended that the Queensland Government prioritises the eDV project and the Single Person Identifier project for completion as soon as practically possible within a defined time limit (recommendation 91).

180 Queensland Child Death Case Review Panel. (2017). Annual Report on the Queensland Child Death Case Review Panels, 2015-16. DCCSDS: Brisbane. 181 Queensland Child Protection Commission of Inquiry. (2013). Taking Responsibility: A roadmap for Queensland Child Protection. State of Queensland: Brisbane. 182 The QFCC released a supplementary report on information sharing to enhance the safety of children in regulated home-based services in accordance with recommendation 28 of their report, ‘When

a child is missing: Remembering Tiahleigh – A report into Queensland’s children missing from out-of-home care. The supplementary report is available online at: http://www.qfcc.qld.gov.au/ knowledge-and-resource-hub/recommendation-28-supplementary-review-report-information-sharing-enhance

These notifications are however, linked to the mother of the child, whereas, as is applicable to all of these cases, the risk may pertain to the father.

Details of the father are not always as robustly recorded within hospital records and, in cases where the mother’s partner is not the biological father, that individual may be completely invisible to the system.

A known ‘high-risk’ father, who has had previous contact with child safety, may also refuse to engage with maternity services or other agencies to avoid detection.

Currently, integrated management systems (e.g. QPRIME, Integrated Case Management System (ICMS) and the range of health client databases) do not talk to one another, and the information contained within them can be voluminous. This impedes the capacity of frontline responders, or clinicians, to quickly and accurately assess any safety concerns for a person or family unit.179

Information recorded in case notes with Queensland Health for instance, can become buried under the volume of clinical notes. In fact, in their latest report, the Queensland Child Death Case Review Panel continues to identify cases where a lack of communication, coordination and collaboration between government departments and non-government agencies led to fragmented service delivery to vulnerable children and young people.180

In 2013, the Carmody Inquiry reported a need for improved information exchange between child safety services and other agencies to support child protection reform activities. This included the broad recommendation that the Child Protection Act 1999 be amended to better enhance information sharing.181

The Queensland Family and Child Commission (QFCC) have recently completed a review of information sharing legislation, policies and procedures between agencies responsible for decision-making about the safety of all children in regulated service environments, including out-of-home care placements with foster or kinship carers.182

Within their final report, a number of recommendations were made to enhance information sharing including a recommendation to create a centralised system (register) to record home-based

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services and provide greater visibility of home-based services and facilitate information sharing between relevant agencies.

While not intended to replace existing systems or databases, the QFCC suggested this database would be useful in improving safeguards as all relevant government stakeholders could contribute to, and access, this register which would outline potential risks to children.

There are also existing legislative provisions under the Child Protection Act 1999 which authorises the exchange of information about a relevant child who is, or may be, in need of protection however, the QFCC report noted that a child may still be at risk of suffering significant harm, even in circumstances where a parent is considered able and willing to protect them.

The QFCC further noted there were limited QPS policies and procedures governing information sharing in circumstances outside the scope of the Child Protection Act 1999. This is a focus of current work being undertaken by the QPS including to develop a central resource hub identifying what information can be provided and to whom, and a standardised process to record the information provided to other agencies in relation to children who are at a risk of harm.

With respect to the above, the Board welcomes efforts to enhance information sharing and implement an interagency alert system for high risk cases that allows for more cohesive and secure information exchange across government services. This would ideally arise through a technological interface across relevant systems rather than separate databases. Further investigation as to the feasibility of this is required.

Consideration should also be given to enhancing the capability of QPRIME to identify child protection concerns within the immediate familial environment that may prompt officers to consider additional action or the making of a notification to child safety services.183 The potential benefit or need for this became apparent in one filicide case where the responding police officers were not aware of the very recent closure of the case by this agency. If they had had this knowledge, they may have been better equipped to consider potential risks to the child more thoroughly when responding to a familial dispute where concerns pertaining to the safety and well-being of, and parental capacity to care for, the infant were raised.

Recommendation 14

That the Department of Health develop a mechanism to assist practitioners to identify persons experiencing domestic and family violence, or high-risk families who have presented to the service previously; and to better take into account previous presentations to enhance future responses.

183 Within QPRIME a warning flag can be recorded at any time by any person and can be added to the following QPRIME record types: occurrence, intelligence submission, street check, person, business/organisation, property, vehicle, address, telephone or office/unit. Flags generally require police to take action (e.g. wanted person or vehicles) or monitor conditions or activities of person (e.g. people’s subject to order conditions or directions) There are currently 74 warning flags contained on the QPS QPRIME system for officers to utilise where appropriate (refer to appendix A). Of these 74 existing warning flags there is nothing that relates to child safety. Cautions can be added by any person however, cautions can only be added to records once the record has been linked to an occurrence, intelligence submission or street check. Cautions can be added to the following record types: person, business/organisation, property, vehicle or address. Cautions advise police of a person’s health/state (e.g. disability or disease), persons requiring protection or a dangerous situation (e.g. violent persons or hazards). There are currently 35 cautions contained on the QPS QPRIME system for officers to utilise where appropriate (refer to appendix B). Of these there are 3 that can be linked to the person (Child at risk, Child in safety system and Vulnerable person) and one that can be linked to the address (Child at risk).

184 Recommendations 9, 74, 75, 76, 77, 78, 79, 80, 82 and 83 - Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author.

185 Refer to https://www.communities.qld.gov.au/resources/gateway/campaigns/end-violence/info-sharing-guidelines.pdf.

Recommendation 15

That the Queensland Police Service implement a process within QPRIME and across the service, which includes consideration of a warning flag, to assist frontline officers to identify when a child may be at risk of harm, and to inform their investigations at any calls for service.

Further, while such system change may be required to assist police and other services to better understand, and respond to, a prior substantiated history of harm, or to ensure they have information available to them to inform a better assessment of risk, it is also the case that information sharing requires cultural change and a willingness and desire from the practitioner or organisation to do so.

A key component of the Special Taskforce on Domestic and Family Violence reform agenda is the establishment of an enhanced integrated service system response to identify and manage cases of domestic and family violence.

The DCCSDS is leading this work across government and the community, to design and test holistic and integrated approaches to improving the safety of victims and their children and holding perpetrators to account for their violence, in response to a series of recommendations made by the Taskforce.184

As part of the implementation of applicable recommendations, they have engaged with sector partners to co-design the models for the trials and commissioned the Australian National Research Organisation for Women’s Safety (ANROWS) to develop a suite of tools to support this initiative.

This includes a common risk assessment and management framework model for high risk cases, supporting professional resources, and information sharing guidelines based on new legislation enabling key government and non-government entities to share information that will help identify and manage serious domestic and family violence threats.185

Three trial sites have been selected to consider how service systems can work together in a structured, collaborative way to ensure people affected by domestic and family violence receive quality and consistent support: Logan/Beenleigh (urban trial site); Mount Isa (regional trial); and Cherbourg (discrete Indigenous community trial).

The Cherbourg trial aims to provide an opportunity to co-design and develop a culturally-specific integrated response to domestic and family violence that is tailored to the needs of discrete Aboriginal and Torres Strait Islander communities.

Multi-agency high risk teams commenced operating in the trial sites in 2017. These teams consist of officers from all agencies with a role in keeping victims safe and holding perpetrators to account — including police, health, corrections, justice and domestic violence services — collaborating to provide integrated,

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culturally appropriate responses to victims and their children assessed to be at high risk of serious harm, or death.

Between 2017–18 and 2018–19, five additional high risk teams will join the trial sites, specifically, in Cairns/Mossman, Brisbane, Ipswich, Mackay/Whitsunday and Moreton Bay areas.

The Queensland Centre for Domestic and Family Violence Research has been commissioned to evaluate each of the three integrated service response trials, with the first stage scheduled for completion in June 2017.

Queensland legislation provides a flexible framework which supports professionals in sharing information in certain situations, while recognising the individual’s right to confidentiality and privacy. In Queensland several legislative instruments allow for information sharing in a range of circumstances to protect the health, safety and wellbeing of consumers, families, carers and the community, including the Domestic and Family Violence Protection Act 2012 (DFVPA 2012).

To strengthen existing provisions information sharing amendments to the DFVPA 2012 were passed by the Queensland Parliament in October 2016 and commenced on 30 May 2017.

Under part 5A of the DFVPA 2012, prescribed agencies may share relevant information with other prescribed agencies,186 specialist domestic and family violence services and support service providers, where there is an assessed level of risk of domestic and family violence, demonstrable by a person’s fear of pending violence, a person’s experiences of actual violence, or a person’s exposure to serious threat of future violence.

While recommending consent be sought whenever safe, possible and practicable, these amendments recognise that in almost all situations involving domestic and family violence, consent should not be sought from perpetrators, and the safety and protection of victims takes precedence over gaining a perpetrator’s consent to share information.

To support practitioners to appropriately share information under the new legislative provisions, Domestic and Family Violence Information Sharing Guidelines187 have been developed. These Guidelines provide information about what is permitted under the legislation, who is allowed to share information, what circumstances allow information sharing without consent to ensure the safety of victims and children and what information can be shared.

Queensland Health have also developed specific information sharing guidelines for health practitioners, clinicians and staff where there is an assessed risk of domestic and family violence.

These guidelines articulate that health practitioners may give, receive or use information under the DFVPA 2012 if the person’s duties include assessing threats to life, health or safety because of domestic violence; or they are taking action to lessen or prevent threats to life, health or safety because of domestic violence, including by providing assistance or a service to a person involved in the domestic violence.

The Queensland Government has also requested that the Queensland Law Reform Commission (QLRC), in accordance with its functions under section 10 of the Law Reform Commission Act 1968 conduct

186 The Department of Health and associated agencies, including public health services and public hospitals (Authorised Mental Health Services), and the Ambulance Service are prescribed agencies under the DFVP Act.

187 Available at https://www.communities.qld.gov.au/resources/gateway/campaigns/end-violence/info-sharing-guidelines.pdf 188 For more information, refer to: http://www.qlrc.qld.gov.au/current-reviews.

a review and investigation into the introduction of a domestic violence disclosure scheme in Queensland.188

The purpose of this type of scheme is to permit disclosure of an individual’s history of domestic and family violence to a person who may be at risk, for example a new partner. This information could then allow the person at risk to make more informed choices about whether to continue that relationship and/or to seek help and support.

England and Wales were the first Commonwealth jurisdictions to introduce legislative disclosure schemes, followed by Scotland and New Zealand. New South Wales introduced a pilot scheme in April 2016 (for two years). Western Australian and Victoria both considered but did not introduce a scheme; and South Australia’s consideration of this matter is ongoing.

This issue was not considered by the Special Taskforce on Domestic and Family Violence in Queensland, and the matter has been referred to the QLRC for consultation and consideration.

A final report was due by 30 June 2017 but was not yet publicly available at the time of writing this report. It is important to be cognisant that there may be unintended consequences for such a scheme as no or limited previously recorded history of violence may lead to a false perception of safety. There is a high likelihood that there are circumstances in which a person may have abused others in the past but this violence has not come to the attention of police or other formal services

Interventions with victims who may use violence

In 12 of the 27 cases (44.4%) considered by the Board, the adult female victims had been identified by police as a respondent in domestic and family violence related occurrences, on one or more occasions either in the index relationship or in a previous one.

Analysis of these cases established that these females had experienced a significant prior history of victimisation within either the current or former relationships and for a substantial proportion, a protection order was also in place listing the male partner as a respondent.

This demonstrates the need for increased awareness of when, why and how victims may use violence.

For example, in one case considered by the Board, the female victim used physical violence in an attempt to stop her partner from carrying out his threats to commit suicide, and on another occasion, in retaliation to violence perpetrated against her. In a different case, the female primary victim used a makeshift weapon to slash at the perpetrator in the middle of a physical assault and was subsequently served with a (cross) application for a protection order by police, listing her as the respondent, while she was in hospital receiving treatment for injuries sustained during this assault.

Similarly, in the majority of cases reviewed by the Board in the Aboriginal family violence homicide meeting, nearly all of the victims had a prior history of being recorded as both respondents and aggrieved parties, in both their current and historical relationships. This is discussed in further detail within Chapter 7 of this report.

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Violent resistance refers to violence used by (predominantly) female victims as a means of self-defence or protection against their perpetrators. The use of violence towards an abuser may appear counter-intuitive to avoiding physical harm however, victims tend to use it as an active coping strategy.189

‘Violent resistance’ or reactionary use of violence by victims, particularly where a perpetrator is adept at ‘image-making’ and creating a perception of the primary victim as ‘crazy’ or ‘difficult’ may result in victims being seen as the ‘problem’, meaning that they are less likely to receive the assistance they require and in some cases this may also serve as a barrier to accessing services.

This is problematic, as when a victim discloses their experiences of violence and no assistance emanates from this disclosure, a perpetrator’s abusive behaviour is further reinforced and normalised, and the victim is less likely to seek assistance in the future.

There is also evidence to suggest that some men may call the police first as a pre-emptive strike190 against their aggrieved partner particularly where cross-protection orders are in place. It is clear that this tactic was used in several cases considered by the Board, including the perpetrator threatening to report false allegations against the victim to police in an attempt to get her in trouble.

As such, it is of critical importance that the person most in need of protection, and the person most likely to inflict harm, are correctly identified at every point of contact with services who may be in a position to assist.

Conversely, there are significant challenges for a service system in not responding to violence used by victims as it may be seen to be condoning or dismissing their use of abusive tactics. It may also be difficult, when considering any particular incident, to identify any patterns of harm over time, if that information is not easily accessible or when there is a need for an immediate response to a crisis situation.

For example, the QPS Protective Assessment Framework currently utilised by police, is an incident focused response tool that does not require officers to take into account prior assessments of risk conducted by police or to consider salient risk indicators, such as prior acts of non-lethal strangulation or a victims intuitive sense of fear, that may have been present in other episodes of violence recently reported to police.191

As such, greater consideration is required as to how historical episodes of domestic and family violence, or prior protective assessments, are interpreted by responding officers when seeking to identify the person most in need of protection; as required by the DFVPA 2012.192

This is particularly relevant in circumstances in which a primary victim of violence has previously been recorded as a respondent, before legislative amendments in 2012 that now require that consideration is given to the identification of the person most in need of protection where both parties use violence. In such instances, there is a potential for the primary victim of violence to

189 Leone, J. M., Johnson, M. P., & Cohan, C. L. (2007). Victim help seeking: Differences between intimate terrorism and Situational couple violence. Family Relations, 56(5), 427–439. 190 Hester, M. (2009). Who Does What to Whom? Gender and Domestic Violence Perpetrators Bristol: University of Bristol in association with the Northern Rock Foundation 191 The Queensland Police Service is currently commissioning an evaluation of the DV-Protective Assessment Framework with findings expected during 2017-18. 192 S4(2)(d) - in circumstances in which there are conflicting allegations of domestic violence or indicators that both persons in a relationship are committing acts of violence, including for their self-

protection, the person who is most in need of protection should be identified. 193 Refer to www.dvturningpoints.com for further information about this program. 194 For example, the Domestic Violence Prevention Centre (Gold Coast) are running programs for females who use violence at two south-east Queensland correctional centres: Brisbane Women’s

Correctional Centre and Numinbah Correctional Centre.

continue to be labelled as a respondent by police and the courts because of this prior history.

Such nuanced analysis does not need to be conducted by the responding officers, but may more appropriately fall within the scope of those officers working within high risk teams, vulnerable persons units or domestic and family violence coordinators within the QPS.

Due to the gendered nature of domestic and family violence, perpetrator intervention programs are almost universally targeted towards changing the behaviour of violent men. Commensurate with the prevalence and impact of domestic and family violence perpetrated by men this is wholly appropriate. There are also cases where female victims themselves resort to violence, albeit for different reasons and usually in the context of ongoing victimisation.

This use of violence by victims is largely not addressed by services through specific interventions, and while any effort to do so must be contextualised appropriately to avoid further victimisation of women, there are some potential benefits in working with women to help them understand their behaviour and break the cycle of violence.

While there are limited identifiable interventions that specifically consider this issue, a model developed in the United States by one of the co-founders of the Duluth Domestic Abuse Intervention Project, Ellen Pence, may provide a starting point for consideration. Turning Points: A non-violence curriculum for women193 is an educational program for women who use violence against their partners. The course focuses on helping women understand the connection between the violence they experience and the violence they use; with the overall goal being to support women to end both.

While there may be some trials194 underway in this area in Australia, there is limited information available about best practice approaches, or how best to work with victims who may themselves use violence to improve protective outcomes.

As such, robust evaluation and a focus on continuous improvement in this area is critical; and where the victim remains within an abusive relationship, all efforts should be made to correspondingly work with their partner to address the underlying relationship dynamics that may be perpetuating this type of violence.

Recommendation 16

That the Queensland Government commission research which aims to identify how best to respond to the person most in need of protection, where there are mutual allegations of violence and abuse. This research should take into account the identification of potential training or education needs for service providers, across applicable sectors to better assist in the early identification of, and response to, victims who may use violence, particularly where they come to the attention of services during relevant civil proceedings for domestic and family violence protection orders.

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Perpetrator interventions

In all cases reviewed by the Board, perpetrator interventions and accountability were an important consideration. It was clear that where interventions were provided, they fell far short of having the desired effect of reducing future recidivism or the likelihood of further harm.

This was particularly evident in one of the filicide case where the offender demonstrated a clear pattern of perpetration against his intimate partners and their children.

It appears that this offender would target vulnerable single mothers by befriending them and rapidly attempting to commence an intimate partner relationship; moving from partner to partner in quick succession. This particular offender was caring for at least six children when they suffered various injuries (including life threatening injuries), prior to commencing the index relationship. He also brutally assaulted and raped one of his former partners, and is known to have been highly controlling of his female partners, socially isolating them from family and friends.

The offender’s abusive behaviours came to the attention of formal services on multiple occasions, were well known to family and friends, and commenced at an early age. There was very limited intervention or support provided across these incidents, with the delivery of services being impeded by his transiency, with the abuse occurring within (at least) three states. Allegations of suspected child abuse within the context of domestic and family violence were reported and investigated with multiple children although there is limited evidence that services provided any long term intervention or support with the perpetrator around these concerns,195 or that he was required to complete any programs to address this risk over time (either through a voluntary referral or mandated treatment).

Referrals to rehabilitative programs are vital to ensuring that perpetrators receive appropriate support to change their abusive behaviours over the longer term.

A significant challenge to achieving positive outcomes through such interventions is the perpetrator’s motivation to change. An intervention will not be successful if a perpetrator does not believe that their behaviours are inappropriate, or if they are unmotivated to change.196

Change can only be achieved when responsivity factors are also addressed.197 This can include treatment of mental illness and substance misuse issues, which may co-exist in perpetrators of domestic and family violence. Despite the importance of holding perpetrators to account, with participation in evidence-based interventions considered most appropriate to promote change, unless the perpetrator is psychologically motivated the effects are likely to be negligible. As a result, consideration needs to be given as to what preparatory work may be required with

195 At the age of 14 this offender was required to complete court ordered counselling for sexual offences against a young child. 196 From literature on addiction it is generally accepted that there are six recognised stages of change: Pre-contemplation; Contemplation; Preparation; Action; Maintenance; Termination. For

intervention to be successful, a perpetrator must be assisted in progressing to the fourth stage, action. Motivational interviewing (MI) is a key psychological technique used by practitioners with individuals who are resistant to change (i.e. in the pre-contemplation or contemplation stages of change). MI is a technique used to encourage individuals to resolve their ambivalence to change and is achieved through an accurate appraisal of the costs and benefits of change. MI enhances retention and engagement in treatment, increases motivation to change and also assists to change behaviour; however, MI alone is not sufficient to realise change in domestic violence perpetration.

197 Responsivity factors can be described as individual factors that interfere with or facilitate learning. These factors may not impact directly on recidivism but need to be considered as they affect an offender’s receptiveness to intervention. Examples of responsivity factors include: anxiety, self-esteem, depression, poor verbal skills, poor literacy skills, cognitive ability, and cultural factors – QCS. (2006). Appendix – The Principles of What Works

198 McClure, T.E. (2013). A comparison of domestic violence recidivism rates of defendant-initiated diversion and court-mandated treatment. Partner Abuse, 4, 444-462. Just 8.6% of diversion participants and 32.7% of mandated program participants had a DV re-offence within 2 years.

199 Ibid. 200 Ibid.

offenders prior to commencement in mandatory or voluntary intervention programs.

Voluntary intervention orders issued by the court are, by definition, tautological. There is a lack of consequences for offenders who fail to attend, engage or complete voluntary interventions in the community. In one study, domestic violence offenders who completed a voluntary diversion program had significantly reduced odds of being charged for further domestic violence offences than those who completed a mandated treatment program.198 This demonstrates the impact that self-determination can play in realising actual behaviour change; although it was noted by the Board that for court referred ‘voluntary’ programs there may still be extrinsic motivators for perpetrators to participate within the programs.

Perpetrator intervention programs aim to prevent violence by changing attitudes and behaviours through a range of strategies including individual counselling, case management and group work. Different approaches and methodologies are employed to achieve this aim including goal setting, solution focused approaches, counselling, behaviour change, narrative therapy and anger management. The most commonly used model underpinning perpetrator intervention programs is the Duluth model, which focuses heavily on gender equity issues, and teaching strategies to control violence.

