The Queensland advisory board tasked with reviewing domestic and family violence deaths has quietly stopped routinely analysing new cases, and has not looked into most of the latest deaths for more than two years.
Guardian Australia’s Broken trust investigation has uncovered evidence and allegations that raise concern about the way the coronial system investigates women’s deaths and the accuracy of Queensland’s DFV statistics.
Coroners have repeatedly made rulings that nothing more could have been done to prevent homicides, in the face of evidence of serious policing and system failures that have contributed to women’s deaths and the mounting toll.
Queensland’s Domestic and Family Violence Death Review and Advisory Board is considered a “critical” part of the state’s response to domestic and family violence. Its aim is to “prevent future avoidable deaths”.
The board has historically analysed comprehensive reports about all DFV-linked deaths, identified systemic issues raised by those cases, made recommendations for reform, and published detailed anonymised case studies in its annual report. Some of these have revealed significant police failures that would otherwise have not been made public.
But Guardian Australia can reveal the board has stopped routinely reviewing deaths. Its last two annual reports do not include detailed case studies and instead look at mostly historic cases that fit chosen “focus areas”.
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Prof Molly Dragiewicz, a DFV researcher, resigned from the board this year citing concerns about the “change in focus”.
“I am resigning due to the board’s change in focus away from comprehensive timely review of domestic and family violence deaths, publishing substantial annual data reports on those cases, making current case-based recommendations to strengthen systems responses to prevent future deaths, and publicising those findings to educate the public and professionals about domestic and family violence,” Dragiewicz wrote in her resignation letter.
Her letter said the board lacked representation from domestic and sexual violence services and First Nations experts. She said this “presents a challenge for meaningful case analysis and the formulation of pragmatic recommendations to improve practice, policy, and procedure to prevent future deaths”.
“Death reviews play an essential violence prevention role as the single most comprehensive and accurate data source on domestic and family violence cases and responses to them,” she wrote. “I hope that the board returns to its exemplary work fulfilling its core functions in the near future.”
Betty Taylor, the founder of DFV charity the Red Rose Foundation and a former death review board member, said she was concerned the board had stopped “centring women’s experiences”.
“We’ve got to hear survivors voices … we’ve got to listen to dead women. They’ll tell us more about what’s gone wrong than anyone. We can only do that by doing the most thorough reviews.”
The board is supported by a “unit” of coronial staffers and a representative of the Queensland police service, who review cases and provide reports to coroners and the board.
Guardian Australia has obtained a review of the unit from 2020 that found significant concerns about staff wellbeing, processes and a lack of expertise. Multiple people familiar with the unit’s work say its operation has become “significantly worse” since the review and have raised concerns that problems with cases are not being picked up.
The review found that the unit had been ineffective due to resource changes, a lack of staff and that staff were susceptible to psychological injury. For long periods, more than half the unit’s roles have been vacant.
“The unit holds a critical role in the state’s DFV response and it is therefore imperative to ensure it is set up to operate in a high-performance capacity within the intended organisational design,” the review found.
It also found the unit had no “fit-for-purpose” database. Data and other information about DFV deaths “used to support national decisions” was kept in an Excel spreadsheet. This practice continued long after the review.
The coroner’s court of Queensland did not respond directly when asked if the data was being kept in a spreadsheet. It said in a statement there had been “investment in leadership data capability” at the coroner’s court registry.
Kate Pausina, a former senior detective, worked periodically as the police liaison to the unit. She says that liaison position was often vacant, including at the time of the murders of Hannah Clarke, Doreen Langham and Kelly Wilkinson – cases in which there have been documented police failings.
“And they’re [just the] high-profile deaths that we’re aware of when no one was there,” she says.
“There was nobody there to go through the system of looking at reportable deaths every day to find out how many others would should have fallen within the scope.”
Pausina says on one occasion, when she returned from a four-week holiday, she found 18 deaths during that period in which there was a history of domestic and family violence but which “weren’t looked at or reported at all”.
A whistleblower from within the coroner’s court, Elsie*, reported concerns as part of a disclosure to the Crime and Corruption Commission in 2024.
“Queensland’s coronial system was under-resourced and failing to adequately support coroners and the bereaved,” Elsie said in her statement to the CCC.
“There were significant leadership issues in the coroner’s court, including ineffective communication, limited approachability, lack of accountability or transparency in decision making, failures to address staff concerns, and an urgent need to upskill most leadership personnel.”
Elsie alleged staff in the unit were “so traumatised and distressed one started to lose their hair in clumps. Another expressed suicidal thoughts. I was really scared someone would take their own life.”
A spokesperson from the coroner’s court said support for vicarious trauma was available to board members and staff.
The spokesperson confirmed that the board had decided to look at themed cases – rather than the latest – over the past two years, and that those had included some recent cases that fit the chosen theme.
“The work plan and approach of the board to its case review function is settled at the commencement of each financial year,” the spokesperson said.
In Australia, the crisis support service Lifeline is on 13 11 14 and the national family violence counselling service is on 1800 737 732. Other international helplines can be found via www.befrienders.org
Do you know more? Contact ben.smee@theguardian.com
