Olivia lives with the rare Kleefstra Syndrome.

Inquest finds gaps and flaws in the family violence system Analysis

Inquest finds gaps and flaws in the family violence system

This week the State Coroner, Judge Ian Gray, handed down his findings from the inquest into the tragic death of 11-year-old Luke Batty. Luke was killed by his father, Greg Anderson, at cricket practice in Tyabb, east of Melbourne, in February 2014.

Other than those of Greg Anderson, the inquest found that none of the actions of organisations or individuals, caused or directly contributed to Luke’s death. However, it identified a number of gaps and flaws in Victoria’s criminal justice and family violence processes and systems that need to be addressed.

Copies of the findings were provided to, the Royal Commission into Family Violence, among others, to inform its report in February next year, and to the Premier of Victoria, for his action.

Judge Gray made 29 important recommendations to improve the family violence prevention and response system. Some of these recommendations are summarised below.

System integration

The inquest found that although much work has been done through the implementation of the ‘integrated family violence system in Victoria’ to improve collaboration and information sharing, Luke’s death and other cases show there is much more work to be done. In his finding Judge Gray said:

“The evidence in this case is that no single agency held or assessed all of the information for the purposes of conducting risk assessments, and managing the risks posed by Mr Anderson. There was no:

  1. 360° information sharing
  2. Uniform approach to risk assessment
  3. Coordinated approach to risk-management and safety planning.”

Judge Gray found that although Luke’s mother, Rosie Batty, had contact with numerous agencies, actively seeking and receiving assistance from them, each agency’s involvement was “episodic, limited and not integrated with other agencies”.

He recommended, among other things, that all agencies operating within the integrated family violence system (including police, courts, child protection and family violence services) use the Common Risk Assessment Framework (CRAF), provide comprehensive training on how to undertake family violence risk assessment, share risk assessments in a way that is accessible to all elements of the system, and identify and remove any impediments to the sharing of relevant information.

It was also recommended that Victoria Police introduce a warning flag within their shared information system to identify ‘high risk’ family violence perpetrators.

For high risk perpetrators, the Risk Assessment and Management Panels (RAMPs) were highlighted as an important recent development. Judge Gray recommended RAMPs be rolled out in all areas of Victoria as soon as possible.

Perpetrator accountability

Judge Gray said “the fact is that the perpetrator ultimately controls the risk of family violence”. He said it is therefore critical that they are engaged, or forced to engage, with the family violence and the criminal justice system at every opportunity, to ensure they are held to account and receive appropriate treatment and support to change their behaviour.

Judge Gray found that while Mr Anderson may not have willingly engaged in behaviour change programs, there are other ways in which he could have been better held to account for his behaviour. These include:

  • Criminal matters being heard more promptly
  • Warrants being executed that may have resulted in him being held in custody
  • Bail conditions directing him to engage in treatment or counselling to address his mental health
  • Requirements to submit to medical assessment and treatment to identify the causes of his behaviour and appropriate interventions or treatments.

Judge Gray also recommended that Magistrates should have the capacity to mandate compulsory attendance, and timely access to and participation in Men’s Behaviour Change Programs.

Advocacy support

Luke’s mother, Rosie Batty, gave evidence that she would have been assisted in managing the risk posed by Greg Anderson, if she had someone consistently assisting her as she dealt with the various parts of the system.

She said “… I wish there was a way that people work with you through a journey of – rather than isolated incidences…” and “…you need more support than what are currently there for you, because really you’re just alone, to enforce all these things.”

Judge Gray highlighted evidence from Fiona McCormack from Domestic Violence Victoria and Catherine Plunkett from the Domestic Violence Resource Centre Victoria that the capacity of family violence services to undertake advocacy roles for women is limited, due to the large increase in referrals to them, and the limited funding they receive. Judge Gray recommended the Victorian government consider creating and resourcing family violence advocate positions, based on the successful United Kingdom model.

Child protection

The inquest found that “the Department of Human Services relied on Rosie Batty’s own courage and strength of character in substitution for a proper safety plan for Luke’s safety”.

A number of recommendations were made to improve the ability of the Department of Health and Human Services (DHHS) to identify children at risk and support families, including that in cases where one parent is assessed as ‘protective’ but the other is a risk, DHHS should support the protective parent to manage the risk posed by the other parent.

More information

Judge Gray’s full list of recommendations and his report from the coronial inquiry into Luke’s death is available on the Coroners Court of Victoria website.

Dr Chris Atmore, Senior Policy Advisor from the Federation of Community Legal Centres attended the inquest hearings and reported her observations on the Community Law Blog.

The Victorian Royal Commission into Family Violence continues its work, with findings expected in February 2016.