Domestic violence intervention programs have also been shown to have limited treatment effectiveness in reducing reoffending.199 The North American Domestic Violence Intervention Program Survey also revealed that programs vary considerably in terms of their underlying ideologies, treatment length, delivery modality, participant type (e.g. group, individual, couple), and intake/ screening processes.200

Treatment that is based exclusively on the traditional causal theory of patriarchy contradicts the empirical research literature, and a failure to consider other mechanisms is limited and dismissive of the needs of a diverse treatment population.

Treatment program options need to be targeted to the specific intervention needs of perpetrators to promote optimal behaviour change circumstances.

As outlined above, perpetrators also need to be motivated and responsive to change, which can take considerable effort from multiple agencies to get perpetrators to this point. As such, intervention programs may not necessarily be a ‘quick fix’ solution.

Despite research questioning the effectiveness of perpetrator intervention programs, there is the potential for successful outcomes to be achieved if the right conditions are met.

Successful perpetrator intervention programs include some core traits, such as:

» A systemic, integrated response that is a coordinated, appropriate and consistent response aimed at enhancing

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victim safety, reducing secondary victimisation and holding abusers accountable for their violence.201 This requires a focus on the program in the context of the broader intervention system of arrest practices, court procedures, probation and parole monitoring, victim services and other community services which may substantially affect program success.202

» High quality therapeutic alliance between the client and program workers.203

» Better and more inclusive measuring of outcomes which take into account how victims may benefit or be adversely affected by their partner’s participation in a program and are not just reliant on self-reports.204 Another key measure may be that women and children also get access to help, or that women are given realistic advice about what change may be expected so that they don’t gain a false sense of security just because their partner entered into a program.205

» Acknowledgement of the diversity and individuality of those attending group sessions. For example, provision should be made for groups that include consideration of the needs of persons residing in rural and remote areas; experiencing mental health issues; who are incarcerated; have limited language and literacy skills; people from culturally and linguistically diverse backgrounds; Aboriginal and Torres Strait Islander people; and members of the lesbian, gay, bisexual, transgender and intersex community.206

In their Final Report, the Special Taskforce on Domestic and Family Violence highlighted the importance of perpetrator interventions as part of an integrated service response to address domestic and family violence and recommended increasing access to perpetrator intervention initiatives. Importantly, the Special Taskforce also recognised that programs need to be tailored to different levels of readiness, based on risk-need-responsivity principles and the specific cultural needs of Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse backgrounds.207

In the cases reviewed by the Board, five perpetrators had completed domestic and family violence intervention programs. Three men completed a program while imprisoned. In addition, two other perpetrators were offered intervention programs while in prison ‘at their discretion’ as they had not breached protection orders or their sentence was not in relation to domestic and family violence offending. Further, one young female victim was referred to a perpetrator intervention program while in custody for unrelated offences, despite only having a record of victimisation at that point.

Of note, one particular perpetrator was referred to a program as a condition of his probation order, following a conviction for breaching his protection order against a former partner. The perpetrator was noted in the pre-assessment to minimise his abusive behaviours claiming that he ‘never’ controlled decision making, expressed intense jealousy or threw her around; but he did have some insight by acknowledging that he ‘sometimes’

201 Mulroney, J. (2003). Trends in interagency work, Topic Paper 2, Australian Domestic and Family Violence Clearinghouse. 202 Laing, L. (2003). What is the evidence for the effectiveness of perpetrator programmes? Australian Domestic and Family Violence Clearinghouse. 203 Day, A., O’Leary, P., Chung, D., & Justo, D. (2009). Programs for men who perpetrate domestic violence: An examination of the issues underlying the effectiveness of intervention programs’. Journal of

Family Violence, 24, 203-212. 204 Laing, L. 2003. What is the evidence for the effectiveness of perpetrator programmes? Australian Domestic and Family Violence Clearinghouse. 205 Day, A., O’Leary, P., Chung, D. & Justo, D. (2009). Programs for men who perpetrate domestic violence: An examination of the issues underlying the effectiveness of intervention programs’. Journal of

Family Violence, 24, 203-212. 206 Mullender, A., & Burton, S. (2000). ‘Reducing domestic violence: what works? Perpetrator programmes’. London, Policing and Crime Reduction Unit, Home Office. 207 Recommendation 80 – Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 208 For example, recommendations 80, 81, 82 - Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in

Queensland. Brisbane: Author.

threatened to kill her, punched her, kicked her, threatened to hit, and tried to keep her from doing things she wanted to do. The perpetrator also reported putting her down to her friends and family ‘very often’.

Furthermore, the perpetrator was assessed as posing a high risk to other women should he enter a new relationship in the future at the pre-program assessment, although the continued risk to his former partner was correspondingly not highlighted. This suggested that the assessor may not have been cognisant of the significant risks that remain for former partners even after separation. Indeed, there is evidence to suggest that violence did occur within that relationship post-separation and the subsequent homicide occurred in the middle of a separation.

This perpetrator exited the program after completing 27 weeks of classes. The program was extended for an additional three weeks from the mandatory 24 weeks due to the perpetrator’s lack of participation during program sessions. In his exit report, it was noted that he rarely contributed to group discussions and when he did, he blamed his former partner for his offending and minimised his use of violence. Furthermore, he failed to articulate or demonstrate any strategies he developed while attending the program to keep any new partners safe, or to be respectful in his intimate relationships.

At the end of the program, the perpetrator was assessed as a future high risk of reoffending in terms of domestic violence offences; he was rated as high risk at each of the 27 sessions he attended.

In their discussions on this topic, Board members emphasised that participation in an intervention program alone should not be considered to reduce the risk of future offending. Mandating program participation needs to be considered within a broader context of concerns about a perpetrator’s motivation to change at that point in time. Criminogenic programs are not mandated for certain offences (e.g. sexual offences) for this reason.

Behaviour change programs also need to match the risks and needs of a particular perpetrator in terms of the intensity and duration of the program. Participant fit, and access to appropriate role modelling are important considerations for program facilitators.

In circumstances in which it is clear that a program is not working for a particular person, consideration should be given to the need for alternative interventions to maximise that opportunity for intervention.

While the Special Taskforce on Domestic and Family Violence produced a suite of recommendations aimed at holding perpetrators accountable,208 including expanding the availability of perpetrator intervention programs, current programs have had limited evaluation with respect to key outcomes such as reductions in recidivism.

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In this sense, it is necessary to consider perpetrator intervention programs as one part of a broader system response and to recognise that achieving perpetrator’s attitudinal or behavioural change is only one measure of effectiveness. For example, other critical benefits of such programs may include:

» providing women and children with access to support services

» ensuring ‘system visibility’ of perpetrators through sustained, long-term engagement

» improving opportunities for monitoring and prompt intervention for breaches related to non-compliance of any conditions of court or protection orders.

In accordance with recommendation 82 of the Special Taskforce Final Report,209 the DCCSDS has oversight of a number of ongoing initiatives that aim to support best practice service delivery in the delivery of perpetrator interventions, including:

» The undertaking of a review of existing practice standards, including analysis of current research and evidence, consultation with key stakeholders and the development of a new, evidence based contemporary suite of practice guides and standards covering the full range of domestic and family violence service responses.

» The development of a tool which can be used by an external agency to monitor compliance of perpetrator intervention services with the new standards through an accreditation style system.

» The development of a training package, including a range of training materials that may be used by the department to embed the new practice guides and standards into the practice of service providers.

In their discussions Board members highlighted the need to ensure minimum requirements for staff skills and capabilities, as well as a monitoring and oversight function, are incorporated into these standards. There should also be a strong focus on driving continuous improvement in this area and robust evaluations which are shared across the service sector. It is also the case that program facilitators need to be connected with broader service responses that are working with victims of violence, and information sharing needs to occur to ensure that service providers working with both parties have access to relevant information to drive more tailored interventions.

This commitment towards increased delivery of new or enhanced perpetrator intervention programs has also seen a funding and investment model of $10.3M allocated over four years commencing 2016–17 to services.

In addition to current reforms in Queensland, the need for consistent and robust perpetrator interventions has also been recognised at a national level.

In 2016, the Commonwealth Government commissioned ANROWS to implement a dedicated Perpetrator Interventions Research

209 Recommendation 82 states: The Queensland Government: (a) Reviews and updates the Professional Practice Standards: Working with men who perpetrate domestic and family violence and the accompanying principles to ensure they reflect the most recent developments and knowledge in the field and include models of practice and standards to ensure safe and appropriate practice for individual (as well as group) intervention sessions. (b) Ensures that practice standards require that initiatives for perpetrators of domestic and family violence are to be delivered in conjunction with an integrated response in order to establish adequate safety and accountability protocols. (c) Establishes a clear and rigorous process for evaluating and approving initiatives and providing ongoing monitoring of compliance with the Practice Standards to ensure that issues of non-compliance and service system development requirements are identified. (d) Considers establishing a formal accreditation process for practitioners, including minimum qualification requirements for practitioners, be implemented gradually so as to not adversely impact on service availability.

210 Refer to: https://www.dss.gov.au/women/programs-services/reducing-violence/the-national-plan-to-reduce-violence-against-women-and-their-children-2010-2022 211 These were developed by the Australian Commonwealth, state and territory governments and endorsed by the Council of Australian Governments on 11 December 2015, and aim to inform

interventions to reduce re-offending, to better understand the nature of perpetration against high risk groups, to evaluate existing program models, and to determine the characteristics of effect perpetration intervention programs. https://www.coag.gov.au/sites/default/files/communique/National_Outcome_Standards_Perpetrator_Interventions.pdf

Stream which is a priority of the National Plan to Reduce Violence against Women and their Children 2010-2022.210

The Perpetrator Interventions Research Stream is funded by the Commonwealth Government to support states and territories to implement the National Outcome Standards for Perpetrator Interventions.211

The research will consider the broad range of interventions with perpetrators of violence in Australia, including interfaces with the community sector and interventions within the context of the civil, criminal, child protection and family law systems, in addition to men’s behaviour change programs and other related programs. The program commenced in early 2017 and comprises 13 projects with total funding of just over $2.1M.

Four research themes are to be addressed between 2017–19 including: System effectiveness; Effectiveness of interventions; Models to address diversity of perpetrators; and Interventions developed by, with and for Indigenous communities.

Ongoing monitoring for earlier intervention

Abusive behaviours rarely occur in isolation and domestic and family violence perpetration is best conceptualised as a pattern of behaviour within an intimate partner or familial relationship, which at times is repeated across multiple relationships. As is evident in a number of cases reviewed by the Board within this reporting period, there was a proportion of perpetrators who represented a sustained and extreme risk to others.

Ensuring processes are in place to better identify those high risk perpetrators when they re-present to services may provide an opportunity for agencies to more swiftly respond if it is apparent that the perpetrator has entered a new relationship or has ongoing contact with children or other potential victims.

This may improve protective outcomes for potential victims, and further ensure opportunities for intervention are more readily utilised, with a sustained focus on perpetrator accountability by the system.

Such processes need to account for circumstances where a perpetrator may have been incarcerated or moved interstate as an absence of service contact may be incorrectly attributed to a cessation of abusive behaviours, as occurred in one filicide case. In this case, without checking collateral information, a child safety officer considered a lack of recent offending to be reflective of a cessation of criminal activity when in fact the perpetrator had instead been incarcerated and recommenced his offending behaviours upon his release.

Currently, alerts are in place for Child Safety Services to advise interjurisdictional counterparts when high risk children move interstate however, these alerts are not attached to the parents if they move interstate without the children. Further, it appears that limited mechanisms exist to proactively alert Child Safety Services of the history of a high-risk offender if they enter a new

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relationship in which there are children present until or unless a notification is made and/or an investigation is commenced.

For example, with respect to one particular filicide death where the perpetrator was suspected of a near fatal assault of an infant in another state, no interstate alert was activated between states after his relocation to Queensland without the infant or family. The extent to which child safety officers in Queensland were aware of these prior occurrences, upon receipt of new notifications involving this perpetrator (some 10 months later) appears to have been limited.

While Child Safety Services can include alerts for perpetrators on their system where prior harm has been substantiated, future action and swift intervention is largely dependent on this agency becoming aware that these persons are in contact with another child through a new notification of suspected harm.

Consideration is therefore required as to the feasibility of enhancing processes to monitor recidivist perpetrators across different jurisdictions, where significant harm to children has been reasonably suspected or substantiated, to assist in preventing harm to other children in the future and to facilitate earlier intervention.

There are currently provisions for offenders with serious convictions against children to be included on the Child Protection Offender Register (CPOR) in Queensland212 with similar registers established in other states although the primary policy intent behind these instruments is with respect to monitoring child sex offenders.213

When an offender of a prescribed offence is convicted, they automatically become a reportable offender and are subject to reporting obligations under the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004 (CPOROPOA). For offences that are not prescribed offences there is a provision within s. 13 of CPOROPOA to make application to the Court for an Offender Reporting Order (ORO) if an offender is found guilty, convicted and sentenced. The court must be satisfied that the person poses a risk to the lives or the sexual safety of one or more children, or of children generally. It is not necessary that the court be able to identify a risk to particular children, or a particular class of children.

The court may also make an offender reporting order on its own initiative or on an application for the imposition of the order made by the prosecution. The prosecution may make an application at any time within six months after the day the court imposes the sentence for the offence.

The National Child Offender System (NCOS) is a web-based application which enables police in each state and territory to share and record child offender information to enable them to meet their requirements under respective child protection legislation, for example, CPOR in Queensland.

The national scheme requires child sex offenders, and other defined categories of serious offenders against children, to keep police informed of their whereabouts and other personal details for a period of time after they are released into the community. The intent of NCOS is to protect the community by reducing the

212 Established by the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004. As per Schedule 1 of the Child Protection (Offender Register and Offender Prohibition Order) Act 2004, (CPORAOA), in Queensland, applicable to the circumstances of these deaths prescribed offences include: Indecent treatment of children under 16; Carnal knowledge with or of children under 16; Taking child for immoral purposes; Maintaining a sexual relationship with a child; Defilement of girls under 12; Attempt to abuse girls under 10; Sexual intercourse / conduct with child under 16; Procuring sexual acts by coercion; Procuring young person for carnal knowledge; Incest; Conspiracy to defile; Murder; Rape; Attempt to commit rape; Assault with intent to commit rape; Sexual assault. https://www.legislation.qld.gov.au/view/pdf/inforce/current/act-2004-052

213 It is noted that the offender in this case had been convicted of sexual offences against a child, and was also suspected of acts of sexual abuse and serious physical assaults of other children.

likelihood that an offender will reoffend and to facilitate the investigation and prosecution of any future offences they may commit.

While provisions exist to allow for offenders to be included on the register currently, an opportunity exists to consider expanding the categories of prescribed offences to more clearly specify other offences in which an offender is convicted in conjunction with a child fatality (or near fatality), or in which serious abuse concerns have been identified (such as acts of torture).

This is salient given that a number of the filicide offenders had been identified as representing a significant risk to any child in their future care by applicable authorities. At least one filicide offender had been identified as posing a significant risk of harm to any child in his care, at least four years prior to the subsequent death.

Although civil monitoring of individuals presents a financial and resourcing impost, in circumstances where there is a high risk of harm to children by individuals, there must be some recourse to ensure they remain visible within the system and this may, in certain circumstances, necessitate a controlled impost on the civil liberties of perpetrators.

In their discussions pertaining to this issue, the Board considered the potential benefit of:

» ensuring alerts and monitoring regimes are in place for high- risk perpetrators of domestic and family violence particularly those who are suspected of causing significant harm to children, as well as other offences already within the scope of existing monitoring schemes

» increasing awareness and education about existing legislative functions so that prosecutors are able to make applications as a matter of course during hearings, even if they do not proceed to trial by virtue of a guilty plea. This could mirror the process for courts in ensuring offences are classified as serious violent offences or domestic violence offences

» expanding the scope of offences which automatically classify persons as reportable offenders so that those who commit serious offences against children do not go unregistered

» processes for Child Safety Services to become aware that a person may be a reportable offender, to inform their response to a future notification.

In recognition of the need to balance public safety and civil rights, the Board considered further work would be required to resolve this issue and develop a robust, fair solution that prioritised the safety of victims and their children without overburdening civil monitoring systems.

With respect to the circumstances of the filicide cases in which there was evidence of significant abuse and injuries sustained over a prolonged period of time by the infants prior to their deaths, it is clear that for a small proportion of extreme offenders, we must do more to protect those most vulnerable to harm, who are unable to protect themselves and are often largely invisible to those services who are required to respond.

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Recommendation 17

That the Queensland Government consider opportunities to strengthen legislative, policy and practice requirements within Child Safety Services and the Queensland Police Service to enable each agency to have timely access to relevant information about past offending conduct, including charge and conviction information from Queensland and other jurisdictions, when undertaking their respective and joint investigative functions and powers. This should include, but not be limited to, a review of prescribed offences within the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004, to consider the appropriateness of broadening the scope to other violent offences against children (e.g. manslaughter, or torture) for the duration of reporting obligations, and the feasibility of broadening access to the National Child Offender System to Child Safety Services.

Recommendation 18

That the Director of Public Prosecutions, and Queensland Police Service, develop guidelines and educational resources with regard to the Child Protection (Offender Reporting and Offender Prohibition Order) Act 2004 to ensure that prosecutors have the necessary knowledge to make applications for an Offender Reporting Order as a matter of course for serious offences against children that are not prescribed offences, even if they do not proceed to trial by virtue of a guilty plea.

Community and bystander interventions

Recent research suggests that many people are aware of, or suspect they know of, someone who is a victim of intimate partner violence.214 How people respond in these circumstances depends in part on social norms and attitudes to domestic and family violence.215

The role of family, friends and colleagues in the identification of and response to domestic and family violence was a key theme discussed within each case review meeting.

In 26 out of 27 (96.3%) cases, there was evidence to suggest that family and friends were aware of the abuse occurring within the relationship prior to the death, with many instances identified in which these informal supports attempted to intervene in the abuse and on occasion placed themselves at significant risk of harm by doing so.

In the other case, no family member or other party was aware of the abuse occurring in the relationship, which ultimately led to the death of an infant child, as the perpetrator had, over a period of years, exerted significant control over the aggrieved and exploited her mental and physical health impairments, to the point where she was almost totally isolated from her support networks.

Family and friends

Informal social support networks are often the first point of contact and support for victims, and while they may be aware a relationship is ‘volatile’ they may not necessarily consider it in the

214 Beeble, M., Lori, A., Post, L.A., Bybee, D., & Sullivan, C.M. (2008). Factors related to willingness to help survivors of intimate partner violence. Journal of Interpersonal Violence 23(12): 1713 – 1729. 215 VicHealth. (2006). Two steps forward, one step back. Community attitudes to violence against women. Progress and challenges in creating safe and healthy environments for Victorian women.

Melbourne: Victorian Health Promotion Foundation, Australia. 216 An international campaign, ‘Neighbours, Families and Friends’ has evolved from recommendations from domestic and family violence death review processes, and has shown some promise: http://

www.nsdomesticviolence.ca/nff . In addition to a dedicated phone line this campaign includes guides for: Identifying and helping women at risk of abuse; Safety planning for women who are abused; and How to talk to men who are abusive

context of the potential risk or understand the underlying patterns of abuse.

Informal networks are a valuable source of support for victims of domestic and family violence as they may be positioned to intervene at an earlier point or to assist a victim in seeking help and in navigating an often complex service system.

On occasion, there may also be a sense of normalisation among informal support networks of the ‘dysfunctional’ dynamics apparent within a relationship for both perpetrators and victims.

Recent public awareness campaigns have focused on highlighting that all sections of the community have a role to play in responding to domestic and family violence as part of the implementation of recommendations from the Special Taskforce on Domestic and Family Violence. This campaign is focused on encouraging workplaces, sporting clubs and community groups to ‘stop and think’ about certain abusive behaviours which may be normalised.

Increased awareness of risk may encourage people to act on concerns. While such campaigns may increase the detection of abusive behaviours, they do not always provide guidance and support as to how to respond to this risk, and family members may feel helpless to assist.

For example, statements from the family of one intimate partner homicide victim indicated that they were overwhelmed prior to the death as everything was getting worse and they felt helpless to respond as they had tried everything that they could. There may also be a sense of frustration for families and friends when they try to help a victim who returns to the relationship.

Currently, there are no services that provide dedicated support to concerned families and friends and the avenues for them to seek support and assistance for their loved ones at risk of domestic and family violence remain limited and not easily accessible.

While the police or other specialist services may try and assist when help is sought by family members, this is not their primary function. Agencies may also feel compromised in providing support to family and friends because of confidentiality issues. For example, legal services may encounter issues with potential conflicts, and may not be able to help the victim should the latter subsequently try to seek legal advice.

Specialist domestic and family violence services are also primarily funded to support victims and support for family or friends may not be part of their service agreement or within their resources to be able to provide.

Consequently, there are underlying barriers for informal support networks in accessing support for their loved ones even when they try. Family and friends also need guidance on how to safely respond and support victims and/or perpetrators of violence.

