During the session she called for an Australian Death Review Team to get a national picture of domestic violence related deaths.
“I strongly believe that gathering high-quality data and information about the scale and nature of discrimination faced by people in our community is a critical first step to addressing this problem,” she said.
“Not only does a strong evidence base highlight what the issues are and who they affect, it enables us to monitor progress towards gender equality over time, identify successful initiatives as well as any barriers to progress for women.”
She added that one of the key principles underpinning the concept of acting with ‘due diligence’ is a duty to ensure that actions aimed at preventing violence against women are based on accurate empirical data.
Below we’ve shared an edited extract of Jenkins’ speech.
Domestic and family violence homicides reflect the most serious end of the spectrum of gender-based violence, with women making up the overwhelming majority of victims.
Historically, there has been a tendency to perceive these deaths as tragic, but isolated incidents.
In reality, they are usually preceded by a significant history of escalating physical and non-physical violence, a series of identifiable risk factors and, often, as in Andrea’s case, significant failures on the part of services to intervene effectively or at all.
Behind each homicide is a personal story of tragedy and loss. Examining these deaths collectively, as well as the factors and system failures which precede them, can teach us important lessons.
Currently, this is a function performed in some Australian states by domestic and family violence death review teams. The Human Rights Commission has identified a need to expand this work to all jurisdictions and to report nationally on findings, to ensure greater awareness among government and policy makers of the particular factors and indicators around domestic violence related homicides.
What is domestic and family violence death review
The first domestic and family violence death review team was established in San Francisco in the early 1990’s after a 28 year old woman named Veena Charan was murdered by her ex-husband Joseph.
For over a year before her death, Veena had interacted with various services and agencies in San Francisco, making complaints to police, seeking restraining orders and custody orders. Joseph had repeatedly violated the restraining order and had also made attempts to kidnap the couple’s son.
A restraining order was in force when Joseph murdered her in front of their son at his elementary school.
The fact that this happened so publicly, and that Veena had been killed despite her repeated attempts to seek help, prompted the Commission on the Status of Women to conduct an investigation into service gaps which might exist in relation to domestic violence which might have prevented this case from escalating to a murder.
A review into the factors surrounding Veena’s killing highlighted that there were innumerable structural and systemic failures and barriers which preceded her death.
Over the past nine years, we have seen the establishment of similar functions in Australia, with the first death review team being founded in Victoria in 2009.
Teams have since been established in most jurisdictions, with the exception of the Northern Territory, Tasmania and the Australian Capital Territory.
Although the death review teams vary in size and operate slightly differently in each jurisdiction, they share a common function.
They view domestic violence deaths ‘as a connected group’ rather than isolated events
They operate with the philosophy that recommendations for improvement in systems and services provide opportunities to prevent similar deaths occurring in future.
Death review is a forensic investigation into the complex array of factors leading to domestic and family violence deaths. Death Review Teams look at the circumstances leading up to the death, including the history of service engagement and interactions with government and non-government agencies.
They examine the ways in which systems and services performed when they were most challenged.
Death Review Teams are the only entities to collect data on all domestic violence deaths within a jurisdiction. Using a common definition of domestic and family violence death, they collect categories of data about a range of characteristics.
The Teams review deaths regardless of whether there has been a coronial inquest or not.
Although there is some national data collected and reported on by the Australian Bureau of Statistics and the Australian Institute of Criminology, neither of these agencies has access to the depth of information that death review teams do.
Death reviews identify patterns of deaths and can detect vulnerable groups or lethality factors. If there are clusters of deaths amongst a cultural group or located in a geographic area, the death review can distinguish trends and recommend action to target services and support to these areas.
For example, available data shows us that Aboriginal and Torres Strait Islander women are five times more likely to be homicide victims than non-Indigenous women. Likewise, women from culturally and linguistically diverse backgrounds have particular vulnerabilities in relation to domestic violence.
More research needs to be done to map the trends and patterns of these vulnerabilities. Death reviews can map demographic patterns as well as lethality or ‘risk’ factors.
Recommendations made by Death Review Teams can be directed to all government and non-government agencies with a role in preventing or protecting against domestic violence death. Some recommendations are published in Coronial findings, public reports and in some jurisdictions, recommendations are tabled in Parliament.
