Police ‘missed opportunity’ before family-violence fatality: Coroner

Coroners Court of Victoria.

by Cam Lucadou-Wells

A Noble Park woman was fatally stabbed to death by her partner after a “missed opportunity” to charge the man over previous violence against her, a State Coroner has found.

The 33-year-old, who worked in the beauty industry, was stabbed to the neck and chest in the couple’s home on 29 July 2019 after three previous reports of family violence.

About 8.30am on 29 July, the partner called the victim’s mother – who thought she could hear her daughter screaming and telling him to “stop, stop” several times.

While on the phone, it was believed the man had stabbed the victim with a kitchen knife.

At one point, the knife blade broke off from the handle. He took a filleting knife from the kitchen and fatally stabbed the woman in the neck.

The alarmed mother woke up her son, who called triple-0 to request a welfare check.

The bloodied perpetrator was approached by police on Princes Highway Doveton that morning, saying “I sacrificed her, the house, the car, everything”. He admitted assaulting the victim with a knife.

The man was found not guilty by the Supreme Court of Victoria due to his mental impairment and sentenced to a 25-year custodial supervision order.

In a ruling on 20 May, State Coroner John Cain noted there had been four reported family violence incidents during the two-year relationship.

In 2018, the man allegedly punched the woman to the face multiple times while he was driving. He’d also punched the windshield causing it to shatter.

With significant bruising to her face and body, she was reportedly in fear for her life.

Both of them were placed on temporary treatment orders as compulsory hospital patients.

On his discharge, the man absconded to NSW – with criminal charges for the assault later dropped despite “significant evidence”, Judge Cain noted.

“This is concerning given that Victoria Police have a pro-prosecution position in relation to family violence offences to ensure that perpetrators are held to account.”

The man, who was jailed for driving offences in NSW, returned to Noble Park in June 2019.

He was interviewed by police over the 2018 charges, gave largely ‘no comment’ or that he could not remember. Police decided not to charge him.

A limited family-violence intervention order was in place at the time of the fatal stabbing.

The perpetrator had a history of violence against intimate partners, drug abuse and mental illness including schizophrenia, Judge Cain stated.

In the days leading up to the attack, police attended the house three times.

Once when the couple had been arguing after the man admitted cheating on her. Her parents called triple-0 to report she was intoxicated.

Police determined the man had breached the IVO – which led to the man voluntarily spending the night at his parents’ home.

The second time was when the man was found substance-affected, slumped on a toilet and taken by ambulance to hospital.

He didn’t stay for a full assessment, and police were called to do a welfare check.

They attended the couple’s home where the woman “declined any need for support” and said the couple were having a “break”.

On the night before the fatal attack, the man called triple-0 for police assistance, saying the woman was holding a knife and threatening to self-harm.

Attending police observed that the man was “rambling and behaving erratically”. He was taken to Dandenong Hospital for a mental health assessment, but cleared for release.

The woman was also cleared after a voluntary assessment, who admitted holding a knife to her own throat but denied she was suicidal.

She reported her concerns about the man’s welfare.

Judge Cain noted a Victoria Police family violence death assessment (FDA) found the earlier incidents – including the 2018 assault – were treated “primarily as mental health incidents” despite evidence of family violence.

It meant family violence risk assessments and specialist referrals weren’t provided, he stated.

A Professional Standards Command investigation found “some instances of alleged duty failure by the (police) members involved”.

“(It) discussed the challenging intersection between family violence and mental health, noting that incidents can have features of both.”

Judge Cain said in the five years since the victim’s death, Victoria Police had worked to improve its response to family violence, including where it intersects with mental health issues.

Legislation had also undergone “significant changes” in the meantime.

He found the issues identified in the FDA didn’t contribute to the victim’s death.

“However, I note that Victoria Police’s treatment of the January 2018 was a missed opportunity to prosecute (the man) and hold him to account for his behaviour.”