In this regard there should be more intensive support for family members so they have avenues to seek help, report concerns and get advice. This could be a dedicated agency that concerned others can contact to get information and support.216

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Workplace responses

Domestic and family violence may have a detrimental impact in the workplace as the abusive partner seeks opportunities to use power and control to undermine the aggrieved. Harassing a partner or ex-partner at work can lead a victim to be fired, subsequently increasing their dependence and susceptibility to control by the perpetrator.217

In a number of cases reviewed by the Board, employers were aware of and directly raised concerns about the safety of their staff who they suspected were experiencing domestic and family violence.

In one case, the employer staunchly supported the victim and assisted her in obtaining a protection order and linked her with relevant services to flee the relationship. The perpetrator made multiple attempts to demean and humiliate the victim to this employer, including making allegations that she was having an affair. The employer had also previously implemented workplace strategies to restrict the offender’s access to the victim in the workplace, as he was known to continuously call and harass his female partner, becoming agitated if she did not respond immediately to his contacts. He would also make it difficult for her to attend work functions and he would show up or wait outside for her to finish where she did attend.

In this respect, workplaces were identified as a key setting for intervention and support by the Board. Employment may serve a positive function for victims as it means they have access to supports from others and have time away from their violent partner. As such, the Board recognised that although offering victims special leave may be of benefit in some circumstances, it may also be the case that women feel better supported by their employers by remaining in the workplace.

Further, workplace responses also need to extend to perpetrators, with businesses being mindful of abusive behaviours occurring in the workplace, for example, where a perpetrator is using company phones or vehicles to harass a victim, or where they are perpetuating abuse during work hours. In some circumstances, employers may also be in a position to intervene and minimise opportunities for harassment to occur, and in this regard, employers would benefit from access to support and advice to help staff who may be experiencing, or perpetrating, domestic and family violence.

Improving workplace responses to domestic and family violence has been a key focus of the Queensland Government as part of the

217 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 218 Refer to ‘Domestic and Family Violence: A workplace approach to employees who use or may use violence and abuse. A Resource for all Queensland Workplaces’, available at: https://forgov.qld.gov.

au/file/27586/download?token=8rfjQ-2J 219 Refer to https://www.communities.qld.gov.au/gateway/end-domestic-family-violence/our-progress/shifting-community-attitudes-behaviours/recognise-respond-refer-e-learning-program 220 Refer to: https://www.forgov.qld.gov.au/news/2016/white-ribbon-australia-workplace-accreditation 221 Refer to: https://www.forgov.qld.gov.au/workplace-package-domestic-and-family-violence 222 Refer to: https://www.forgov.qld.gov.au/support-employees-affected-domestic-and-family-violence 223 Refer to: https://www.forgov.qld.gov.au/inclusion-and-diversity-commitment 224 Refer to: https://www.forgov.qld.gov.au/constructive-workplace-cultures

Special Taskforce on Domestic and Family Violence reform agenda. Targeted efforts have been made to share insights, resources and training in the workplace that promote violence prevention, support employees affected by domestic and family violence and promote a safe, respectful and inclusive workplace culture. Key initiatives as part of these reforms include:

» partnering with Minter Ellison, DV Connect and Australia’s CEO Challenge to strengthen the workplace response218 to employees who use or may use violence and abuse

» partnering with Australia’s CEO Challenge to implement the Recognise, Respond, Refer e-Learning program219 within agencies

» participating in the White Ribbon Australia Workplace Accreditation Program220

» developing a Domestic and Family Violence workplace package221 which is available for all workplaces to adopt and tailor

» introducing domestic and family violence leave for government employees222

» creating a more inclusive and diverse workforce through the Queensland public sector’s Inclusion and diversity strategy 2015–2020 and Gender equity strategy 2015–2020223

» Fostering a supportive and collaborative workforce, and modelling contemporary workplace practices through the Constructive workplaces cultures framework.224

» funding for programs such as the Working Women’s Centre DV Work Aware program that provides individual advocacy to vulnerable women who experience domestic and family violence and work related concerns as well as support/ education and information to work places.

Recommendation 19

That the Queensland Government review existing responses that provide support, practical advice and referral pathways for families and friends concerned about loved ones who may be at risk of domestic and family violence, and employers who identify that their staff may be experiencing domestic and family violence; in order to ensure the state-wide availability and accessibility of dedicated supports in this area.

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Chapter 7: A call for change: responding to Aboriginal and Torres Strait Islander family violence

225 Hovane, V., & Cox, D. (2011). Closing the Gap on Family Violence: Driving Prevention and Intervention through Health Policy. Australian Domestic and Family Violence Clearinghouse. Issues Paper 21 226 Aboriginal Child Sexual Assault Taskforce. (2006). Breaking the Silence: Creating the future: Addressing child sexual assault in Aboriginal communities in NSW. Sydney: NSW Attorney -General’s

Department. 227 Aboriginal and Torres Strait Islander Social Justice Commissioner. (2006). Ending family violence and abuse in Aboriginal and Torres Strait Islander communities 2001 – 2006. Australian Human

Rights Commission. 228 Olsen, A., & Lovett, R. (2016). Existing knowledge, practice and responses to violence against women in Australian Indigenous communities: State of knowledge paper Sydney: ANROWS. 229 Willis, M. (2011). Non-disclosure of violence in Australian Indigenous communities. Trends and issues in crime and criminal justice No.405. Canberra: Australian Institute of Criminology. 230 Chan, A. & Payne, J. (2013). Homicide in Australia: 2008-09 to 2009-10. National homicide monitoring program annual report, AIC Reports, Monitoring Reports 21. Canberra: Australian Institute of

Criminology. 231 Steering Committee for the Review of Government Services. (2009). Overcoming Indigenous Disadvantage: Key Indicators 2009. Canberra: Productivity Commission.

This chapter explores the disproportionate impact that family violence has on Aboriginal and Torres Strait Islander families and communities. Given the unique nature of family violence and need for nuanced understanding and targeted responses, this final chapter is comprised of three sections:

» Part A: Overview

» Part B: Key issues and themes

» Part C: System responses

In their review of the homicides and suicides of people who identified as Aboriginal and Torres Strait Islander, the Board recognised the impact of dispossession, the breakdown of kinship networks, child removal policies and entrenched disadvantage, as well as intergenerational trauma and grief, on Aboriginal and Torres Strait Islander families and communities. They also acknowledged the significant and pervasive history of violence experienced by the victims, and perpetrators, often across multiple intimate partner and familial relationships.

The impact of trauma was pervasive throughout the cases reviewed by the Board. While the Board identified a range of key themes and issues which are outlined in this chapter, the overarching message is clear: the impact of this type of violence is devastating for families and communities, both for current and future generations.

We must be bold, we must do more, and we must commit to elevating this issue to one of paramount importance.

Overview The term ‘family violence’ is commonly used when referring to violence that occurs within Aboriginal and Torres Strait Islander families and communities. This concept places a greater emphasis on the impact on the family as a whole and contextualises this type of violence more broadly, recognising the impact of dispossession, breakdown of kinship networks, child removal policies and entrenched disadvantage, as well as intergenerational trauma and grief on Aboriginal and Torres Strait Islander families and communities.225

Family violence describes all forms of violence including physical, emotional, psychological, sexual, sociological, economic and spiritual, in intimate partner, family and other relationships of mutual obligations and support.226 It includes any use of force,

be it physical or non-physical, which is aimed at controlling another family or community member and which undermines that person’s wellbeing.227

The Board acknowledges at the outset, that caution is required not to oversimplify these issues by failing to recognise that family violence may involve non-Aboriginal or Torres Strait Islander partners or family members. For example, although both partners in the intimate partner homicides were of Aboriginal descent the family dynamics in some of the victim suicides and filicides involved non-Indigenous individuals. It is also the case that the cultural journey of an individual is unique and services must first and foremost be responsive to the personal needs of their clients, wherever they are positioned on their journey.

Although responding to individual needs is a fundamental requirement of all service responses, in circumstances where one or both clients identifies as Aboriginal or Torres Strait Islander, extra consideration regarding how best to respond in a way that appropriately accounts for this, is required. This requires flexibility and an ability to adapt culturally specific and mainstream approaches in a holistic way.

The rate of family violence

The true rate of violence against Aboriginal and Torres Strait Islander women is difficult to establish due to systemic under- reporting, lack of appropriate screening by service providers and limitations in obtaining and comparing data.228

Despite these difficulties, there is still disturbing clear evidence about the disproportionately high rates of family violence experienced by Aboriginal and Torres Strait Islander men and women:

» Aboriginal and Torres Strait Islander people are between two to five times more likely than non-Indigenous people to experience violence as victims or offenders.229

» Aboriginal and Torres Strait Islander females are five times more likely to be victims of homicide than non- Indigenous females.230

» Aboriginal and Torres Strait Islander females are 35 times more likely to be hospitalised due to family violence related assaults, and Aboriginal and Torres Strait Islander males are 21.4 times more likely, than non-Indigenous females and males.231

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» For Aboriginal and Torres Strait Islander females, rates for non-fatal family violence related assaults were 34.2 times that of other non-Indigenous females in 2012-13.232

Causes of family violence

Many theories have been advanced to explain the causes of Aboriginal and Torres Strait Islander family violence.233 One framework234 that comprehensively accounts for the inherent complexities identifies three broad categories of causes:

» Precipitating causes: particular events that precede and trigger a violent episode by the perpetrator, such as an argument with a family member or jealousy directed towards intimate partners.

» Situational factors: circumstances in the social environment of the perpetrator and victim which might elevate risk including problematic substance use, mental health problems, and financial stress.

» Underlying factors: the historical circumstances of Aboriginal and Torres Strait Islander people, which make them vulnerable to enacting, or becoming a victim of, violent behaviour including trauma linked with dispossession of land, colonisation, genocide, racism and the large-scale removal of children, the Stolen Generation, from their families.

High unemployment, low socioeconomic status, poor housing and overcrowding, poor health, high mortality, poor governance in local communities, and a lack of support services are all likely to contribute to higher levels of conflict and violence.235

In this sense, family violence can be seen as a multi-dimensional problem, sharing many of its antecedents with a range of other health and social issues236 affecting Aboriginal and Torres Strait Islander communities.

For example, data from the 2008 National Aboriginal and Torres Strait Islander Social Survey237 revealed a range of socio-economic stressors associated with violence. The survey identified that Aboriginal and Torres Strait Islander people who reported a recent experience of physical violence were more likely to:

» live in a household which ran out of money for basic living expenses

» live in a household that had difficulty paying bills on time

» report high or very high levels of psychological distress

» have recently witnessed physical violence

» have experienced removal from their natural family

» experience a disability or long term health condition.

232 Steering Committee for the Review of Government Services. (2014). Overcoming Indigenous Disadvantage: Key indicators 2014 Report. Canberra: Productivity Commission. 233 Marchetti, E. & Daly, K. (2016). Indigenous partner violence, Indigenous Sentencing Courts, and Pathways to Desistance. Violence against Women. 1-23. 234 Memmott, P., Stacy, R., Chambers, C., & Keys, C. (2001). Violence in Indigenous communities: full report. Barton: Crime Prevention Branch, Attorney-General’s Department. http://www.

crimeprevention.gov.au/ Publications/FamilyViolence/Documents/ violenceindigenous.pdf 235 Ibid. 236 Anderson, I. (2002). Understanding Indigenous violence. Australian and New Zealand Journal of Public Health, 26(5), 408-409. 237 Australian Bureau of Statistics. (2009). National Aboriginal and Torres Strait Islander social survey 2008. Canberra: ABS. 238 Weatherburn, D., Snowball, L., & Hunter, B. (2008). Predictors of Indigenous arrest: An exploratory study. The Australian and New Zealand Journal of Criminology, 41(2), 307-322. 239 Council of Australian Governments. (2009). Closing the Gap on Indigenous Disadvantage: The challenges for Australia. 240 A short synopsis of current approaches to reducing family violence can be found here: Cripps, K. & Davis, M. (2012). Communities working to reduce Indigenous family violence, Indigenous Justice

Clearinghouse (Brief 12) http://www.indigenousjustice.gov.au/briefs/brief012.pdf 241 Olsen, A., & Lovett, R. (2016). Existing knowledge, practice and responses to violence against women in Australian Indigenous communities: Key findings and future directions. ANROWS Compass

series. Research to policy and practice. Issue 01 January 2016. Available online at: https://d2c0ikyv46o3b1.cloudfront.net/anrows.org.au/C1_3.2%20AIATSIS%20Compass.pdf

Another study238 linking aspects of violence with socio- demographic characteristics similarly found a high correlation between higher rates of violent victimisation among those who: live in an area with neighbourhood problems; are exposed to social stressors; are members or are related to members of the Stolen Generation; consume alcohol or drugs; live with someone who has been formally charged with an offence; are sole parents; are under the age of 35; are unemployed; experience financial stress; and, have a severe or profound disability.

The pervasive and systemic nature of these issues have been recognised as a significant problem by all levels of Australian Government. Through COAG a commitment has been made to improving outcomes for Aboriginal and Torres Strait Islander people across health, education, economic, social and justice indicators however, progress is slow and inconsistent.

What works and what is needed

The Closing the Gap239 strategy aims to reduce disadvantage among Aboriginal and Torres Strait Islander people with respect to life expectancy; child mortality; access to early childhood education; educational achievement; and employment outcomes. These indicators are underlying determinants of a range of health, social and justice related issues.

Noting that some of the goals have been revised and some improvements are claimed, the most recent progress report demonstrates that overall, progress is occurring too slowly and for the most part, governments are not on track to meet targets across these domains.

Community safety remains a key priority for COAG in this area, in recognition that the rates of family violence for Aboriginal and Torres Strait Islander women far outweigh that of their non- Indigenous counterparts. The COAG considers affecting positive change in this regard requires action to reduce substance abuse and harm, prevent crime, reduce violence and support victims, particularly women and children.

Undoubtedly, these are complex issues and lack any ready quick fix solution.240 We know from research, and the voices of communities, that there are certain elements required to affect positive change.

ANROWS recently undertook a review of perspectives on ‘what works’241 to prevent family violence against women and identified the following themes and issues:

» Solutions to violence developed by Indigenous people are likely to focus on community healing, restoration of family cohesion and processes that aim to let both the victim and perpetrator deal with their pain and suffering.

» Indigenous communities want to play a more significant role in shaping program and service responses.

» Because Indigenous family violence is, in part, attributed to

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the breakdown of traditional culture and kinship practices, the rebuilding of these family and kinship ties is often seen as central to developing any type of response to Indigenous family violence.

» Generalised services and programs can be considered effective if they are operated in a culturally sensitive way and/or run in partnership with Indigenous organisations.

» The criminal justice system is not considered the most appropriate means for dealing with family violence in Indigenous communities. Instead, communities prefer Indigenous sentencing courts which allow for Elders and community representatives to be part of the law and order process aimed at healing relationships and rehabilitating offenders.

» Ongoing planned and consistent funding for service provision is considered a major issue.

With respect to programs and services, ANROWS research further suggests that:

» Funding for services and programs should include resources242 for Indigenous community input and, where possible, community delivery.

» Multi-component programs are likely to be most effective as are programs that address the broader wellbeing of Indigenous families and communities, including the ongoing impacts of colonisation.

» Funding for services and programs for Indigenous communities should include resources to implement quality evaluation including both qualitative and quantitative research.

» Opinions and viewpoints from Indigenous people on ‘what works’ should be included in programs and initiatives.

» Family and community cohesion are central to Indigenous viewpoints on how to address family violence.

» The cumulative nature of intergenerational trauma and socio-demographic disadvantage such as personal, economic and family related stressors suggests that reducing violence against Indigenous women requires a multifaceted and holistic approach.

» There is currently a ‘patchwork’ of responses to family violence in Indigenous communities provided by federal, state and territory governments as well as local initiatives in services and community groups.

242 Ibid. 243 Taylor, J., Cheers, B., Weetra, C., & Gentle, I. (2004). Supporting community solutions to family violence. Australian Social Work, 57(1), 71-83. 244 Cripps, K. (2007). Bad dreaming needs balance. The University of Melbourne Voice 1(5) 245 Tayton, S., Kaspiew, R., Moore, S., & Campo, M. (2014). Groups and communities at risk of domestic and family violence: A review and evaluation of domestic and family violence prevention and early

intervention services focusing on at-risk groups and communities. Canberra: Australian Institute of Family Studies. 246 Pugh, R. (2006). Government partnerships with the Aboriginal community in Tasmania: Building a stronger community to overcome family violence. Canberra: Office of Indigenous Policy

Coordination. 247 Rawsthorne, M. (2010). Aboriginal Women Against Violence Project: Evaluation report. Sydney: University of Sydney. http://ses.library.usyd.edu. au/bitstream/2123/6267/1/AWAV%20

Evaluation%20report%20library.pdf 248 Olsen, A., & Lovett, R. (2016). Existing knowledge, practice and responses to violence against women in Australian Indigenous communities: State of knowledge paper Sydney: ANROWS. 249 Keel, M. (2004). Family Violence and sexual assault in Indigenous communities: ‘walking the talk’. Australian Centre for the Study of Sexual Assault (ACSSA) Briefing no. 4. Melbourne: Australian

Institute of Family Studies. http://www.aifs.gov.au/ acssa/pubs/briefing/acssa_briefing4.pdf 250 Cripps, K. (2007). Indigenous family violence: From emergency measures to committed long-term action. Australian Indigenous Law Review, 11, 6-18. 251 Chan, C. (2005). Domestic violence in gay and lesbian relationships. Sydney: Australian Domestic and Family Violence Clearinghouse. 252 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 253 Rawsthorne, M. (2010). Aboriginal Women Against Violence Project: Evaluation report. Sydney: University of Sydney. http://ses.library.usyd.edu.au/bitstream/2123/6267/1/AWAV%20

Evaluation%20report%20library.pdf 254 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 255 Ibid. 256 Widders, R. (2003). Domestic violence, sexual assault and the health of Aboriginal people. Developing Practice: The Child, Youth and Family Work Journal, 6, 40-45.

Given the complexity and interconnectedness of family violence with a broader range of social, economic and health determinants, the restoration of the fabric of the community and culture is seen as integral and fundamental to addressing the problem of family violence243 in Aboriginal and Torres Strait Islander communities.

Solutions must therefore account for the cultural context of family,244 aim to strengthen family ties, empower communities and ensure continued cultural growth in a holistic manner.245

An effective strengths-based approach recognises the hope Aboriginal and Torres Strait Islander people share about their community’s strengths, culture and traditions. This requires a focus on developing community-led programs, enhancing community autonomy through local programs, sharing information and experiences, and keeping families together.246,247

A common theme identified in the literature is the belief that holistic models must incorporate a role for the offender in recognition of the perpetrator being a direct part of, and/or, extended family248 with a focus on healing, rather than excluding or punishing perpetrators.249,250 This inclusivity is somewhat counter to mainstream or feminist approaches to domestic violence which are increasingly punitive with respect to perpetrators.

Consistent with findings in all other fields, including health, education and justice, research suggests that responses that are Indigenous-led and staffed, involve family and other community members, and are based on self-determination are most effective251,252 in improving outcomes for Aboriginal and Torres Strait Islander Australians.

There is also recognition that generalist services can, and do, offer important options for Aboriginal and Torres Strait Islander families and communities. Evidence suggests that improving and developing culturally appropriate mainstream services or partnerships to respond to family violence can be achieved by:

» employing Aboriginal and Torres Strait Islander workers or partnering with Aboriginal and Torres Strait Islander services253

» establishing communication pathways which promote integrated service delivery and continuity of service254

» providing culturally competent service delivery for Aboriginal and Torres Strait Islander families in regional and remote areas255

» developing models or frameworks acknowledging the past practices of governments including how contemporary Aboriginal and Torres Strait Islander family violence is impacted by this history256

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» providing cultural awareness training for police, lawyers, judges, support workers and service providers257

» enhancing communication from the police and lawyers with the victims of crime about relevant criminal proceedings258

» providing a range of services and long-term assistance to improve service use and outcomes for Aboriginal and Torres Strait Islander victims of violence presenting with a wide range of protection, psychological, mental health, accommodation, financial and child assistance needs259

» understanding that Aboriginal and Torres Strait Islander women may use refuges differently from non-Indigenous women260 by seeking immediate protection rather than intending to separate in the long term

» recognising services should cater for families, particularly children

» providing one-on-one counselling with a focus on cultural awareness and family centred approaches.261

The recent Victorian Royal Commission into Family Violence262 also made a suite of recommendations noting that Aboriginal and Torres Strait Islander people in Victoria experience higher rates of family violence than their non-Indigenous peers and this is further compounded as they face unique barriers to obtaining support, whether from mainstream or from cultural services.

The Commission noted a strong theme identified during their consultation on this issue, was the importance of involving Aboriginal community controlled organisations and tailoring justice system responses with a broader recognition of the history and culture of Aboriginal and Torres Strait Islander communities.

Among their applicable recommendations, were amendments to the justice system response in Victoria; increasing immediate funding for culturally appropriate services with an enhanced focus on early intervention; prioritising major service models for evaluation using culturally appropriate measures, methodologies and providers; and increasing the availability of culturally appropriate, community-led services for women, children and men affected by family violence, including crisis accommodation, legal services, family-centred services and programs, and specialist services.