Why domestic and family violence death review needs to be national
While Coroners operate in Tasmania, the Australian Capital Territory and the Northern Territory, these jurisdictions do not have established entities to collect death review data on all domestic and family violence deaths.
It is therefore not possible to compare deaths Australia wide.
There is good reason to collate data nationally. Domestic violence does not always fall within jurisdictional borders and families cross borders to escape violence. In an encouraging development, since 25 November 2017, all domestic violence protection orders are automatically recognised and enforceable across Australia.
Death review data that is national in scope may eventually be able to assess the coherence and communication of systems across jurisdictions.
The national picture is also important because federal agencies have contact with victims and perpetrators. Without a federal body, there are limitations on monitoring coronial or death review recommendations made to agencies such as the Federal and Family Courts or Government Departments such as Centrelink.
It may also encourage jurisdictions to learn from one another. For example, where a systemic failure is identified in relation to a death in New South Wales, other states and territories might examine their own policies and procedures to identify whether similar issues exist in their jurisdiction, giving them the potential to address these issues before a homicide occurs.
All of this information is extremely valuable for decision-makers with influence on policy, law, procedures and funding allocations. It has the potential to significantly improve outcomes for victims of family and domestic violence.
Over the past two years, work has commenced to report nationally on this data.
The Australian Domestic Violence Death Review Network was established in 2011 and is made up of members from each of the jurisdictions with a death review function.
To date, the Network has developed a set of principles that underpin the effective functioning of the death review process. In order to create a consistent national approach, newly established Death Review Teams or functions should be guided by the same principles.
They have also developed a Homicide Consensus Statement which defines the inclusion criteria adopted by the Network for domestic and family violence homicide as well as a Data Collection Protocol for use in establishing a national data set.
The Network will publish a report later this year with the first results of their national data set. This is important work and the Network are to be commended for this.
However, they do this work in addition to their existing death review functions, and receive no additional funding or support to perform this function, which impacts on the capacity to report in a regular and timely manner.
Recommendations from Commission’s phase one report
In 2016, the Commission released our first report on this issue, which made a total of ten recommendations.
We recommended that the domestic violence death review function be expanded to the jurisdictions where it does not currently exist – the Northern Territory, ACT and Tasmania.
We also recommended that efforts be undertaken by the government to ensure that meaningful national level data is collated so death prevention measures are based on empirical evidence, including evidence from domestic violence death reviews.
In relation to the monitoring of recommendations made, the Commission recommended that the Government establish an entity with a mandate and function to monitor and report on national domestic violence deaths and the implementation of coronial recommendations made to federal agencies.
Second phase of the work
In light of these recommendations, the Commission has been asked by the Federal Department of Social Services to conduct a second phase of this work which:
* Brings together and analyses all existing data and recommendations made in relation to domestic violence deaths, and
* expanding the Death Review function to all eight jurisdictions,
* establishing a national function to collect and report on data and monitor recommendations made.
This work has been funded by the Department under the Australian Government’s National Plan to Reduce Violence against Women and their Children.
Over the past 12 months, the Commission has been working with death review teams and conducting research to determine the best way of approaching a national system of death review.
In order to bring together our second report on this topic, we have conducted a desktop review of available coronial findings relating to domestic and family violence related homicides and analysed key themes and recommendations which emerged.
We have done the same for all data and recommendations made in existing death review reports.
We have also identified other existing sources of data about domestic violence deaths from the Australian Bureau of Statistics, the Australian Institute of Criminology and the National Coronial Information Service.
It is by no means a comprehensive view of the issues. However it is the first attempt to bring together this information to provide a national picture of domestic and family violence related homicides, and contains some important findings.
Key findings in relation to domestic and family violence related deaths
I thought I might briefly highlight some of the key findings and system gaps which have been identified as a result of our review.
As I said at the start of this speech, women make up the overwhelming majority of victims of domestic and family violence related homicide.
However, what has also been identified is that the majority of murders of women in Australia can be attributed to family violence related homicides.
The data also indicates that intimate partner homicides make up the majority of homicide deaths which occur in a family or domestic violence context.
Men are, overwhelmingly the perpetrators of intimate partner homicides.