In 2016, Northern Territory Coroner Greg Cavanagh held an inquest into the death of two Aboriginal women who had been killed by their partners in the context of persistent family violence.263 His findings articulate the complexities of family violence and the need to consider models of intervention and justice responses that account for the unique needs and circumstances of Indigenous Australians.

Both of these cases were characterised by repeated charges for domestic violence related assaults and other matters, the

257 Laing, L. (2013). “It’s like this maze that you have to make your way through”: Women’s experiences of seeking a domestic violence protection order in NSW. Sydney: Faculty of Education and Social Work, University of NSW.

258 Aboriginal Family Violence Prevention and Legal Service Victoria. (2010a). Improving accessibility of the legal system for Aboriginal and Torres Strait Islander victims/survivors of family violence and sexual assault. Melbourne: Aboriginal Family Violence Prevention and Legal Service Victoria.

259 Wendt, S., & Baker, J. (2013). Aboriginal women’s perceptions and experiences of a family violence transitional accommodation service. Australian Social Work, 66(4), 511-527. 260 Gordon, S., Hallahan, K., & Henry, D. (2002). Putting the picture together: Inquiry into Response by Government Agencies to Complaints of Family Violence and Child Abuse in Aboriginal

Communities. Perth: Department of Prime Minister and Cabinet. 261 Aboriginal Family Violence Prevention and Legal Service Victoria. (2010b). Strengthening on-the-ground service provision for Aboriginal and Torres Strait Islander victims/ survivors of family violence

and sexual assault in Victoria. Melbourne: Aboriginal Family Violence Prevention and Legal Service. 262 State of Victoria, Royal Commission into Family Violence. (2016). Royal Commission into Family Violence: Summary and recommendations. Parl Paper 132 (2014-16). Melbourne: Victorian

Government. http://www.rcfv.com.au/Report-Recommendations 263 Cavanagh, G. (2016). Inquest into the Deaths of Wendy Murphy and Natalie McCormack. Coroners Court, NT. https://justice.nt.gov.au/__data/assets/pdf_file/0004/373207/A00172015-Natalie-

McCormack.pdf

presence of protection orders and multiple periods of incarceration for the perpetrators.

Coroner Cavanagh noted that despite increasingly proactive policing responses in the Northern Territory, these women were ultimately unable to be protected, or saved, from their high- risk violent partners. He was critical of the lack of effect of the correctional system and said it did not provide deterrence and further, ‘if the objectives of law and order are to protect the victims and punish, denounce and deter the offenders, those objectives were not met.’

Coroner Cavanagh asserted in his findings that:

» Imprisonment was not a deterrent factor for the men in this case and that there is some evidence suggesting imprisonment may be seen as a rite of passage among Aboriginal and Torres Strait Islander men in some communities.

» Domestic violence orders (DVOs) are usually designed to keep couples apart, however, it is apparent that Indigenous couples are less likely to separate as a result of intimate partner violence and therefore less likely to comply with protection orders. Therefore, dealing with intimate partner violence as victim and offender using arrest and DVOs as the main means of intervention seems unlikely to be effective as a primary strategy.

» Alternative intervention strategies should be considered that allow for a more flexible family and community focused approach ‘that will both ensure the victim’s safety and give the couple the choice to remain together or not’.

Finally, appropriate funding, sustainable resourcing and well- structured governance mechanisms are required to implement community-led and mainstream solutions effectively. These barriers to implementation are not unique or isolated to addressing Aboriginal and Torres Strait Islander family violence, and are common to all domestic and family violence services.

It is also noted that evaluating the effectiveness of Aboriginal and Torres Strait Islander specific solutions is further impeded by a paucity of data and evidence, which limits robust evaluations of these programs, to enhance our understanding of what works, why, when and how.

Key issues and themes

The Board identified a range of key themes and issues in the review of the Aboriginal family violence cases, noting some important distinctions related to the unique cultural needs and experiences of the victims and perpetrators in these cases, when compared to the non-Indigenous deaths subject to their review.

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Normalisation of violence

The Board acknowledged the extensive and pervasive history of family violence consistent in all cases for both the victims and perpetrators, across multiple intimate partner relationships, and with other family members. In those cases where records were available regarding the perpetrator’s childhood, it is evident they themselves were victims of abuse by their parents or other family members.

Each of the deaths occurred in the context of persistent verbal, physical and sexual violence. The female deceased had all been subject to repeat victimisation in multiple relationships, with one exception, and all were known to have witnessed significant violence within their kinship networks.

Cyclical or intergenerational violence has been described as the ‘normalisation’ of violence in Aboriginal and Torres Strait Islander families and communities.264 This concept attributes family violence to the early aggression faced upon colonisation being ‘transferred through the fabric of Aboriginal society over several generations.’265 This trauma is further compounded by subsequent traumas created in the recent past and present by a range of social problems,266 such as racism, alcohol and drug addiction, family violence and high rates of incarceration.

The Special Taskforce on Domestic and Family Violence suggested that the violence experienced in some Aboriginal and Torres Strait Islander families and communities can be so disproportionally prevalent that it has become normalised, seen as inevitable and minimised to avoid confrontation or aggravating the situation.267

A community survey of Aboriginal and Torres Strait Islander people living in Bundaberg in 2014 supports this view, and identified widespread concern from male and female community members about the normalised cycles of violence in families.268 Participants reported:

» Some families believe that violence is normal and therefore do not discuss it.

» Many women and children accept violence as normal.

» Young people consider sexual assault as a normal part of dating relationships.

» Many people believe that violence, especially intergenerational violence, is a problem and want to break the cycle.

The Board acknowledges that this concept of normalisation does not, and cannot, describe the experience of all Aboriginal and Torres Strait Islander people, but rather the minority for whom violence is a common part of life.269

264 Memmott P et al. (2001). Violence in Indigenous communities. Canberra:Attorney-General’s Department. 265 Hazelhurst, K. (1994). A Healing Place (ed). Rockhampton: Central Queensland University Press. 266 Stanley, J., Kovacs, K., Tomison, A.M. & Cripps, K. (May 2002). Child abuse and family violence in Aboriginal communities: Exploring child sex abuse in Western Australia. National Child Protection

Clearinghouse. Australian Institute of Family Studies. Accessed on 22 February 2017 at: https://aifs.gov.au/cfca/publications/child-abuse-and-family-violence-aboriginal-communities 267 An analysis of customary violence and the problem of the abnormal enculturation of violence can be found here Memmot, P., Stacy, R., Chambers, C. & Keys, C. (2001). Violence in Indigenous

communities. Canberra: Attorney-General’s Department. 268 Blair, B., Chapman, J., Little, B., Little, L., Prentice, K., Tanner, G. & Walker, C. (2014) The Yarning Up! Project report. Queensland: Phoenix House. 269 Smallacombe, S. (2004). Speaking positions on Indigenous violence. Hecate, 30 (1), 47-55. 270 Kinnane, S., Farringdon, F., Henderson-Yates, L., & Parker, H. (2010). Fitzroy Valley alcohol restriction report December 2010. Mt Lawley: Drug and Alcohol Office Western Australia. 271 Campo, M. (2015). Children’s exposure to domestic and family violence. Key issues and responses. Child Family Community Australia, Paper No. 36 2015. Available online at: https://aifs.gov.au/

cfca/sites/default/files/publication-documents/cfca-36-children-exposure-fdv.pdf 272 Price-Robertson, R., Rush, P., Wall, L., & Higgins, D. (2013). Rarely an isolated incident: Acknowledging the interrelatedness of child maltreatment, victimisation and trauma (CFCA Paper No. 14).

Melbourne: Australian Institute of Family Studies. Available online at: www.aifs.gov.au/cfca/publications/rarely-isolated-incident-acknowledging-interrelatedn Available online at: www.aifs.gov.au/ cfca/publications/rarely-isolated-incident-acknowledging-interrelatedn

273 For example, Human Rights and Equal Opportunity Commission. (2006). Ending family violence and abuse in Aboriginal and Torres Strait Islander communities: Key issues. An overview of the research findings by the Human Rights and Equal Opportunity Commission, 2001 – 2006. Sydney: HREOC.

274 For example, Millward, K. (2013). Meeting the needs of our children: Effective community controlled strategies that prevent and respond to family violence. (Fact Sheet No. 1). Melbourne: Secretariat of the National Aboriginal and Islander Child Care.

The circumstances of these cases undoubtedly warrant consideration of the impact of the ‘normalisation of violence’ as this was inherent in the perception of, on some occasions, the victims themselves and within their families and communities. Most importantly, it was also evident in the service system response to both the victims and offenders in these cases, where the severity and incidence of violence rarely prompted a more intensive coordinated response.

While not an exhaustive rationale, it is important to note that this perceived normalisation of violence may also influence the behaviour of victims and others, including by: limiting help- seeking behaviour; discouraging people from intervening when witnessing violence; contributing to the public nature of violence in some communities; and perpetuating a cycle of family violence.270

As such there is a need to consider what strategies are required to break this cycle of violence. This should encompass the consideration of the specific drivers underlying these behaviours, and highlight the need to address cultural norms that are unique to community. In this regard, there is an immense role for primary prevention, which needs to be community informed and led.

The Board further acknowledged that Elders, and other community workers need therapeutic support and respite as there is a significant personal impact and trauma when working with people and communities experiencing family violence.

A significant proportion of the cases reviewed by the Board as part of the family violence homicide and filicide cases involved episodes of violence perpetrated in the home, in the presence of children or, in some cases, directed at children. As outlined above it was also apparent that some of the victims and perpetrators had their own childhood experience of abuse.

The significance of this intergenerational transmission of violence cannot be over stated, with studies consistently linking childhood exposure to domestic and family violence with future perpetration of violence and a range of other social and health-related issues such as socio-economic disadvantage, parental mental illness and/or substance use and subsequent child abuse.

As highlighted by the AIFS,271 within a psychosocial framework, different forms of maltreatment and abuse may result in complex trauma or cumulative harm which is thought to have long-term effects on a child’s developmental and psychosocial outcomes, including the ability to form attachments and healthy, respectful relationships in adulthood.272

This AIFS report also cited several studies and suggested that within Indigenous populations, the prevalence of childhood exposure to violence is more frequent, reflecting the higher rates of domestic and family violence that exists more generally within Aboriginal and Torres Strait Islander populations.273,274

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In recognition of the need for culturally sensitive and community- informed responses to Indigenous children,275 the Queensland Government has enacted several strategies designed to prioritise the health and wellbeing of Aboriginal and Torres Strait Islander children in Queensland.

For example, the Queensland Government, in partnership with the University of Melbourne, has made a commitment to invest $1.5M over three years to introduce the ‘First 1000 days’ initiative to Queensland and improve the health and wellbeing of vulnerable Aboriginal and Torres Strait Islander children and families. This initiative aims to provide comprehensive and coordinated services to address family violence, unemployment, substance misuse, mental illness and disability with a focus on the period from pre- conception to the age of two.

The First 1000 Days Australia276 program is premised on the family remaining the primary and preferred site for developing and protecting culture and identity in Aboriginal and Torres Strait Islander children. As such, the work is guided by a First 1000 Days Council comprised of Aboriginal and Torres Strait Islander Elders, researchers, community members, front-line workers and policy makers; and ensures that the work is led by Aboriginal and Torres Strait Islander people and employs Indigenous methods of knowledge generation.

The First 1000 Days program is also premised on culture being the main protective factor in ensuring the health and wellbeing of Aboriginal and Torres Strait Islander families; and provides an important focus on generating evidence that is both informed by, and culturally appropriate to, Aboriginal and Torres Strait Islander people who are co-creators in the processes of engagement, implementation, evaluation and knowledge exchange.

Help-seeking behaviour by Indigenous victims of family violence

In their review of these cases, the Board accepted the evidence- based premise that victims of family violence are often less likely to perceive the behaviour as a crime, or may not report the incident because of shame or embarrassment, fear of the perpetrator, or the (perceived) consequences of reporting the incident.277

Research suggests that for Aboriginal and Torres Strait Islander victims of family violence, their willingness to seek help can be limited by a:

» fear of negative consequences and repercussions, particularly in small, interconnected communities where privacy cannot be maintained

» fear and mistrust of police, the legal system and other government agencies including a fear that children will be removed by child protection services

» fear of men’s death in custody

275 Cripps, K., & Davis, M. (2012). Communities working to reduce Indigenous family violence. Canberra: Indigenous Justice Clearing House. 276 For more information refer to: http://www.first1000daysaustralia.org.au 277 Morgan, A., & Chadwick, H. (2009). Key issues in domestic violence. Research in Practice, Summary Paper No. 7, Australian Institute of Criminology. 278 Tayton, S., Kaspiew, R., Moore, S., & Campo, M. (2014). Groups and communities at risk of domestic and family violence: A review and evaluation of domestic and family violence prevention and early

intervention services focusing on at-risk groups and communities. Canberra: Australian Institute of Family Studies. 279 Phillips, J., & Vandenbroek, P. (2014). Domestic, family and sexual violence in Australia: An overview of the issues. Canberra: Department of Parliament. 280 Meyer, S. (2011). Seeking Help for Intimate Partner Violence: Victim’s Experiences when Approaching the Criminal Justice System for IPV Related Support ad Protection in an Australian Jurisdiction.

Feminist Criminology, 6, 268-290. 281 See for example: Fredericks, B., Adams, K., Angus, S. and Australian Women’s Health Network Talking Circle. (2010). National Aboriginal and Torres Strait Islander Women’s Health Strategy,

Melbourne: Australian Womens Health Network.; Cheers, B., Binnell, M., Coleman, H., Gentle, I., Miller, G., Taylor, J. and Weetra, C. (2006). Family violence: An Australian Indigenous community tells its story. International Social Work, 49(1), 51 – 63.

282 Quayle, C. (2002). Breaking the silence: Putting the violence into context. Forum: Family Violence in Indigenous communities, 207-211.

» fear that the perpetrator may be imprisoned, or that they may be seen as responsible for the perpetrator’s imprisonment

» feelings such as shame and responsibility for maintaining families

» shyness, language differences and fear of being misunderstood

» normalisation of violence in some families and communities

» lack of trust that services will provide culturally appropriate care

» lack of female staff at some services, particularly the police

» lack of awareness of, or access to, services.278, 279

A reluctance to seek help can increase risk of future harm and abuse, as it limits a victim’s access to important services and supports, who may be in a position to assist.

By the time victims of family violence do seek support from police or through the courts to protect themselves and/or their children, it is highly likely they have endured abuse for an extended period of time and are desperately in need of support and protection.280 Further, formally reported episodes of violence are likely to represent only a small percentage of actual assaults, which is particularly salient given the overwhelming reported episodes of violence available in some of these cases; which spanned over a decade.

Research suggests281 that for those Aboriginal and Torres Strait Islander women who experience family violence and do seek support, they:

» do not necessarily wish to deal with family violence through the criminal justice system

» often do not want to leave their family and home

» do not want to be isolated from family and friends

» do not want to bring shame or disruption to the community

» fear losing custody of children and do not want to risk exposure to child protection services

» want to follow a process which involves sympathy for the offender

» want responses to family violence that focus on healing, including family support and counselling

» often do not want the offender arrested or, if they do, they would prefer a rehabilitative approach rather than imprisonment.282

The Board noted that individual motivators for help-seeking are varied, and recognised that seeking to frame the help-seeking behaviour of the victims in these cases in terms of their motivation

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for doing so was not possible although trends were identified consistent with the above factors.

Overall, the pattern of help-seeking behaviour in these cases was sporadic and generally occurred during extreme episodes of physical violence, often during periods of intoxication for both parties. The victims sought immediate protection from harm or crisis interventions and were often reluctant to engage with police or health staff after the situational crisis was resolved.

This was compounded where individual’s resided in discrete Indigenous communities, as access to relevant supports was at times limited, or not immediately available.

Community and bystander interventions

The Board noted a common characteristic in each of these cases was the ‘public’ nature of the episodes of violence with friends, family, community members and, on occasion, service providers, bearing witness to episodes of physical and verbal violence occurring in private homes or public spaces.

Critically, family and friends were present on multiple occasions of reported episodes of violence in all but one of the intimate partner family violence homicides.

Families and kinship networks can play a positive role in supporting a victim of family violence and reporting the violence however, family and kin may also play a negative role in pressuring a victim not to report episodes of violence, particularly as there may be cultural pressures for the couple to remain together.283

When violence occurs, witnesses may be traumatised but also be ambivalent with a propensity to ‘look the other way’. Sympathy may be offered by relatives but this falls short of encouraging victims to invite a ‘new set of problems’ by seeking support from police or courts.284

The perpetrator’s family may also become involved in acts of violence against a primary victim or engage in retaliatory violence after an assault has occurred against their family member; as was evidenced in three cases subject to review by the Board.

The Board suggested that the willingness of bystanders to intervene appeared to be inconsistent and influenced by a range of factors including concerns for personal safety and future retribution, the significance of which should not be discounted.

There were multiple instances in which friends, family and community members did intervene to protect the victims exposing themselves to further risk of harm by doing so, and

283 Cuneen, C. (2007). Alternative and Improved Responses to Domestic and Family Violence in Queensland Indigenous Communities. For example within the Fourmile matter, the offender’s former partner Zoe Sands was seeking support through the Women’s Group who were encouraging her to stay in the relationship.

284 While this research is based in Canada, the circumstances of Aboriginal family violence have significant similarities to other first national peoples. Dickson-Gilmore, J. (2014) Whither Restorativeness? Restorative Justice and the Challenge of Intimate Violence in Aboriginal Communities, Canadian Journal of Criminology and Criminal Justice, 56, 417-446.

285 Wundersitz, J. (2010). Indigenous perpetrators of violence: Prevalence and risk factors for offending. Research and public policy series no. 105. Canberra: Australian Institute of Criminology. 286 Hennessy, S., & Williams, P. (2001). Alcohol-related social disorder and Indigenous Australians: recent past and future directions, in Williams P (ed), Alcohol, young persons and violence. Research

and public policy series no. 35. Canberra: Australian Institute of Criminology: 145–162. http://www.aic.gov.au/publications/current series/rpp/21-40/rpp35.aspx 287 Olsen, A., & Lovett, R. (2016). Existing Knowledge, Practice and Responses to Violence against Women in Australian Indigenous Communities: State of knowledge paper. ANROWS: Sydney. 288 Wundersitz, J. (2010). Indigenous perpetrators of violence: Prevalence and risk factors for offending. Research and public policy series no. 105. Canberra: Australian Institute of Criminology. 289 Mouzos, J., and Makkai, T. (2004). Women’s experience of male violence: findings from the Australian component of the International Violence against Women Survey, Research and Public Policy

Series, 56, AIC, Canberra 2004, p98. 290 Wall, L., & Quadara, A. (2014). Under the influence? Considering the role of alcohol and sexual assault in social contexts. ACSSA Issues 18: Melbourne: Australian Centre for the Study of Sexual

Assault. 291 Dearden J., & Payne, J. (2009). Alcohol and homicide in Australia. Trends & issues in crime and criminal justice no. 372. Canberra: Australian Institute of Criminology. http://www.aic.gov.au/

publications/current series/tandi/361-380/tandi372.aspx 292 Cuneen, C. (2010). Alternative and improved responses to domestic and family violence in Queensland Indigenous communities. Research Report. Brisbane: Australia. Department of Communities. 293 Kelly, A. & Kowalyszyn, M. (2003). The association of alcohol and family problems in a remote indigenous Australian community. Addictive Behaviours, 28, 761-767. 294 Cuneen, C. (2010). Alternative and improved responses to domestic and family violence in Queensland Indigenous communities. Research Report. Brisbane: Australia. Department of Communities. 295 Bryant, C., & Willis, M. (2008). Risk factors in Indigenous Victimisation. Technical and Background Paper, No. 30 Australian Institute of Criminology. 296 Graham, K., & Homel, R. (2008). Raising the bar: preventing aggression in and around bars, pubs and clubs. Devon, UK: Willan Publishing. 297 Although the Special Taskforce on Domestic and Family Violence highlights this relationship it doesn’t make any recommendations that aim to specifically target alcohol misuse as it relates to

violence perpetration.

were successful in securing immediate safety and support for this person. There were also multiple instances where witnesses minimised the severity of the assaults or do not appear to have addressed the violence with either party; including in the events leading up to the actual death.

Problematic substance use

The Board noted that excessive alcohol and to a lesser extent drug use was a prevailing issue for both victims and perpetrators in each of the subject cases (excluding the child deaths). This was a prominent feature of historical and recent service contact and an immediate factor in the circumstances of each death.

The Board recognised at the outset research which shows a large number of Aboriginal and Torres Strait Islander Australians do not consume alcohol at all and the proportion of those that do is lower than that of the Australian population generally.285,286 The critical difference is that for those Aboriginal and Torres Strait Islander Australians who do consume alcohol, they are more likely to do so at dangerous levels and experience severe alcohol problems.287

Alcohol misuse is not a causal factor for violence but it is now regarded as one of, if not the main, risk factor for Indigenous violence.288 Research suggests:

» Abusive males with alcohol or drug problems inflict violence against their partners more frequently and are more likely to inflict serious injuries.289,290

» Intimate partner homicides involving an Aboriginal and Torres Strait Islander offender and victim are 13 times more likely to be alcohol related than other intimate partner homicides.291

» Between 70 and 90% of all assaults are committed while under the influence of alcohol or drugs.292

» Aboriginal and Torres Strait Islander people who consume high volumes of alcohol report more family conflict compared to those without alcohol problems.293

» Aboriginal and Torres Strait Islander people who reported alcohol consumption at a high risk level were also more likely to report being a victim of threatened or actual violence.294,295

» Easy access to alcohol, particularly in Indigenous communities, is a significant risk factor for family violence.296

While not discounting the importance of perpetrator accountability, addressing a perpetrator’s alcohol or other substance misuse has the potential to reduce the incidence and severity of violence, increasing protection for victims.297

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As a dynamic risk factor, it lends itself to targeted intervention, with the potential to reduce the overall level of risk within a relationship characterised by domestic and family violence.

In the review of the subject cases, the Board found that:

» There was limited, if any, evidence of effective intervention, counselling or support for substance dependency issues.

» If support was provided there were high levels of non- attendance or incompletion.

» Community service and parole orders had limited success in mandating participation in community based treatment programs.

» Options provided (usually group counselling sessions in community settings) were not commensurate with the extreme levels of addiction and dependency. For example, it was noted by the facilitator who delivered the training to one perpetrator that upon the cessation of the program he disclosed he had every intention to continue to use alcohol.

» Post-release, most of the offenders recommenced consumption of alcohol and continued to perpetrate acts of violence or commit other offences associated with their alcohol use,298 and conditions on orders which sought to prohibit an offender’s consumption of alcohol post-release were largely ineffectual.

Review of available records also indicates there were systemic barriers that precluded the provision of effective supports including:

» a lack of service availability or beds in local facilities

» competing needs or priorities, particularly homelessness or family violence

» a lack of understanding by services of the cyclical and chronic nature of substance dependency

» a lack of appropriate referrals for support to specialist services, even where such referrals were requested.

Substance use disorders are chronic, relapsing conditions which are generally interlinked with a range of other social, health and interpersonal problems. It is for this reason a treatment response needs to be broader than clinical intervention or psychoeducation and encompass the long term and seamless provision of social support services.

This is because substance misuse issues rarely occur in isolation, and are usually associated with mental and physical health problems, as well as social challenges and disadvantages including homelessness, involvement with the criminal justice system, and ‘dysfunctional’ familial and social relationships.

There may also be recurrent difficulties in attempting to engage with a severely substance dependent person in terms of their capacity to make or attend appointments, or engage in treatment. As such, because of the chronic nature of substance dependency, imposing conditions on a severely substance addicted person (either via a protection order or as part of probation and parole conditions) may be unrealistic and unattainable, without

298 This ‘association’ may have been self-reported by the offender, records indicate that the offences were committed during periods of acute intoxication or Corrective Services had assessed alcohol use as a criminogenic factor for that offender

299 National Indigenous Drug and Alcohol Committee. (2014). Alcohol and other drug treatment for Aboriginal and Torres Strait Islander peoples. Australian National Council on Drugs 300 Ibid.

corresponding intensive supports (such as treatment commencing in jail while situational influences may be more easily controlled).

There is an evidence base to support the effectiveness of certain mainstream interventions for alcohol and other drug treatment including: screening and assessment; referrals; brief interventions; withdrawal management; cognitive behavioural therapy; relapse prevention; therapeutic communities; maintenance pharmacotherapy; outreach and aftercare.299 Culturally specific interventions can be incorporated throughout these stages of intervention through such strategies as focusing on a strengths-based and person-centred approach; using an Aboriginal family systems approach to care, control and responsibility; and, reconnecting with country.

It has been suggested that as therapeutic communities are best suited to people who have moderate to severe levels of dependence, severe deterioration, less social stability and are at a high risk of relapse, all of which are characteristics of many Aboriginal and Torres Strait Islander people seeking alcohol and other drug treatment, residential treatment may be the best, or only practical option.300

This is in part because to a large extent service provision in the alcohol and other drug sector is fractured, with an ongoing need to enhance workforce capacity and increase focus on continuity of care over the longer term, through the various stages of treatment and intervention.

Of relevance to some of the cases considered by the Board, women have been found to have lower participation rates in treatment programs, particularly residential programs, as they are likely to be the primary caregivers to children, and do not have the capacity to leave them for the time required to undertake residential treatment programs.

Conversely, in couple relationships, both parties may have substance use issues and residential service providers may require partners to enter treatment individually, as such (particularly where children are present) one person is likely to be excluded from the treatment, increasing relationship and familial stressors. Consequently, there is a need for more family specific residential services or resourcing of current facilities to enable existing services to cater for families.

It is important to note that shortly prior to one Indigenous intimate partner homicide, the victim and perpetrator were excluded from a rehabilitation centre after originally being accepted to the facility. A staff member denied support to them because he was of the opinion that the couple were at different stages regarding their drug use, the relationship did not seem healthy, and he did not want to provide falsified information about their past issues to the rehabilitation centre in order to have them accepted.

This was a substantial missed opportunity for intervention in this case, and ultimately had treatment been effective the risk of future violence, including homicide, within this relationship may have been substantially reduced; given the severity of alcohol misuse and violence perpetration evident in that relationship.

While both the deceased and offenders in these cases may have participated in programs to address their substance misuse issues, this predominantly took the form of participation in group psychoeducation programs through Queensland Corrective

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Services. While such initiatives that aim to address underlying drivers for offending behaviours are critically important, they are likely to have less efficacy with people who have a chronic substance addiction.

It has been suggested that although opportunities for intervention exist while an offender is incarcerated, strategies to manage the complexities of problematic substance use in this setting may be limited in scope and treatment; under-resourced; have restricted accessibility and eligibility requirements; be lacking in culturally appropriate services and programs; and, impeded in their delivery by the often intimidating and violent environment of prisons.301

Recent recommendations to develop a plan to screen prisoners to prioritise substance misuse rehabilitation, and increase opportunities for rehabilitation as part of the Queensland Parole System Review302 (the Parole Review) are likely to make significant improvements if they are appropriately resourced, implemented and monitored with a strong focus on culturally appropriate interventions and programs.

Of relevance to this reform agenda, research indicates that as problematic substance use for Aboriginal and Torres Strait Islander detainees or prisoners can sometimes be a broader familial or intergenerational problem, programs and treatment should have sufficient flexibility to be inclusive of family members.303

Another significant gap for Aboriginal and Torres Strait Islander people in service provision across the alcohol and other drug treatment sector is a lack of on-going care, and the provision of services after an intensive phase of treatment. On-going care is critically important and should be considered as an essential part of a treatment program.

This needs to constitute more than simple practitioner follow-up and take into consideration any co-morbidities, and the need for integration into a range of other community supports. On-going care has been shown to significantly reduce relapse rates and the costs of additional intensive (and expensive) clinical services.

Use of violence by victims

The Board noted that most of the victims in these cases304 were documented to have used violence, both in the subject relationship, and other intimate partner or family relationships.

Aboriginal women’s use of violence has been subject to somewhat limited consideration in research. The available research suggests:

» Aboriginal women may be more inclined to retaliate with physical force when victimised due to their reluctance to report violence to police or other services.305

» Aboriginal women may have fewer ‘misgivings’ about responding to violence with violence.306

301 National Indigenous Drug and Alcohol Committee. (2009). Bridges and barriers: addressing Indigenous Incarceration and Health (Revised Edition) Australian National Council on Drugs. 302 Sofronoff, W. (2016). Queensland Parole System Review: Final report. Brisbane. Queensland Government. 303 Ibid. 304 Excluding the children deaths 305 Yeo, S. (1996). The recognition of Aboriginality by Australian criminal law, in Bird G, Martin G & Nielsen J (eds), Majah: Indigenous peoples and the law. Sydney: Federation Press: 229–265 306 Aboriginal and Torres Strait Islander Social Justice Commission. (2004). Social Justice Report 2005. Australian Human Rights and Equal Opportunity Commission. 307 Mouzos, J., & Makkai, T. (2004). Women’s experiences of male violence: Findings from the Australian component of the international violence against women survey (IVAWS). Research and public

policy series no. 56. Canberra: Australian Institute of Criminology. 308 Participants frequently explained their substance use – especially during periods of elevated use which often corresponded with offending – as a response to other events in their lives, such as the

suicide of a family member, removal of children by child safety services, or a partner’s sustained violence. 309 Mouzos, J., & Makkai, T. (2004). Women’s experiences of male violence: Findings from the Australian component of the international violence against women survey (IVAWS). Research and public

policy series no. 56. Canberra: Australian Institute of Criminology. 310 Kerley, K., & Cunneen, C. (1995). Deaths in custody in Australia: The untold story of Aboriginal and Torres Strait Islander women. Canadian Journal of Women and the Law, 8, 531–552 311 Violent resistance refers to violence used by (predominantly) female victims as a means of self-defence for protection against their perpetrators. The use of violence towards an abuser may appear

counterintuitive to avoiding physical harm however, victims tend to use it as an active coping strategy. Refer to: Leone, J. M., Johnson, M. P., & Cohan, C. L. (2007). Victim help seeking: Differences between intimate terrorism and Situational couple violence. Family Relations, 56(5), 427–439.

» The use of violence by Aboriginal women is often enacted in response to male violence.307

Recently, an Australian study considered the use of violence in the lives of incarcerated Aboriginal women in Western Australia, which provides significant insight into understanding and contextualising this behaviour, with a view to informing more effective service responses.

This study found that:

» Most of the group came from disadvantaged backgrounds and many depicted childhoods characterized by disruption, family substance misuse and violence.

» Most of the women had experienced multiple traumas growing up, including witnessing family violence, premature deaths of family members, and had experienced sexual abuse or rape.

» Substance use308 (most commonly alcohol but also other illicit substances) featured heavily in the stories of participants who related this to their use of violence.

» Most had witnessed intimate partner violence between their parents and other family members.

» Almost all (90.7%) participants reported a history of victimisation which they linked to a ‘self-defence or retaliatory’ use of violence.

» Many perceived their incarceration to be unlawful, particularly when the index episode for incarceration was because of a reaction to a man’s use of violence as a means of self-defence or to protect self or others, including children.

Research suggests that while self-defensive violence may be a resistance strategy for some abused women,309 and possibly used with even greater frequency among Aboriginal women,310 it may also increase their vulnerability to acute injury. This was supported by the facts of the subject cases in which all female victims sustained significant physical injuries including broken ribs and bones, as well as severe head injuries.

There was limited evidence to suggest in any of the applicable cases that the male partners sustained any significant injuries in relation to these episodes of violence, or received any medical treatment associated with these injuries.

The use of violence by the women in these cases can broadly be considered as ‘violent resistance’,311 as a reaction to the abuse being perpetrated against them, and used in self-defence, to stop the abuse or to pre-empt their partner’s violence.

For example, one victim openly admitted that she had used violence, including with weapons, with no attempt to minimise or excuse her use of violence within this context. She told police

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that if they wouldn’t do anything about her partner’s continued harassment of her (including breaking into her house and assaulting her) that she would have no choice but to take matters in to her own hands.

These disclosures also led to an increased likelihood of successful prosecution against her, and increased negative consequences for her as a primary victim of family violence.

With respect to the use of violence by the victims within these cases, in the context of significant and severe prior victimisation, it is necessary to consider ways to better differentiate between various types of violence used by both a victim and/or a perpetrator to inform service system responses where there are allegations of violence used by both parties.

This is because further victimisation occurs when the primary victim is named as a respondent on a protection order, as not only does it affect the likelihood of them seeking help in the future but it also affects criminal justice system responses to them. Perpetrators may also feel that their behaviour has been validated by the system and they may use their status as an ‘aggrieved’ to further control the other party.

In the cases under review, the Board noted that being identified as a respondent was detrimental to the primary victims and this extended to including periods of incarceration for some of the female victims.

The DFVPA 2012 contains provisions to encourage the identification of the person most in need of protection partly to reduce the use of cross-applications, and to improve victim safety. Despite this, the use of cross-applications is still reportedly seen in Queensland courts, which is particularly problematic for Aboriginal and Torres Strait Islander women given that the use of physical violence is more prevalent within these communities.312

Consequently, the inability to appropriately recognise, and respond to, a victim’s use of violence tends to disproportionately affect an already vulnerable cohort reducing their likelihood of seeking assistance from services or indeed receiving the necessary support when they do try and seek help.

System responses to family violence

The following section complements Chapter 5, which discusses system responses across all cases reviewed by the Board.

It is intended to highlight specific issues identified with respect to service system responses to the Aboriginal and Torres Strait Islander homicide and suicides considered by the Board.

Health system response

With respect to health service responses, the Board noted that:

» With the exception of one victim, the female victims in each of the family violence cases required medical treatment or hospitalisation for significant assault-related injuries over many years and often in multiple relationships.

312 Special Taskforce on Domestic and Family Violence in Queensland (2015) Not Now Not Ever: Putting an end to domestic violence in Queensland. Brisbane: Queensland Government. 313 Commonwealth Attorney-General’s Department and the Nous Group. (2013). Family Violence Prevention Legal Services: Research and needs analysis report. Commonwealth of Australia, 69. 314 Olsen, A., & Lovett, R. (2016). Existing Knowledge, Practice and Responses to Violence against Women in Australian Indigenous Communities: State of knowledge paper. ANROWS: Sydney. 315 Aboriginal Family Violence Prevention & Legal Service Victoria. (2015). Submission to the Royal Commission into Family Violence. http://www.fvpls.org/images/files/FVPLS%20Victoria%20

submission%20to%20Royal%20Commission%20-%20FINAL%20-%2015Jul15.pdf Accessed 9 November 2016

» The response by the health system was somewhat inconsistent and often focused on the provision of immediate medical treatment although, there were examples of commendable service. For example, on several occasions social workers and other health practitioners provided an out-reach service by driving around to try and locate victims who had discharged themselves prematurely, or when reports were received from other sources that the victim had sustained injuries or threatened self-harm.

» Barriers to the provision of timely and appropriate care included: reluctance or refusal by the victims to engage with services; geographical isolation and limited services in some locations. For example, by the time social workers had been arranged to attend, the victim had discharged themselves; and the transient lifestyle of the victims impeded follow-up care and attempts to link them with other support services

» Optimal outcomes were generally associated with the involvement of a social worker.

» There was limited evidence of culturally appropriate care or Indigenous health worker involvement.

Mainstream services are often limited in their ability to provide culturally appropriate services for Aboriginal and Torres Strait Islander victims and perpetrators of family violence. A lack of understanding of culture, value and needs has been identified as a barrier to the effective engagement by Indigenous women with mainstream services.313

Services which do not routinely engage with Aboriginal and Torres Strait Islander clients may not understand the complexity of the needs of this population group and as such it has been recommended that generalist services should run in partnership with Indigenous organisations where possible.314

Where Aboriginal and Torres Strait Islander staff are employed within mainstream services, they may also become overburdened with expectation that they service all Indigenous clients as well as provide ongoing education of non-Indigenous staff about cultural matters.315

In accordance with Queensland Health’s Cultural Capability Framework 2010 – 2033, it is acknowledged that to improve responses to this vulnerable cohort, services must be culturally and clinically responsive to close the gap in health outcomes for Aboriginal and Torres Strait Islander Queenslanders. This approach also requires strong partnerships across government and the non- government sector, with cultural input from Elders and community.

The Board acknowledged that this reform is a continuous improvement process that requires culturally sensitive and responsive programs, and a culturally capable workforce. The Board noted there was limited evidence in available records that staff sought to address the co-occurring and complex issues experienced by the victims within a culturally appropriate framework.

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Justice system response

Indigenous approaches to justice are founded on principles of rehabilitation, therapeutic jurisprudence316 and restorative justice.317 In the context of family violence, this translates to Indigenous-led approaches where the offender can access rehabilitation and the overall aim is restoration of the relationship between the offender and the victim, and between the offender and the broader community.318

This represents a divergence from the current trend seen in mainstream approaches that emphasise swift accountability for perpetrators of domestic violence which is largely achieved by a more punitive criminal justice response.

Recent (unpublished) research completed as part of a PhD submission by Dr Heather Nancarrow,319 suggests that ‘the gendered aspirations of domestic violence laws, particularly police powers, are not effective or appropriate responses for classed and racialized realities of violence’, particularly in regional and remote communities.

Nancarrow argues that for domestic violence law to be useful it must distinguish between coercive controlling violence (that is a pattern of physical and/or non-physical strategies to subvert autonomy, liberty and equality) and fights (physical and non- physical aggression motivated by a range of factors other than coercive control), and victims must retain choice about state intervention. Further, Nancarrow suggests that we must recognise a particular kind of violence that occurs in the context of the chaos associated with the legacy of colonisation in the lives of some Indigenous people.

This approach has implications for the design and delivery of interventions including justice mechanisms; and would require significant reconstruction of current system responses to family violence.

What is clear, is that Aboriginal and Torres Strait Islander victims of family violence often experience difficulties in engaging and participating in the justice process. Victims have reported that they feel police do not always take their reports seriously320 and several studies have described discrimination against Aboriginal and Torres Strait Islander women and the ways in which the criminal justice system fails to take into account their customs.321

Key issues for Aboriginal and Torres Strait Islander women experiencing family violence and accessing the justice system include:

» the process can be irrelevant, symbolically, to Aboriginal and Torres Strait Islander families and communities

» it can escalate rather than end the violence

» It is experienced as an artefact of historical government policies and institutions intended to separate Aboriginal and Torres Strait Islander families.322

316 Therapeutic jurisprudence emphasises the quality of interaction between judicial officers and the individuals who appear before them, which is enhanced by direct engagement, empathy and communication.

317 Restorative justice personalises the crime by having victims and offenders mediate a restitution agreement to the satisfaction of each, as well as involving the community. This contrasts with a more punitive approach where the main aim is retributive justice.

318 Nancarrow, H. (2006). In search of justice for domestic and family violence: Indigenous and non-Indigenous Australian women’s perspectives. Theoretical Criminology, 10, 87-106. 319 This PhD research is available at: http://www.accessitsoftware.com.au/AST01/ais/downloadfile/Qj0xNTA2ODM0OTM2JlU9NTc5NQ==/Nancarrow_PhDthesis.pdf 320 Laing, L. (2013). “It’s like this maze that you have to make your way through”: Women’s experiences of seeking a domestic violence protection order in NSW. Sydney: Law and Justice Foundation of

New South Wales. 321 Quayle, C. (2002) Breaking the silence: Putting the violence into context. Forum: Family Violence in Indigenous communities. 207-211. 322 Nancarrow, H. (2006). In search of justice for domestic and family violence: Indigenous and non-Indigenous Australian women’s perspectives. Theoretical Criminology, 10, 87-106. 323 It is noted that pursuant to section 245 of the Queensland Criminal Code, where assault is an element of an offence, police must prove that the assault took place without consent. This becomes

problematic when witnesses recant their version of events or are unwilling to assist police with pursuing the assault charges.

Police response

The primary service response in each of the adult homicides and suicides, with the exception of one, was provided by the QPS. Responses were varied, with a noted improvement in responses over the last five years in particular; indicative of legislative, policy and practice improvements over this time period.

In each of the cases, there were occasions of commendable policing which affected positive short-term outcomes for victims and resulted in criminal charges and imprisonment of violent perpetrators. This included:

» Appropriate follow up with victims and/or perpetrators when one or both of them have been too intoxicated to make statements. For example, one victim repeatedly presented to the police station heavily intoxicated and was considered unable to provide an appropriate statement. Nevertheless, police would continue to take the necessary steps to investigate her reports.

» The pursuit of concurrent criminal charges where the circumstances have warranted this course of action. For example, one of the perpetrators was charged with assault as well as breaches of protection orders on one occasion – though it is noted there were many other instances where he was only charged with breaching the protection order when other criminal charges may have been appropriate.

» Attempts to address the underlying drivers of such behaviours with other agencies, as part of a proactive policing strategy, or to assist victims to access appropriate support services for other presenting issues.

» Taking additional steps to try to locate an aggrieved party that extended beyond ‘routine’ policing. For example, police communicated with the bus company to ascertain whether one victim had left town when they tried to locate her to conduct investigations after she had been too intoxicated to provide a statement at the time they attended the index assault.

The Board identified the following issues (sometimes recurrently) with the police responses in these cases:

» The assessment of risk and response to initial calls for service was often limited or delayed particularly with two of the homicides in which the fatal assault was in progress, and there was a significant and identifiable history of violence.

» Dropping criminal charges where a victim requested it to occur, resulting in the perpetrator not being held to account for serious assaults.323

» Substantial delays in the service of orders precluding the ability to charge for future contraventions of the order in place at the time; though it is important to note the difficulties of the service of orders with persons who have unstable accommodation.

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» Inconsistent pursuit of criminal charges where warranted, with a heavy reliance on protection orders, despite high risk and extremely violent behaviour.