A key finding which highlights the dynamics around violent relationships is that while women who were killed by an intimate partner were most often the primary domestic violence victim in the relationship, in cases of intimate partner homicide where the victim was a male, the deceased was more commonly the perpetrator of domestic violence in the relationship.
A key risk factor in intimate partner homicides was recent separation, or an intention to separate.
We have also examined available data on domestic violence homicides of other family members. Devastatingly, children under the age of 18 are the most likely victims of this category of homicide.
Aboriginal and Torres Strait Islanders are overrepresented as victims of family and domestic violence homicides. In Western Australia, for example, where 3.3% of the population are Aboriginal, they made up 35% of people who died in domestic and family violence homicides between 2012 and 2017.
Domestic and family violence homicides are also more likely to occur in rural and regional areas – possibly highlighting issues in relation to service gaps and provision in those areas.
Reporting from death review teams can also highlight the presence of particular risk factors prior to a death. Threats of suicide, controlling behaviour and jealousy over a new partner have all been found to be behaviours often exhibited by perpetrators before committing intimate partner homicides.
Our review of recommendations made by coroners and death review teams has highlighted some key systemic failures.
- It is clear that individuals dealing with domestic and family violence victims – such as police, health professionals and even domestic violence workers – do not always have a deep knowledge and understanding of family and domestic violence issues, which can lead to inadequate support being provided to victims.
- It is also evident that sharing of information between services and government departments is often poor, meaning that there is no agency or agencies with a holistic understanding of the nature of violence being experienced.
- The complexity of the legal system can weigh very heavily on victims of domestic violence, who are often relied upon to enforce protection orders in that they are usually the ones required to call the police in the event a breach.
We have all read of the individual stories of these homicides. For example Zahra Abrahimzadeh, who left her husband after more than 20 years of violence and abuse, and just a year later was stabbed to death in front of 300 witnesses inside the Adelaide Convention Centre.
In 2014, Greg Anderson killed his 11-year-old son, Luke Batty, at a cricket ground in Victoria.
In September 2015, a young woman named Tara Brown died of catastrophic head injuries inflicted by her estranged partner and only weeks later on the Gold Coast, Karina Lock was shot and killed by her husband in a restaurant in front of 30 people.
In January this year, British backpacker Amelia Blake was killed by her partner in a murder-suicide in their apartment in inner Sydney.
And just last week we heard reports of what appears to be a horrific family violence homicide in Margaret River, involving the murder of six family members and the suicide of one other.
These are the stories that haunt us, that galvanise public opinion and that prompt political leaders to take action.
These stories also focus public attention on the issue of domestic and family violence homicides and filicides in Australia.
However, it is clear that national data and reporting are key to providing law and policy makers with the information they need to better target services and interventions.
What our review has identified is that many of the service gaps and failures that exist in Australia today echo the findings of the investigation into the murder of Veena Charan in San Francisco almost 30 years ago.
I also think it highlights the importance of undertaking more prevention work to address the attitudes and inequality underpinning this violence.
In 2016, Judge Greg Cavanagh held an inquest into the unrelated deaths of two Aboriginal women, Wendy Murphy and Natalie McCormack, who were killed by their intimate partners in the Northern Territory. Reading his comments, Justice Cavanagh’s frustration is apparent. He said:
Domestic violence is a contagion. In the Aboriginal communities of the Northern Territory it is literally out of control. As a Local Court Judge I witness it most days. As the Coroner I see the terrible lives these women endure and their horrifying deaths.
We are now into the third quarter of The National Plan to Reduce Violence against Women and their Children 2010 – 2022.
However, any positive impact on domestic violence in the Aboriginal community is difficult to detect. It is time to take stock. To re-evaluate the strategies dealing with domestic violence in Aboriginal communities. 
We must have a national evidence base on which to base actions to address domestic violence homicides.
The Government’s investment in this issue is a recognition of the vital work that coroners and domestic and family violence and child death review teams have done to improve our understanding of domestic homicide.
However the evidence we do have is telling us that what we have been doing is not having a significant impact on the outcomes for women and children who experience domestic violence.
It is critical that we learn the painful lessons arising from past tragedy in order to prevent avoidable deaths in the future.
If you or someone you know is impacted by sexual assault or family violence, call 1800RESPECT on 1800 737 732 or visit www.1800RESPECT.org.au
In an emergency, call 000.