» Limited investigation of alleged assaults and a tendency to exclude further action when both parties were intoxicated, even when independent witnesses were sober. For example, one perpetrator was charged with a breach of a protection order but not an assault charge despite people driving along a highway witnessing him punching and kicking his victim in the middle of the street; and making reports to the police pertaining to this event.

Research has previously identified perceptions by Aboriginal women of indifference by police towards acts of violence being perpetrated against them.324 This includes self-reported concerns relating to lengthy delays in time taken for police attendance at reported breaches, not taking up with the perpetrator if he absconds, inappropriate action taken against the protected person, as well as negative police attitudes to Indigenous women as victims.325

Recent initiatives have aimed to improve policing responses within discrete Indigenous communities,326 and it is clear from a review of records officers within these cases to a large extent, sought as much as practicable, with the resources available to them, to respond to those episodes of violence reported to them.

Enforcing protection orders in discrete communities

Many of the victims and perpetrators within these cases who identified as Aboriginal or Torres Strait Islander lived or had previously lived in remote and/or discrete Indigenous communities, which presents specific issues and barriers to accessing and receiving appropriate supports.

In April 2016, the Public Safety Business Agency published a paper, ‘Enforcement of domestic violence orders in Queensland’s discrete Indigenous communities’327 in response to recommendation 11.8 of the Queensland Child Protection Commission of Inquiry Report.

The Inquiry Report highlighted the risk that high levels of violence, particularly within families, can pose to the wellbeing of children and noted that exposure to family violence is compounded in remote communities where victims and their children may not be able to physically escape the situation.

Key findings of this report included:

» Community stakeholder satisfaction with the police response was mostly positive, including satisfaction with timeliness and cultural sensitivity of the response.

» Police officers identified that reporting by female victims had improved and police collaboration with services was working well.

» Administrative processes were reported to have improved and were less likely to influence the decision to initiate domestic violence applications.

324 Memmott, P., Stacy, R., Chambers, C., & Keys, C. (2001). Violence in Indigenous Communities 325 Kelly, L. (1999). Indigenous women’s stories speak for themselves: the policing of Apprehended Violence Orders, Indigenous Law Bulletin, 4(25), 4-7. 326 Crime and Misconduct Commission. (2009). Restoring Order: Crime prevention, policing and local justice in Queensland’s Indigenous communities. Brisbane: Author 327 Refer to: https://www.police.qld.gov.au/corporatedocs/reportsPublications/other/Documents/EnforcementDVOinQLD_DiscreteIndigenousCommunities.pdf

» Very few applications for orders were initiated by the aggrieved party which was attributed to a lack of engagement or confidence in the system, or potentially reflective of cultural values that may influence engagement with the criminal justice system.

» Limited understanding by parties of orders including the operation of the order and associated conditions, often leading to breaches.

» The incidence of female respondents and male aggrieved was of significant concern and this represents a dynamic not readily evident in the Queensland community as a whole (this was noted as perhaps attributable to the relatively small size of the discrete communities in which violence by women may be more visible and apparent).

» A strong commitment to reducing the impact of violence in communities but a frustration with entrenched issues that are created or compounded by remoteness, isolation and the challenges of service delivery in these areas.

Particular barriers in the provision of an effective response were identified as:

» reluctance by women to contact police in relation to domestic violence incidents largely due to a fear of repercussions by the perpetrator and intervention by child protection authorities

» difficulty in applying the full range of available protections as conditions on orders (such as no contact or ouster conditions) in small communities where contact between parties is likely difficult

» lack of evidence to support the arrest and detainment of perpetrators, particular complaints from victims or the availability of witness statements

» logistics of detaining suspects in communities or transferring detained suspects away from the community

» the practice of requiring a new application rather than extending an existing order where protection is still needed, creating an administrative burden and potentially leaving a gap for the protection of victims.

» lack of support services operating full time in communities including for both female and male victims and perpetrators.

This report highlights the entrenched complexities associated with policing and enforcing protection orders in discrete communities and importantly, noted the critical impact low levels of enforcement and compliance may have on the impact of children living in the home. They also accord with the issues identified by the Board within the review process of applicable cases, and the Board welcomes the actions being undertaken by police to address these concerns and enact a range of improvements that

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aim to improve protective outcomes for victims and their children, within a culturally appropriate way.328

The effectiveness of protection orders with high-risk perpetrators

The Board noted that consistent to all adult deceased who identified as Aboriginal and Torres Strait Islander reviewed within this reporting period was the presence of protection orders between the deceased and their present or former partners.

Research generally indicates that women with protection orders experience less violence and abuse from their (ex) partner compared to women who do not have a protection order.329 The effectiveness of protection orders among Aboriginal and Torres Strait Islander people in preventing family violence has been questioned because of a perceived lack of engagement with, and confidence in, these processes.

There is often a lack of attendance by Aboriginal and Torres Strait Islander aggrieved and respondents at court when an order is made, which may affect their level of understanding of the order. It is further indicative of a lack of ownership in this process.330

It is also the case that the effectiveness of protection orders decreased in cases where the risk of violence is deemed high. In identifying high-risk cases and occasions when perpetrators are more likely to breach a protection order, there are several factors which indicate elevated risk:

» separation (in the case of intimate partners)331

» perpetrator’s history of violence and crime332

» perpetrator’s history of non-compliance with court imposed conditions.333

The Board acknowledged that for the last two factors, the applicable cases demonstrated high levels of risk and pervasive recidivism which were undeterred by either a civil or criminal response. It was suggested that these cases support the proposition that while protection orders can, in some circumstances, be a useful protective measure for victims of domestic and family violence, there is a need for additional protective actions to prevent future violence in high-risk cases.334

The Board noted the findings of a recent review into the use of protection orders in domestic and family violence fatalities conducted by the Western Australian Ombudsman335 which

328 These include the: ongoing review and commitment to police training about domestic violence as well as cultural awareness and sensitivities (Action 1); encouraging police to consider the individual and complex circumstances of each case and making applications that meet the needs of the aggrieved – this will include police seeking orders that are relevant, practical and tailored to individual circumstances (Action 2); implementing cultural change programs and enhanced training packages to ensure a more consistently positive community experience (Action 3); ensuring examples of good practice involving police liaison officers (PLOs) are shared among officers in charge (OIC) of discrete communities and that they are encouraged to consider using PLOs in this type of work where it suits the circumstances of each community and where PLOs have received appropriate DV training (Action 4); that the QPS will explore options for enhancing police communication regarding explanation of DV orders, particularly through the service of documents by police (Action 5); review of information training packages about private applications for protection orders with a view to making them available to police and other community organisations working in discrete communities (Action 6); that issues regarding gender, family and cultural dynamics of domestic violence will be considered as part of the QPS audit of training (Action 7); to address shortcomings in evidence impacting on domestic violence outcomes through focusing on increasing criminal prosecution of perpetrators through enhanced investigative and evidence gathering techniques (Actions 8 and 9); consider long-term, sustainable solutions to staffing levels, resource allocation and operational demands (including supervision of watch houses) (Action 10); examine the issue of alerting prosecutors about expiring orders in more detail to determine if any improvements can be made to standardise the approach across locations (Action 11).

329 Ombudsman Western Australia (2015) Investigation into issues associated with violence restraining orders and their relationships with family and domestic violence fatalities. Accessed at http:// www.ombudsman.wa.gov.au/Improving_Admin/AI_Reports.htm#family-domestic-violence-report-recommendations

330 One magistrate attributed that the non-spousal family orders reflected police using domestic and family violence orders where they could not support a criminal charge, as family members would not cooperate or lay charges. Cuneen, C. (2007). Alternative and Improved Responses to Domestic and Family Violence in Queensland Indigenous Communities.

331 Women’s Aid. (2006)., Why doesn’t she leave? Women’s Aid Federation of England, Bristol, 2006. 332 University of Kentucky, Centre for Research on Violence against Women. (2011). Top Ten Series: Do Protective Orders Work? Who Violates Protective Orders the most? University of Kentucky. 333 Ibid. 334 Strand, S, ‘Using a restraining order as a protective risk management strategy to prevent intimate partner violence’, Police Practice and Research: An International Journal, vol. 13, issue 3, pp. 264-

265. 335 Ombudsman Western Australia (2015) Investigation into issues associated with violence restraining orders and their relationships with family and domestic violence fatalities. Accessed at http://

www.ombudsman.wa.gov.au/Improving_Admin/AI_Reports.htm#family-domestic-violence-report-recommendations 336 Snyder, R. (2013). . ‘A raised handhand’. The New Yorker. 22 July 2013 p38. 337 Braaf, R., & and Sneddon, C. (2007). , ‘Arresting practices: exploring issues of dual arrest for domestic violence.,’ Australian Domestic & Family Violence Clearinghouse, Sydney, 2007, p. 2. 338 Marchetti, E., & Daley, K. (2016). Indigenous Partner Violence, Indigenous Sentencing Courts and Pathways to Desistance. Violence against Women, 1-23. 339 Australian Human Rights Commission. (2006). Ending Family Violence and Abuse in Aboriginal and Torres Strait Islander Communities – Key Issues http://www.humanrights.gov.au/publications/

ending-family-violence-and-abuse-aboriginal-and-torres-strait-islander-communities-key#s2

found that restraining orders (equivalent to protection orders in Queensland) are insufficient if used alone and need to be supported by other measures, including:

» consideration of deferral of bail, or in some circumstances, a presumption against bail for high-risk offenders noting that holding perpetrators in custody on remand might disrupt an elevating cycle of violence.336

» pursuit of criminal charges where an offence has been committed to protect victims and hold perpetrators accountable for their behaviour .337

» recognition of, and response to, the harm caused to children who are exposed to domestic violence, noting that 21 of 30 fatalities considered, involved Aboriginal children; and that this requires a culturally appropriate, targeted approach

» ensuring thorough risk assessment and management frameworks are utilised which account for the historical behaviour of the perpetrator and patterns of violence over time

» completing safety planning with adult victims of family violence in relation to their children.

Sentencing and specialist court processes

The Board acknowledged that all of these cases demonstrated an experience best compared to a revolving door, with offending behaviour predominantly punctuated by periods of incarceration; contraventions of release conditions; continued bouts of intoxication, (and associated public order offences); violent recidivism and subsequent resentencing to terms of imprisonment or other penalties (such as fines or suspended sentences).

Evidence suggests that mainstream courts and criminal justice interventions have little success in changing the behaviour of domestic and family violence perpetrators, let alone members of socially marginal groups including Aboriginal and Torres Strait Islander people.338 Although criminal justice system responses are important elements of a systemic response to violence and abuse, a more holistic response is required that addresses the underlying causes, and consequences of, Aboriginal and Torres Strait Islander family violence.339

The recent Queensland Government announcement of specialist domestic and family violence courts to be trialled in Townsville,

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Mt Isa and Palm Island, are intended to have a specific focus on meeting the needs of Aboriginal and Torres Strait Islander people, which may improve responses in this area.

Incorporating restorative justice approaches within a Western criminal justice system also has the potential to improve outcomes for both victims and perpetrators of family violence, support the broader kinship network and provide an opportunity for community participation in addressing justice issues.340

Restorative justice processes which are assisted and reinforced by the coercive oversight of the courts show the most promise in balancing the very real concerns of ensuring risks for family violence victims are considered, while also addressing the complexity of this problem.341

Indigenous sentencing courts, like the Murri Court in Queensland, are associated with restorative justice or therapeutic jurisprudence approaches which aim to better meet the needs of victims and can strengthen or improve accountability through encouraging perpetrators to take ownership of their offending behaviour by capitalising on community ties.

While there are clear benefits to both perpetrators and victims by involving community Elders in the process, it is also the case that these courts may not be well resourced or equipped to provide intensive or specialist support to victims of family violence; a critical element of an effective response in this context.

The Board noted there is also a lack of uniformity in Elder capacity, capability and responses across various locations; an artefact of the personalised and flexible approach which is a benefit in some instances but may jeopardise or impede a coordinated and consistent approach to preventing family violence. Certainly, for high-risk cases involving recidivist and extremely violent perpetrators the Board suggested it was important to ensure the Murri Court, including community Elders, be mindful of the need for a sustained focus on protective outcomes for victims.

Although the Queensland Government has recently invested to support further roll-out of the Queensland Murri Court and Community Justice Groups, the ability to provide a more culturally appropriate restorative justice approach specifically for family violence remains somewhat limited. Significant funding and program re-design would be required to achieve this.

In their Final Report, the Special Taskforce on Domestic and Family Violence recommended that the Queensland Government works with discrete Indigenous communities to develop and support an effective local authority model to respond to crime and violence

in those communities, with a priority focus on addressing family violence (Recommendation 92).342

As part of this work, it was recommended that consideration should be given to resourcing and expanding the role of community justice groups, Magistrates courts and related local justice initiatives as appropriate, as well as examining the specific role that community justice groups could play in conferencing, mediation and criminal justice system support.

340 Cox, D., Young, M., & Bairnsfather-Scott, A. (2009). No justice without healing: Australian Aboriginal people and family violence. The Australian Feminist Law Journal, 30, 151-161. 341 Dickson-Gilmore, J. (2014) Whither Restorativeness? Restorative Justice and the Challenge of Intimate Violence in Aboriginal Communities, Canadian Journal of Criminology and Criminal Justice, 56,

417-446. 342 Special Taskforce on Domestic and Family Violence in Queensland. (2015). Not Now, Not Ever: Putting an end to domestic and family violence in Queensland. Brisbane: Author. 343 Extrapolated from healing models with the justice system in Canada, which have extensive longitudinal evaluations. Limitations and barriers to effective programs include inadequate and/or

insecure funding, changes in the political climate, breakdown in communication between stakeholders, lack of clear guidelines on stakeholder responsibilities, lack of community understanding of the program, lack of training and support of the program, and lack of judicial support. Cox, D., Young, M. & Bairnsfather-Scott, A. (2009). No justice without healing: Australian Aboriginal people and family violence. The Australian Feminist Law Journal, 30, 151-161.

344 This is generally made up of custodial officers, psychological services officers, sentence management services staff and probation and parole officers.

In response to this recommendation, the scope of the Family Responsibilities Commission (FRC) was expanded. The FRC is a statutory body that works in partnership with the state and Australian Governments, and the Cape York Institute for Policy and Leadership to lead welfare reform for Aboriginal and Torres Strait Islander Australians by helping them to restore their culture and Indigenous authority.

Legislative amendments were made to create a trigger to facilitate FRC conferencing and referrals in circumstances where DVOs are made by the courts involving a welfare reform community resident as the respondent. This allows the FRC to request the person attend case conferencing; a community led process to encourage clients, individuals and families to engage in socially responsible standards of behaviour while promoting the interests, rights and wellbeing of children and other vulnerable persons living in the community.

The Board acknowledged that these are important steps towards embedding a culturally appropriate justice response to family violence across Queensland.

In addition, with extensive planning and development, community commitment, a comprehensive risk management framework, established stakeholder collaboration and partnerships and a functional and supportive program structure, restorative justice processes show promise in improving responses to family violence within Aboriginal and Torres Strait Islander families and communities.343

Issuing or management of parole orders for high-risk and/or recidivist offenders

The Board noted that four individuals involved in the family violence intimate partner homicide cases were subject to community based parole at the time of the homicides; often in relation to previous domestic and family violence related assaults or breaches of protection orders against their (current or former) partner.

Common to all of the perpetrators in these cases was a history of:

» significant non-compliance with community service, bail conditions and parole orders

» frequent breaches of protection orders with multiple former partners, over a sustained period of time and for serious acts of violence

» itinerant lifestyles or unstable accommodation

» known dependency and addiction to alcohol and/or other drugs.

Currently, to be eligible for parole, prisoners must submit an application to a parole panel,344 who will consider the risks of a particular prisoner being released from prison. The panel, which may not necessarily have personal knowledge of the prisoner, will review relevant notes, and then make a recommendation to the parole board. The parole board, generally has no direct contact

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with the prisoner, then makes the decision whether to grant parole.

The Board noted that balancing and measuring risk against custodial behaviour when determining eligibility for parole must be cognisant of the potential elevation of risk in community settings. For example, the risk of recidivism associated with a resumption of alcohol or drug use in the community was significant in many of the cases, and this was acknowledged through both self-reports and by assessments undertaken by corrective services staff.

In this sense, robust consideration of factors known (and on occasion in these cases personally acknowledged) to be linked to reoffending need to be fully considered when making decisions about granting parole; it is unclear from available records for these cases whether they were.

Equally important, is the effective management of parole orders post-release to ensure offenders engage with the conditions of their order to reduce their risk of recidivism and, dependent upon the nature of offending, future acts of violence.

With respect to these issues, the Board noted the recent release of the Queensland Parole System Review Final Report (2017) (the Parole Review).345 This review examined: the effectiveness of the parole board’s operations (including decision making); transparency of decision making; adequacy of accountability mechanisms; factors which increase successful completion of parole and reintegration; and, effectiveness of the legislative framework.346 The underlying purpose of parole, as explained in the report, is: will this or will this not make the prisoner less likely to offend?

The Parole Review identified that the requirements for successful parole for Aboriginal and Torres Strait Islander people are unable to be met by the general system response currently employed by Queensland Corrective Services, given the communities, circumstances and challenges they face, will be very different. As such rehabilitative and therapeutic efforts must be tailored to the specific risks of this cohort.

To address these concerns, the Parole Review recommended that at least one of the professional members of the Parole Board be an Aboriginal or Torres Strait Islander person. It is important that this membership not be considered a token gesture and that the individual/s be suitably experienced and qualified to perform the role. Additionally, there was a call for the appointment of more Aboriginal and Torres Strait Islander people as cultural liaison officers to support offenders successfully completing their parole and probation orders.

The Board discussions regarding these cases highlighted the importance of these reforms but noted that it is critical that changes are meaningful and sustained, with other elements of the service system also recognising the value of, and supporting, such initiatives in improving engagement and outcomes.

As a result of this review, the Queensland Government have recently committed to a range of reforms to improve the probation and parole system, including the:

345 Sofronoff, W. (2016). Queensland Parole System Review: Final report. Brisbane. Queensland Government. 346 This review was commissioned after the murder of a woman in North Queensland in 2016 by a man who had recently been released from prison to parole. 347 A service mapping project was undertaken to develop a detailed understanding of: the current availability and distribution of specialist domestic and family violence services including the level

of investment in each sector and service area; the demand for services across the state; and the strengths and weaknesses of the current service delivery system. A total of 24 organisations were identified as targeting Aboriginal and Torres Strait Islander clients, with 11 situated in Cape York which had the highest level of funding for domestic and family violence incidents. In contrast there were significant gaps between supply and demand in other regions with high Aboriginal and Torres Strait Islander populations, such as Gulf Country and Central West. https://www.communities. qld.gov.au/resources/gateway/campaigns/end-violence/dfv-services-audit-report.pdf

» implementation of a validated risk and need assessment tool

» introduction of an end-to-end parole process commencing at admission to prison

» continuity of case management, including the involvement of Probation and Parole case managers in the management of the prisoner before they are released from custody

» increased rehabilitation opportunities for offenders, including those which address the specific and complex needs of women and Aboriginal and Torres Strait Islander offenders, short-term prisoners and those serving community-based orders

» reviewing the resourcing of prison and community forensic mental health services, including mental health services for Aboriginal and Torres Strait Islander prisoners

» development of a plan to screen prisoners to prioritise problematic substance use rehabilitation, and increase opportunities for treatment

» expansion of re-entry services for prisoners

» establishment of an interdepartmental taskforce to examine long-term accommodation for prisoners and parolees

» restructuring of the Parole Board and appropriate resourcing including the inclusion of at least one Aboriginal and Torres Strait Islander representative on the Parole Board

» expansion of GPS tracking capabilities to monitor parolees in appropriate circumstances

» increase in the number of Probation and Parole officers

» increase in the numbers of cultural liaison officers to work with offenders in the community

» development of a new training package for Probation and Parole officers

» amendment of legislation including to ensure that the power to suspend parole sits solely with the Parole Board

» improvement in ways to ensure that victims of domestic and family violence continue to be protected while the offender is in custody and when they are released on parole

The Board acknowledged and welcomed the Queensland Government’s commitment to these reforms as well as a review in five years to ensure they have led to sustained improvements in this area.

Specialist services

While there has also been substantial investment in victim services and perpetrator intervention programs in recent budgets,347 and planning is currently occurring with regional communities as to how this is invested, there are challenges in bringing existing program models into remote communities, with a need to identify new models of service practice and delivery.

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Work is progressing in this area, with the Office for Women and Domestic Violence Reform in the DCCSDS overseeing research that aims to explore culturally suitable ‘safe at home’ security options or solutions.348

As part of the review of these deaths, the Board heard from service providers who spoke of their success with engaging with victims of abuse, or working within community. Key factors underlying their approach included:

» out-reach and community-based models of engagement with a strong focus on meeting the client when and where they are comfortable

» holistic focus on issues with a pragmatic approach to addressing underlying risk factors through direct service or appropriate referral regardless of funding restrictions and often requiring going ‘above and beyond’ existing resources

» strong links with community members and community based organisations across a wide range of areas not always specific to their core area of business, enabling a more holistic approach to addressing a client’s individual needs

» long term focus on engagement in recognition of the significant issues and trauma experienced by clients, focusing on the development of trust and rapport.

Several of the service providers discussed the significant benefit of cultural healers who apply traditional constructs of spirituality, connection and culture to improve the social, physical and emotional wellbeing of Indigenous people, families and communities. Research suggests that Aboriginal people place great faith in their own healers, who they believe have special powers derived from their spiritual Ancestors to cure people.349

Use of cultural healers is currently sporadic and often not funded by government agencies, in part because of the paucity of rigorous evaluation and research literature supporting this concept;350 and the difficulties in quantifying outcomes.

The Board expressed an interest in these practices and the guest speakers welcomed any attempt to formally evaluate these practices in accordance with a culturally informed framework, with a view to further expansion of such services given the perceived benefits.

Other key points identified with respect to specialist services included:

» Places of safety and refuge do not just provide physical protection, they can help facilitate the development of rapport and relationships, and provide opportunities for meaningful interventions. This can be achieved through the provision of general programs, such as craft workshops where women can attend and establish relationships, prior to the need for a specific intervention.

348 The Office for Women and Domestic Violence Reform has contracted the Indigenous owned Winangali Pty Ltd research consultancy company to conduct research to explore and consider culturally suitable ‘safe at home’ security options or solutions, that will expressly benefit Aboriginal and Torres Strait Islander women experiencing domestic and family violence, specifically those living in remote areas of the state. Winangali is partnered on this project by IPSOS. The research project is a component of the Keeping Women Safe in Their Homes initiative delivered in partnership with the Australian Government under the Women’s Safety Package. Winangali has commenced engagement with the communities of Pormpuraaw, Coen and Doomadgee in Far North Queensland and North Queensland Regions to gain community consent and approval for the research project to focus on those communities. The seven month research project commenced on 1 July 2017 and will conclude with the receipt of the final report is anticipated by 31 January 2018. Following departmental consideration of the final research report, OFWDVR will look to implement a place based trial to test one or more of the community generated solutions in one or more of the research sites, depending upon the cost and complexity of each solution.

349 Clarke, P. (2008). Aboriginal healing practices and Australian bush medicine. Journal of the Anthropological Society of South Australia, 33, 3-38. 350 For more information, refer to: Williams, E., Guenther, J., & Arnott, A. (2011). Traditional healing: A literature review. Working paper series 2: Evaluation and policy. No 2, Covaluator Network, http://

www.covaluator.net/docs/S2.2_traditional_healing_lit_review.pdf 351 Putt, J., Holder, R., & O’Leary, C. (2017). Women’s specialist domestic and family violence services: Their responses and practices with and for Aboriginal women: Key findings and future directions.

ANROWS: Compass series. Issue 01: March 2017. Available online at: https://anrows.org.au/publications/compass-0/women’s-specialist-domestic-and-family-violence-services-their-responses- and

» While the service history of the cases highlighted a lot of crisis points, there may have also been opportunities during other periods in which meaningful interventions could have occurred, for example where the relationship was more stable or the perpetrator was incarcerated.

» Further, although it is critical to build community capacity to respond, many of the individuals subject to review by the Board had transient lifestyles and moved across communities. As such, while it is important to have strategies focused on community development, or empowerment, there is a concurrent need to work across communities to enhance the effectiveness of interventions over the longer term.

A recent study completed by ANROWS considered the experience of Aboriginal women and service providers of three specialist services to identify opportunities to enhance responses.351

At a policy level, key messages included:

» Women’s specialist domestic and family violence services need to be supported in their work with and response to the needs of Aboriginal women, as they serve as a crucial and reliable option for Aboriginal women in crisis.

» There needs to be greater recognition of how Aboriginal women can influence – and have influenced – service models and practice, especially where they are the majority of clients.

» Defining and monitoring ‘successful’ outcomes should be realistic and grounded in what service user’s value.

» Across the sector, capacity has to be built within services for continuing self-evaluation that is guided by the views and feedback from Aboriginal and non-Aboriginal women. Additional resources and support are essential for this to be done well and with care.

At a practice level, the project also identified learnings for services such as:

» Recognising that formal governance structures for services may not suit Aboriginal women as places to represent their own and others’ views, but that other ways of eliciting guidance and reflection on a group basis exist.

» Cultivating stronger ties between specialist domestic and family violence services and local Aboriginal organisations and leaders is important and necessary.

» Having realistic expectations of the roles and number of Aboriginal frontline staff. In some contexts, mentorship or cultural advisory positions may work well.

» Building and sustaining informal networks and contacts, including through creative outreach and community development activities is effective.

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» Continuing and supporting the constant process of learning by adopting a collaborative approach and by having discussions or conversations with Aboriginal female clients or ex-clients more often, in ways that are ethical, safe and valued by them, provides an important opportunity for continuous improvement in practice.

These findings represent critical opportunities to enhance future responses by specialist services working with and for Aboriginal women.

Recommendation 20

That the Queensland Government, in partnership with community Elders and other recognised experts, develop a specific Aboriginal and Torres Strait Islander family violence strategy as a matter of urgent priority. This work should be informed by the Queensland Government’s Supporting Families Changing Futures reforms, Our Way: A generational strategy for Aboriginal and Torres Strait Islander children and families 2017-2039 and Changing Tracks: An action plan for Aboriginal and Torres Strait Islander children and families (2017-2019). The strategy should:

(a) be led and implemented by Elders and the community

(b) be informed by evidence and account for the various drivers perpetuating family violence

(c) focus on cultural strengths and family-centred services and programs

(d) recognise and seek to address the unique construct, challenges and co-morbidities of this type of violence

(e) have an urban focus as well as addressing the needs of regional and discrete communities

(f) complement broader domestic and family violence strategies, and others of relevance, including health, justice, education and child protection strategies where appropriate

(g) embed trauma-informed approaches that recognise historical and contemporary issues

(h) include a tertiary response but provide equal focus and investment on primary prevention and early intervention

(i) include primary prevention strategies for Aboriginal and Torres Strait Islander children which should be developed in consultation with young people to ensure their needs are met

(j) be sustainably and sufficiently funded, noting the cost benefit to be accrued through reducing the burden on resource intensive services such as emergency departments and child safety services

(k) include allied, wrap-around services to support the development and implementation of the strategy

(l) be formally monitored and independently evaluated using culturally appropriate outcome measures, methodologies and providers. This should include a strong focus on building the evidence base and data around what works in this area

(m) be publicly reported at regular intervals to increase accountability. This should include tracking the investment to ascertain whether it is proportionate to the current investment in crisis response

(n) be supported by a governance body to oversee a co-design approach to the development and implementation of this strategy.

Recommendation 21

That the Queensland Government extend upon culturally informed, family responsive alcohol and other drug treatment options, to ensure they include options for residential treatment or outpatient support, and provide ongoing care as part of the treatment program.

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Appendix A - Intimate Partner Homicide Lethality Risk Factor Form

352 Roehl, J., O’Sullivan, C., Webster, D. & Campbell, J. (2005). Intimate Partner Violence Risk Assessment Validation Study, Final Report. National Criminal Justice Reference Service: U.S. Department of Justice

353 Office of the Chief Coroner (2014) Domestic Violence Death Review Committee Annual Report

Domestic and family violence death review processes are based on the premise that there have been warning signs, and key indicators or predictors of harm, prior to the death. These indicators, such as a noted escalation in violence, prior attempts of strangulation or real or impending separation, have been found to have been associated with an increased risk of harm in a relationship characterized by domestic and family violence.

Consequently they are often included in domestic and family violence assessment and screening tools by specialist and generalist services, with a view to enhancing responses to victims and their children.

The recognition of multiple risk factors within a relationship allows for a more comprehensive assessment of risk, safety planning and, potentially, the prevention of future deaths related to

domestic and family violence.

Assessing and determining the severity of domestic and family violence within a relationship can assist services to identify and quantify the level of risk or danger; allocate resources; and assist victims to understand that they may be at a high risk of violence against them.352

There is a need for a more nuanced understanding of risk assessment processes, including differentiating between static and dynamic risk factors. While static risk factors which are historical in nature (such as prior assaults) are incapable of change, dynamic risk factors such as a perpetrator’s excessive alcohol and other drug use may fluctuate over time. Factors that are capable of change need to be monitored, as they may change an overall assessment of harm at any point in time. More importantly they can also become a potential point of intervention for service providers to target to reduce risk within a relationship, potentially leading to more effective responses to a perpetrator’s use of violence and abuse in a relationship.

While many international domestic and family violence death review mechanisms consider lethality risk factors as part of the review process, assessment tools vary in scope and focus. Currently the DFVDRU adopts the Ontario Domestic Violence Death Review Committee Coding Form as it provides a comprehensive list of 39 risk factors developed cumulatively over time from their reviews of intimate partner homicides.

Established in 2003 and embedded within the coronial jurisdiction, the purpose of this committee is to assist the Office of the Chief Coroner in their investigation and review of domestic violence related homicides, and to make recommendation to prevent deaths in the future. The scope of their review process is restricted to homicides which have occurred within a current or former intimate partner relationship; which, similar to most risk assessment processes, restricts the applicability of the risk factor coding process to only these types of relationships. There is limited research that explores the presence of risk within family relationships characterized by abuse, as the patterns of family violence within these relationships is often very different to patterns coercive controlling violence present in intimate partner relationships. In 75 per cent of cases reviewed by the Ontario Domestic Violence Death Review Committee from 2003 to 2012, seven or more lethality risk factors were present; indicating that these domestic homicides were predictable and may have been prevented with earlier recognition and action.353

See more here: http://www.mcscs.jus.gov.on.ca/english/DeathInvestigations/office_coroner/PublicationsandReports/DVDR/2012Report/ DVDR_2012.html#b

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A = Evidence suggests that the risk factor was absent

P = Evidence suggests that the risk factor was present

Unk = Unknown

Risk Factors Code

(A,P, Unk)

1. History of violence outside of the family by perpetrator

2. History of domestic violence

3. Prior threats to kill victim

4. Prior threats with a weapon

5. Prior assault with a weapon

6. Prior threats to commit suicide by perpetrator

7. Prior suicide attempts by perpetrator* (if check #6 and/or #7 only count as one factor)

8. Prior attempts to isolate the victim

9. Controlled most or all of victim’s daily activities

10. Prior hostage-taking and/or forcible confinement

11. Prior forced sexual acts and/or assaults during sex

12. Child custody or access disputes

13. Prior destruction or deprivation of victim’s property

14. Prior violence against family pets

15. Prior assault on victim while pregnant

16. Choked/Strangled victim in the past

17. Perpetrator was abused and/or witnessed domestic violence as a child

18. Escalation of violence

19. Obsessive behaviour displayed by perpetrator

20. Perpetrator unemployed

21. Victim and perpetrator living common-law

22. Presence of stepchildren in the home

23. Extreme minimization and/or denial of spousal assault history

24. Actual or pending separation

25. Excessive alcohol and/or drug use by perpetrator

26. Depression – in the opinion of family/friend/acquaintance - perpetrator

27. Depression – professionally diagnosed – perpetrator (If check #26 and/or #27 only count as one factor)

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28. Other mental health or psychiatric problems – perpetrator

29. Access to or possession of any firearms

30. New partner in victim’s life

31. Failure to comply with authority – perpetrator

32. Perpetrator exposed to/witnessed suicidal behaviour in family of origin

33. After risk assessment, perpetrator had access to victim

34. Youth of couple

35. Sexual jealousy – perpetrator

36. Misogynistic attitudes – perpetrator

37. Age disparity of couple

38. Victim’s intuitive sense of fear of perpetrator

39. Perpetrator threatened and/or harmed children

Other factors that increased risk in this case? Specify:

Risk Factor Descriptions

Perpetrator = The primary aggressor in the relationship

Victim = The primary target of the perpetrator’s abusive/maltreating/violent actions

Risk Factor Description

1. History of violence outside of the family by perpetrator

Any actual or attempted assault on any person who is not, or has not been, in an intimate relationship with the perpetrator. This could include friends, acquaintances, or strangers. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family members; friends; neighbours; co-workers; counsellors; medical personnel, etc.).

2. History of domestic violence

Any actual, attempted, or threatened abuse/maltreatment (physical; emotional; psychological; financial; sexual, etc.) toward a person who has been in, or is in, an intimate relationship with the perpetrator. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family members; friends; neighbours; co-workers; counsellors; medical personnel, etc.). It could be as simple as a neighbour hearing the perpetrator screaming at the victim or include a co-worker noticing bruises consistent with physical abuse on the victim while at work.

3. Prior threats to kill victim

Any comment made to the victim, or others, that was intended to instil fear for the safety of the victim’s life. These comments could have been delivered verbally, in the form of a letter, or left on an answering machine. Threats can range in degree of explicitness from ‘I’m going to kill you’ to ‘You’re going to pay for what you did’ or ‘If I can’t have you, then nobody can’ or ‘I’m going to get you’.

4. Prior threats with a weapon

Any incident in which the perpetrator threatened to use a weapon (e.g., gun; knife; etc.) or other object intended to be used as a weapon (e.g., bat, branch, garden tool, vehicle, etc.) for the purpose of instilling fear in the victim. This threat could have been explicit (e.g., ‘I’m going to shoot you’ or ‘I’m going to run you over with my car’) or implicit (e.g., brandished a knife at the victim or commented ‘I bought a gun today’). Note: This item is separate from threats using body parts (e.g., raising a fist).

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5. Prior assault with a weapon

Any actual or attempted assault on the victim in which a weapon (e.g., gun; knife; etc.), or other object intended to be used as a weapon (e.g., bat, branch, garden tool, vehicle, etc.), was used. Note: This item is separate from violence inflicted using body parts (e.g., fists, feet, elbows, head, etc.).

6. Prior threats to commit suicide by perpetrator

Any recent (past 6 months) act or comment made by the perpetrator that was intended to convey the perpetrator’s idea or intent of committing suicide, even if the act or comment was not taken seriously. These comments could have been made verbally, or delivered in letter format, or left on an answering machine. These comments can range from explicit (e.g., “If you ever leave me, then I’m going to kill myself” or “I can’t live without you”) to implicit (“The world would be better off without me”). Acts can include, for example, giving away prized possessions.

7. Prior suicide attempts by perpetrator

Any recent (past 6 months) suicidal behaviour (e.g., swallowing pills, holding a knife to one’s throat, etc.), even if the behaviour was not taken seriously or did not require arrest, medical attention, or psychiatric committal. Behaviour can range in severity from superficially cutting the wrists to actually shooting or hanging oneself.

8. Prior attempts to isolate the victim

Any non-physical behaviour, whether successful or not, that was intended to keep the victim from associating with others. The perpetrator could have used various psychological tactics (e.g., guilt trips) to discourage the victim from associating with family, friends, or other acquaintances in the community (e.g., ‘if you leave, then don’t even think about coming back’ or ‘I never like it when your parents come over’ or ‘I’m leaving if you invite your friends here’).

9. Controlled most or all of victim’s daily activities

Any actual or attempted behaviour on the part of the perpetrator, whether successful or not, intended to exert full power over the victim. For example, when the victim was allowed in public, the perpetrator made her account for where she was at all times and who she was with. Another example could include not allowing the victim to have control over any finances (e.g., giving her an allowance, not letting get a job, etc.).

10. Prior hostage- taking and/or forcible confinement

Any actual or attempted behaviour, whether successful or not, in which the perpetrator physically attempted to limit the mobility of the victim. For example, any incidents of forcible confinement (e.g., locking the victim in a room) or not allowing the victim to use the telephone (e.g., unplugging the phone when the victim attempted to use it). Attempts to withhold access to transportation should also be included (e.g., taking or hiding car keys). The perpetrator may have used violence (e.g., grabbing; hitting; etc.) to gain compliance or may have been passive (e.g., stood in the way of an exit).

11. Prior forced sexual acts and/or assaults during sex

Any actual, attempted, or threatened behaviour, whether successful or not, used to engage the victim in sexual acts (of whatever kind) against the victim’s will. Or any assault on the victim, of whatever kind (e.g., biting; scratching, punching, choking, etc.), during the course of any sexual act.

12. Child custody or access disputes

Any dispute in regards to the custody, contact, primary care or control of children, including formal legal proceedings or any third parties having knowledge of such arguments.

13. Prior destruction or deprivation of victim’s property

Any incident in which the perpetrator intended to damage any form of property that was owned, or partially owned, by the victim or formerly owned by the perpetrator. This could include slashing the tires of the car that the victim uses. It could also include breaking windows or throwing items at a place of residence. Please include any incident, regardless of charges being laid or those resulting in convictions.

14. Prior violence against family pets

Any action directed toward a pet of the victim, or a former pet of the perpetrator, with the intention of causing distress to the victim or instilling fear in the victim. This could range in severity from killing the victim’s pet to abducting it or torturing it. Do not confuse this factor with correcting a pet for its undesirable behaviour.

15. Prior assault on victim while pregnant

Any actual or attempted form physical violence, ranging in severity from a push or slap to the face, to punching or kicking the victim in the stomach. The key difference with this item is that the victim was pregnant at the time of the assault and the perpetrator was aware of this fact.

16. Choked/Strangled victim in the past

Any attempt (separate from the incident leading to death) to strangle the victim. The perpetrator could have used various things to accomplish this task (e.g., hands, arms, rope, etc.). Note: Do not include attempts to smother the victim (e.g., suffocation with a pillow).

17. Perpetrator was abused and/or witnessed domestic violence as a child

As a child/adolescent, the perpetrator was victimized and/or exposed to any actual, attempted, or threatened forms of family violence/abuse/maltreatment.

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18. Escalation of violence

The abuse/maltreatment (physical; psychological; emotional; sexual; etc.) inflicted upon the victim by the perpetrator was increasing in frequency and/or severity. For example, this can be evidenced by more regular trips for medical attention or include an increase in complaints of abuse to/by family, friends, or other acquaintances.

19. Obsessive behaviour displayed by perpetrator

Any actions or behaviours by the perpetrator that indicate an intense preoccupation with the victim. For example, stalking behaviours, such as following the victim, spying on the victim, making repeated phone calls to the victim, or excessive gift giving, etc.

20. Perpetrator unemployed

Employed means having full-time or near full-time employment (including self-employment). Unemployed means experiencing frequent job changes or significant periods of lacking a source of income. Please consider government income assisted programs (e.g., O.D.S.P.; Worker’s Compensation; E.I.; etc.) as unemployment.

21. Victim and perpetrator living common-law

The victim and perpetrator were cohabiting.

22. Presence of stepchildren in the home

Any child(ren) that is(are) not biologically related to the perpetrator.

23. Extreme minimisation and/or denial of spousal assault history

At some point the perpetrator was confronted, either by the victim, a family member, friend, or other acquaintance, and the perpetrator displayed an unwillingness to end assaultive behaviour or enter/comply with any form of treatment (e.g., batterer intervention programs). Or the perpetrator denied many or all past assaults, denied personal responsibility for the assaults (i.e., blamed the victim), or denied the serious consequences of the assault (e.g., she wasn’t really hurt).

24. Actual or pending separation

The partner wanted to end the relationship. Or the perpetrator was separated from the victim but wanted to renew the relationship. Or there was a sudden and/or recent separation. Or the victim had contacted a lawyer and was seeking a separation and/or divorce.

25. Excessive alcohol and/ or drug use by perpetrator

Within the past year, and regardless of whether or not the perpetrator received treatment, substance abuse that appeared to be characteristic of the perpetrator’s dependence on, and/or addiction to, the substance. An increase in the pattern of use and/ or change of character or behaviour that is directly related to the alcohol and/ or drug use can indicate excessive use by the perpetrator. For example, people described the perpetrator as constantly drunk or claim that they never saw him without a beer in his hand. This dependence on a particular substance may have impaired the perpetrator’s health or social functioning (e.g., overdose, job loss, arrest, etc). Please include comments by family, friend, and acquaintances that are indicative of annoyance or concern with a drinking or drug problem and any attempts to convince the perpetrator to terminate his substance use.

26. Depression – in the opinion of family/friend/ acquaintance - perpetrator

In the opinion of any family, friends, or acquaintances, and regardless of whether or not the perpetrator received treatment, the perpetrator displayed symptoms characteristic of depression.

27. Depression – professionally diagnosed – perpetrator

A diagnosis of depression by any mental health professional (e.g., family doctor; psychiatrist; psychologist; nurse practitioner) with symptoms recognized by the DSM-IV, regardless of whether or not the perpetrator received treatment.

28. Other mental health or psychiatric problems – perpetrator

For example: psychosis; schizophrenia; bipolar disorder; mania; obsessive-compulsive disorder, etc.

29. Access to or possession of any firearms

The perpetrator stored firearms in his place of residence, place of employment, or in some other nearby location (e.g., friend’s place of residence, or shooting gallery). Please include the perpetrator’s purchase of any firearm within the past year, regardless of the reason for purchase.

30. New partner in victim’s life

There was a new intimate partner in the victim’s life or the perpetrator perceived there to be a new intimate partner in the victim’s life

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31. Failure to comply with authority – perpetrator

The perpetrator has violated any family, civil, or criminal court orders, conditional releases, community supervision orders, or ‘No Contact’ orders, etc. This includes bail, probation, or restraining orders, and bonds, etc.

32. Perpetrator exposed to/ witnessed suicidal behaviour in family of origin

As a(n) child/adolescent, the perpetrator was exposed to and/or witnessed any actual, attempted or threatened forms of suicidal behaviour in his family of origin. Or somebody close to the perpetrator (e.g., caregiver) attempted or committed suicide.

33. After risk assessment, perpetrator had access to victim

After a formal (e.g., performed by a forensic mental health professional before the court) or informal (e.g., performed by a victim services worker in a shelter) risk assessment was completed, the perpetrator still had access to the victim.

34. Youth of couple

Victim and perpetrator were between the ages of 15 and 24.

35. Sexual jealousy – perpetrator

The perpetrator continuously accuses the victim of infidelity, repeatedly interrogates the victim, searches for evidence, tests the victim’s fidelity, and sometimes stalks the victim.

36. Misogynistic attitudes – perpetrator

Hating or having a strong prejudice against women. This attitude can be overtly expressed with hate statements, or can be more subtle with beliefs that women are only good for domestic work or that all women are ‘whores’.

37. Age disparity of couple

Women in an intimate relationship with a partner who is significantly older or younger. The disparity is usually nine or more years

38. Victim’s intuitive sense of fear of perpetrator

The victim is one that knows the perpetrator best and can accurately gauge his level of risk. If the women discloses to anyone her fear of the perpetrator harming herself or her children, for example statements such as, ‘I fear for my life’, ‘I think he will hurt me’, ‘I need to protect my children’, this is a definite indication of serious risk.

39. Perpetrator threatened and/or harmed children

Any actual, attempted, or threatened abuse/maltreatment (physical; emotional; psychological; financial; sexual; etc.) towards children in the family. This incident did not have to necessarily result in charges or convictions and can be verified by any record (e.g., police reports; medical records) or witness (e.g., family; friends; neighbours; co-workers; counsellors; medical personnel, etc).

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Appendix B - Case characteristics

Homicide-Suicides and Perpetrator Suicides

Kate & Jeffrey

Amy & Paul Shane Keith Tony James Michael

Deceased Gender Female Female Male Male Male Male Male

Offender Gender Male Male NA NA NA NA NA

Place of Residence (Coronial jurisdiction)

Brisbane South East- ern

Brisbane South East- ern

Brisbane Northern Central

Relevant Service Contact

Police Police, Men- tal Health

Police, Men- tal Health, Queensland Health

Police, Men- tal Health, Corrective Services, Queensland Health

Police, Queensland Health, Sub- stance abuse service

Police, Men- tal Health, Queensland Health

Police

Known to Family and friends

Yes Yes Yes Yes Yes Yes Yes

History with previous partners

Yes Yes Yes Yes No No No

Relationship separation

Yes Yes Yes Yes Yes Yes Yes

Child custody concerns

No No No No Yes Yes Yes

Other history of offending

Yes Yes No Yes Yes Yes Yes

Substance misuse (perpetrator)

Yes Yes Yes Yes Yes Yes Yes

Mental health concerns (perpetrator)

Yes Yes Yes Yes Yes Yes Yes

Protection order in place at time of death

No No Yes Yes Yes Yes No

Previous suicide attempt or threats

No Yes Yes Yes Yes Yes No

Proximate events Recent relationship separation, sexual jeal- ousy

Relationship separation, sexual jealousy, escalation of controlling behaviour, mental health con- cerns

Relationship separation, ongoing mental health issues

Recent separation, mental health de- terioration, increasing obses- sive and controlling behaviours

Relationship breakdown, substance abuse, exacerbation of mental illness, financial strain

Child custo- dy concerns, relationship breakdown, mental illness, risk taking behaviour

Escalating anti-social risk taking behaviour, substance abuse, criminal offending, unemploy- ment

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Intimate Partner Homicides

Kelly Rosie Nicole Monique* Gabby

Deceased Gender Female Female Female Female Female

Offender Gender Male Male Male Male Male

Place of Residence (Coronial jurisdiction)

Brisbane Northern Brisbane Brisbane South Eastern

Relevant Service Contact Police Child Safety Services; Family Court; Family Relationships

Police; Mental Health Services; Specialist DV ser- vices; Child Safety Services

Police; Specialist DV services

Police; Special- ist DV services; Mental Health Services; Correc- tive Services

Known to Family and friends

Yes Yes Yes Yes Yes

Victim Vulnerabilities Social and geographical isolation

Shared parenting requirements; parenting ability undermined

Alcohol abuse; physical health; depression

Entrenched abuse history; ongoing child custody issues

Intense fear caus- ing her to go into hiding

History with previous partners

No Yes Yes No Yes

Relationship separation Yes, intent to separate

Yes, separated Yes, separated Yes, separated Yes, in process of separating

Child custody concerns No Yes Yes Yes Yes

Other history of offending Yes No Yes Yes Yes

Substance misuse (perpetrator)

Yes, Alcohol No Yes, history of dependence on alcohol and prescription medi- cations

Yes, alcohol No

Mental health concerns (perpetrator)

No Yes Yes Yes Yes

Protection order in place at time of death

Yes No Yes Yes Yes

Previous suicide attempt or threats

No No Yes No Yes

Proximate events Heavy alcohol consumption; situational factors (flood damage re- quire relocation); upcoming court regarding earlier assault; intent to separate

Ongoing child custody concerns

Mental health admission (perpe- trator); protection order issued; suicidal gestures; child custody and visitation issues.

Protection order issued; child custody issues; mental instabil- ity; inability to get appropriate protection

Recent separation including residing at women’s refuge; protection order issued; fam- ily court visitation matters; escala- tion of violence.

* Case characteristics refer to the former partner of the offender

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Victim Suicides

Paula Tricia Stacey Melissa Travis May

Deceased Gender Female Female Female Female Male Female

Offender Gender Male Male Male Male N/A N/A

Place of Residence (Coronial jurisdiction)

Brisbane Northern South Eastern Northern South Eastern Northern

Relevant Service Contact

Queensland Health, Com- munity service, women’s shelter

Police, Ambu- lance, Alcohol Tobacco and Other Drug Service, Hos- pitals, private mental health practitioners, Specialist DV Service

Police, Courts, women’s shelter

Police, Correc- tive Services, Ambulance, Hospitals

Child Safety Services, police, Indige- nous support service, school

Child Safety Services, police, Mental Health service, school

Known to Family and friends

Yes Yes Yes Yes Yes Yes

Victim Vulnerabilities Chronic pain, history of suicidal behaviours, mental illness, isolation, sub- stance misuse history, abused as a child

Substance abuse, mental health, crimi- nal history, his- tory of suicidal behaviours, history of victi- misation

Substance mis- use, abused as a child, mental illness, lack of stable ac- commodation, employment

Mental illness, substance misuse, history of victimisa- tion, history of suicidal behaviours

Young age, exposure to domestic vio- lence, bullying, parental sub- stance abuse

Young age, exposure to domestic vio- lence, bullying, sexual and gender identity issues, pa- rental mental illness

History with previous partners

Yes Yes No Yes N/A N/A

Relationship separation

Yes Conflict Yes Conflict N/A N/A

Child custody concerns

No No No No N/A N/A

Other history of offending

Yes Yes Yes Yes N/A N/A

Substance misuse (perpetrator)

Yes No Yes Yes N/A N/A

Mental health concerns (perpetrator)

No No Yes Yes N/A N/A

Protection order in place at time of death

No Yes (deceased as respondent)

Yes Yes N/A N/A

Previous suicide attempt or threats

Yes Yes Yes Yes Yes Yes

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Proximate events Forced to flee violent rela- tionship, resid- ing at refuge, application for private hous- ing rejected, concerns for children / pets welfare, hospitalisa- tion, mental health issues, harassment from former partner

Upcoming court proceed- ings, detained by police, substance mis- use, ongoing violence

Court proceed- ing against former partner, forced to flee, residing in refuge, relationship breakdown

Intoxication, argument with partner, lost accommoda- tion, ongoing violence

Witnessed confrontation between multiple adult family mem- bers, exposure to domestic violence, bullying

Exposure to domestic vio- lence, parental separation, bullying,

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Aboriginal and Torres Strait Islander intimate partner homicides

Fran Lucy Brian Ella Lauren

Deceased Gender Female Female Male Female Female

Offender Gender Male Male Female Male Male

Place of Residence (Coronial jurisdiction)

Northern Northern Northern Northern Northern

Relevant Service Contact Police, Corrective Services, Ambu- lance, Queens- land Health

Police, Corrective Services, Ambu- lance, Queens- land Health

Police, Corrective Services, Ambu- lance

Police, Corrective Services, Ambu- lance, Queens- land Health

Police, Corrective Services, Ambu- lance, Queens- land Health, Alcohol Tobacco and Other Drug Services, Com- munity support services

Known to Family and friends

Yes Yes Yes Yes Yes

Victim Vulnerabilities History of violence in prior intimate partner and famil- ial relationships; alcohol abuse; unstable accom- modation.

History of violence prior to intimate partner; alcohol abuse; unstable accommodation; previous suicide threats; criminal history

History of family violence; alcohol addic- tion; unemploy- ment; unstable accommodation; previous suicide threat; criminal history including incarceration

History of family violence; unem- ployment; unsta- ble accommoda- tion; geographic isolation; young age.

Homelessness; alcohol abuse; unemployment.

History with previous partners

Yes Yes Yes Yes Yes

Relationship separation No Yes Yes No No

Child custody concerns No No Yes No No

Other history of offending Yes Yes Yes Yes Yes

Substance misuse (perpetrator)

Yes, alcohol Yes, alcohol Yes, alcohol Yes, alcohol Yes, alcohol

Mental health concerns (perpetrator)

Yes No Yes (not current) Yes (childhood) No

Protection order in place at time of death

Yes Yes Yes No Yes

Previous suicide attempt or threats

No Yes Yes Yes No

Proximate events Heavy alcohol consumption; is- sues with service of the protection order; multiple police contacts af- ter this. Offender on bail at time of death

Heavy alcohol consumption; protection order breaches.

Heavy alcohol consumption; protection order breaches; contra- vention of parole order.

Heavy alcohol consumption; contravention of parole order; risk of homelessness

Heavy alcohol consumption; Contravention of parole order; homelessness.

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Filicides

Alice Ben Cameron Dominique

Deceased Gender Female Male Male Female

Primary Offender Gender Male Male Male Male

Place of Residence (Coronial jurisdiction)

Central Central Central Brisbane

Relevant Service Contact Child Safety Services, Police, Mental Health, GP

Child Safety Services, Corrective Services, Police, Hospital Emer- gency, Indigenous Health, Mental Health services

Child Safety Services, police, Mental health

Nil

DFV Known to Family and friends

Yes Yes No No

Relationship separation No No No No

Child protection history Yes Yes Yes No

Parental history as subject child in child protection

Yes Yes Yes No

Other children in the household

Yes No No Yes

Other history of offending Yes Yes Yes No

Substance misuse (perpetrator) Yes Yes Yes Yes

Mental health concerns (perpetrator)

Yes Yes No Yes

Protection order in place at time of death

No No No No

Previous suicide attempt or threats

No Yes No No

Proximate events Ongoing substance abuse, escalating domestic violence

Unstable housing situation, parental substance abuse

Recent reconciliation of parents, escalation of paternal substance abuse and violence

Nil

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Appendix C – Glossary of terms

354 Johnson, M.P. (2008). A Typology of Domestic Violence: Intimate terrorism, violent resistance and situational violence. Boston, USA: University Press of New England.

Aggrieved: the person for whose benefit a domestic violence protection order, or police protection notice, is in force or may be under the Domestic and Family Violence Protection Act 2012.

AIFS: Australian Institute for Family Studies

ANROWS: Australian National Research Organisation for Women’s Safety

COAG: Council of Australian Governments

Coercive controlling violence: an ongoing and often relentless pattern of behaviour asserted by a perpetrator which is designed to induce various degrees of fear, intimidation and submission in a victim.354This may include the use of tactics such as social isolation, belittling, humiliation, threatening behaviour, restricting resources and abuse of children, pets or relatives.

Collateral homicides: includes a person who may have been killed intervening in a domestic dispute or a new partner who is killed by their current partner’s former abusive spouse.

Collusion: the conscious or unconscious collaboration of two or more individuals to protect those engaged in unethical or illegal practices. This can involve friends, family or service systems, and can include the justification or minimisation of abusive behaviours, blaming the victim, and failing to intervene when violence is detected.

Contact abuse: the ongoing use of systems to continue to abuse victims by a perpetrator, typically after a relationship separation (e.g. child custody matters through Family Law Court).

Deceased: the person/s who died.

DCCSDS: Department of Communities, Child Safety and Disability Services

DFVPA 2012: Domestic and Family Violence Protection Act 2012

Domestic and family violence: as defined by section 8 of the Domestic and Family Violence Protection Act 2012, means behaviour by a person (the first person) towards another person (the second person) with whom the first person is in a relevant relationship that: (a) is physically or sexually abusive; or (b) is emotionally or psychologically abusive; or (c) is economically abusive; or (d) is threatening; or (e) is coercive; or (f) in any other way controls or dominates the second person and causes the second person to fear for their safety or wellbeing, or that of someone else.

Domestic and family violence homicide: Queensland uses a nationally consistent definition of a ‘domestic and family violence homicide’ as outlined within the Australian Domestic and Family Violence Death Review Network ‘Homicide Consensus Statement’ which recognises that although there is no universally agreed definition of the behaviours that comprise domestic and family violence, in Australia it includes a spectrum of physical and non-physical behaviours including physical assault, sexual assault, threats, intimidation, psychological and emotional abuse, social isolation and economic deprivation. Primarily, domestic and family violence is predicated upon inequitable relationship dynamics in which one person exerts power over another. This accords with the definition of family violence contained in the Family Law Act 1975 (Cth), which is adopted by the Network. The definition of homicide adopted by the National Network is broader than the legal definition of the term, and includes all circumstances in which an individual’s act, or failure to act, resulted in the death of another person, regardless of whether the circumstances were such as to contravene provisions of the criminal law.

DVO: Domestic violence protection order

Economic abuse: behaviour by a person that is coercive, deceptive or unreasonably controls another person without the second person’s consent in a way that denies economic or financial autonomy, or by withholding or threatening to withhold financial support necessary for meeting reasonable living expenses if the first person is predominantly or entirely dependent on the first person financially.

Emotional or psychological abuse: behaviour by a person towards another person that torments, intimidates, harasses or is offensive to the other person.

Episodes of violence: describes the series of events characterising this type of violence. Referring to episodes of violence allows practitioners to consider the repetitive nature of violence perpetration and victimisation, exposing the ongoing vulnerabilities of victims and cumulative risk that perpetrators pose both within, and across, relationships.

Exposed to domestic violence: a child is exposed to domestic and family violence if the child sees or hears domestic violence or otherwise experiences the effects of domestic and family violence.

Family violence: this term is commonly used when referring to violence that occurs within Aboriginal and Torres Strait Islander families and communities. This concept places a greater emphasis on the impact on the family as a whole and contextualises this type of violence more

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broadly, recognising the impact of dispossession, breakdown of kinship networks, child removal policies and entrenched disadvantage, as well as intergenerational trauma and grief on Aboriginal and Torres Strait Islander families and communities. This describes all forms of violence (e.g. physical, emotional, psychological, sexual, sociological, economic and spiritual, in intimate partner, family and other relationships of mutual obligations and support.

Filicide: the killing of children by parents (including step-parents)

FRC: Family Responsibilities Commission

GP: General Practitioner

Intimate partner relationship: individuals who are or have been in an intimate relationship (sexual or non-sexual), irrespective of the genders of the individuals

Lethality risk indicators: Domestic and family violence death review processes are based on the premise that there have been warning signs, and key indicators or predictors of harm, prior to the death. These indicators, such as a noted escalation in violence, non-lethal strangulation or real or impending separation, have been found to have been associated with an increased risk of harm in relationships characterised by domestic and family violence.

Mental Health Sentinel Events Review (Sentinel Event Review): the Mental Health Sentinel Events Review Committee was established to review recent fatal events involving people with mental health issues in Queensland. The review provided expertise and leadership in public mental health care and forensic mental health care that balanced best practice care with operational practicality. The Sentinel Event Review provides high level guidance for clinicians, administrators, and policymakers on opportunities to improve the identification and quality of care for severely mentally ill consumers while simultaneously considering public safety.355

National Outcome Standards for Perpetrator Interventions: were developed by the Australian Commonwealth, state and territory governments and endorsed by the Council of Australian Governments on 11 December 2015, and aim to inform interventions to reduce re- offending, to better understand the nature of perpetration against high risk groups, to evaluate existing program models, and to determine the characteristics of effective perpetrator intervention programs

Offender: the person whose actions, or inaction, caused the person (the deceased) to die

Perpetrator: the person who was the primary aggressor in the relationship prior to the death and who used abusive tactics within the relationship to control the victim

Perpetrator Interventions: typically refers to specific programs (e.g. behaviour change programs) for perpetrators of domestic and family violence. These interventions generally seek to change men’s attitudes, beliefs and behaviour in order to prevent them from engaging in violence in the future.356

QCS: Queensland Corrective Services

QFCC: Queensland Family and Child Commission

QH: Queensland Health

QLRC: Queensland Law Reform Commission

QPS: Queensland Police Service

Queensland Child Protection Commission of Inquiry (the Carmody Review): led by the Honourable Tim Carmody QC, this inquiry was established in 2012 to review the entire child protection system and to deliver a roadmap for a new system for supporting families and protecting children. The final report, Taking Responsibility: A roadmap for Queensland child protection357, released in 2013 outlined 121 recommendations to government to reform the child protection system; 116 of these recommendations were accepted fully and the remaining five were accepted in principle.

Queensland Parole System Review (the Parole Review): led by the Mr Walter Sofronoff QC, this review examined: the effectiveness of the parole boards’ operations (including decision making); transparency of decision making; adequacy of accountability mechanisms; factors which increase successful completion of parole and reintegration; and, effectiveness of the legislative framework.358 The final report, provided to the Premier on 1 December 2016, featured 91 recommendations. Of these 82 were fully supported by Government, seven were supported in principle and two were not supported.

Relative: Individuals, including children, related by blood, a domestic partnership or adoption. This includes family-like relationships and explicitly includes extended family-like relationships that are recognised within that individual’s cultural group. This includes: a child, step-child, parent, step-parent, sibling, grandparent, aunt, nephew, cousin, half-brother, or mother-in-law.

355 Mental Health Sentinel Events Review Committee. (2016). When Mental Health Care Meets Risk: A Queensland sentinel events review into homicide and public sector mental health services. Brisbane: Queensland Health.

356 Mackay, E., Gibson, A., Lam, H., & Beecham, D. (2015). Perpetrator interventions in Australia: Part one – literature review. Landscapes, Nov 2015. Sydney: Australian National Research Organisation for Women’s Safety.

357 Queensland Child Protection Commission of Inquiry. (2013). Taking Responsibility: A roadmap for Queensland Child Protection. Brisbane: Author. 358 Sofronoff, W. (2016). Queensland Parole System Review: Final report. Brisbane: Author.

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Relevant relationship: as defined by section 13 of the DFVPA, includes an intimate partner relationship, family relationship or informal care relationship

Respondent: a person against whom a domestic violence protection order, or a police protection notice, is in force or may be made under the DFVPA 2012.

Restorative justice: a process where all parties with a stake in a particular offence come together to resolve collectively how to deal with the aftermath of the offence and its implications for the future.359

Risk assessment: a comprehensive evaluation that seeks to gather information to determine the level of risk and the likelihood and severity of future violence. Levels of risk should be continually reviewed through a process of ongoing monitoring and assessment.

Risk management: an approach to respond to and reduce the risk of violence. Risk management strategies should include safety planning, ongoing risk assessment, plans to address the needs of victims through relevant services (e.g. legal, counselling), and liaison between services utilising appropriate information sharing processes.360

Risk screening: a routine process to determine if domestic and family violence occurs to inform further actions, including referral and intervention.

SCAN: Suspected Child Abuse Network

Sexual Jealousy: is a type of jealousy evoked in response to an actual or perceived threat of sexual infidelity.

Special Taskforce on Domestic and Family Violence: was established on 10 September 2014 to define the domestic and family violence landscape in Queensland and make recommendations to inform the development of a long term vision and strategy for Government and the community to rid the state of this form of violence. The Special Taskforce’s Final Report, Not Now, Not Ever: Putting an end to domestic and family violence in Queensland, which made 140 recommendations, was submitted to the Queensland Premier on 28 February 2015.

The Act: within the context of this report refers to the Coroners Act 2003.

Victim: the person who was the primary victim of the domestic and family violence in the relationship and the person most in need of protection

Violent resistance: where one partner becomes controlling and violent, the other partner may respond with violence in self-defence. Within this typology, the violent resister does not engage in controlling behaviours.

359 Marshall, T. (1996). The evolution of restorative justice in Britain. European Journal of Criminal Policy and Research, 4, 210-43. 360 Department of Human Services. (2012). Family Violence: Risk assessment and risk management framework and practice guides 1-3. Melbourne: Author.

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Domestic and Family Violence Death Review and Advisory Board

2016–17 Annual Report