Deceased
Kunmanara May
Demographics
23y, female
Date of death
2015-05-25
Finding date
2024-08-29
Cause of death
stab wound of the chest
AI-generated summary
Kunmanara May, aged 23, was killed by her partner SK in a domestic violence homicide in 2015. Multiple agencies—South Australia Police, Families SA, Aboriginal Family Support Service, and Centacare—knew of escalating violence over two years but failed to intervene effectively. Police did not pursue investigations despite third-party reports, documentation was poor, staff lacked training in family violence, and information sharing between agencies was inadequate. The Family Safety Framework meetings proved ineffective at coordinating protective action. While systemic failures are evident, the coroner found preventability could not be established because Kunmanara's reluctance to cooperate and complex cultural and psychological factors limiting service effectiveness could not be definitively overcome.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 28th, 29th, 30th and 31st days of January, the 3rd, 4th, 5th, 6th and 26th days of February and the 11th day of March 2020 and the 29th day of August 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Kunmanara May.
The said Court finds that Kunmanara May aged 23 years, late of Yalata Community, Eyre Highway, Yalata died at Yalata, South Australia on the 25th day of May 2015 as a result of stab wound of the chest. The said Court finds that the circumstances of her death were as follows:
1.2. She was the daughter of Troy Ware and Janet May and had two siblings. Born at the Queen Elizabeth Hospital, she soon moved to Oak Valley to live with her grandmother, Margaret May.
1.3. Throughout her childhood, Kunmanara May split her time living with family between Yalata and Oak Valley. She grew up in a loving family environment with no domestic violence.
1.4. Kunmanara May attended school in Oak Valley and Yalata and also spent about two years at Woodville High School in Adelaide while she lived with her godmother, Julieana Smart, a former nurse in the Yalata Community.
1.5. Her mother belonged to the Wirangu People. Kunmanara May’s first language was Pitjantjatjara, and she also spoke English.
1.6. Kunmanara May was known as a cheerful and bright girl with many friends, who was dedicated to her education and always willing to help her family. She was described as kind, quiet and gentle. She did not drink alcohol. Until her relationship with SK,1 the man who would later be convicted of her murder, she was happy, open and full of life.
1.7. SK’s mother was living in the Yalata Community when SK came to stay with her.
Kunmanara May and SK began a relationship that lasted about two years, until her death.
1.8. Early in their relationship, Kunmanara May fell pregnant and stayed with her mother Janet in Oak Valley until the birth of their son, C in July 2013. After their son’s birth, Kunmanara and SK, along with their child, moved into a house in the Yalata Community, where they lived with SK’s mother, GK and stepfather, John Mungee.
1.9. Kunmanara May was a devoted mother and her young son was her number one priority.
However, her relationship with SK was plagued by domestic violence.
1.10. In the early hours of Monday 25 May 2015, at just 23 years old, Kunmanara May was murdered by SK.
1.11. Ms Renelle Bryant,2 Kunmanara May’s aunt, witnessed some of the events leading up to her death. Ms Bryant was at the house with Kunmanara, SK and their son when an argument broke out between Kunmanara and SK. SK struck Kunmanara twice in the back ‘really hard’ after she asked for the phone. Ms Bryant fled the house around 5:30am as Kunmanara yelled for SK to stop.
1.12. When Ms Bryant returned later that morning, she saw Kunmanara May lying on the couch, unresponsive, with SK apparently trying to wake her up. Ms Bryant ran scared out of the house again.
1.13. Kunmanara May’s cause of death, determined by post-mortem examination3 performed by specialist forensic pathologist Dr Stephen Wills of Forensic Science South Australia, 1 A youth, at the time of Kunmanara May’s murder, whose name is suppressed 2 Exhibit C4 3 Exhibit C2
was ‘stab wound of the chest’. This I find to have been Kunmanara May’s cause of death.
1.14. SK later pleaded guilty to Kunmanara May’s murder and was sentenced to life imprisonment with a non-parole period of 10 years.
2.2. An Inquest was held to explore the circumstances of Kunmanara May’s death. Whilst the individual directly responsible for Kunmanara’s death, SK, has been convicted and sentenced for that crime in the Supreme Court, the focus of the Inquest was on the government and non-government agencies and service providers that interacted with Kunmanara, in the years preceding her death, in relation to the allegations of domestic violence perpetrated by SK.
2.3. Various agencies including South Australia Police, Families SA (which later became the Department for Child Protection), and the Aboriginal Family Support Service had extensive dealings with Kunmanara May. Those agencies had differing understandings of the extent of the domestic violence relationship, ranging from quite comprehensive to superficial, and communication between them was poor. In the face of this, SK continued to inflict violence over many months without interference or positive action.
This Inquest considered whether her death could have been prevented if any of the agencies aware of that domestic violence had assumed a more vigorous role in the protection of Kunmanara.
2.4. The standard of proof to be applied in making coronial findings is the civil standard, the balance of probabilities. In considering making findings which imply or express criticism of individuals, I am guided by the principles enunciated in Briginshaw v Briginshaw4 and I shall not make such a finding unless the evidence leads me to a comfortable level of satisfaction that the finding should be made.
He commenced working at Yalata in 2012 and was officer in charge from June 2014 until late 2015. As I understood it, Brevet Sergeant was his rank during his time as Officer in Charge, but his substantive and usual rank is Senior Constable. I have referred to him throughout as Brevet Sergeant.
Senior Constable Justine Van Hout is also an employee of South Australia Police (SAPOL). From July 2014 Senior Constable Van Hout commenced aiding in Family Violence Investigations from Ceduna as well as performing her normal duties. Then on 24 December 2014, Senior Constable Van Hout was appointed to the position of Family Violence Intervention Officer when it was first created as a new position in Ceduna.
Joanne Badke was the CEO of Tullawon Health Service. She is a Palawa woman from Tasmania, raised in Central Victoria, who worked in multiple Aboriginal communities prior to commencing her job as CEO of Tullawon Health Service at Yalata in 2014.
Rikki Iversen was an Aboriginal Family Support Service (AFSS) Support Worker, who had conduct of Kunmanara May’s case while AFSS had an active referral from Families SA. She commenced working at AFSS in January 2012 and was assigned Kunmanara’s case on 3 February 2013.
From October 2013 Kathryn Meier was employed by Centacare Catholic Family Services, Diocese of Port Pirie as the Program Manager Regional Domestic Violence and Aboriginal Family Violence, based at Ceduna.
Senior Constable Carly Wilson was a Family Violence Intervention Officer based at Port Lincon between 2012 and December 2016.
Ms Pia Richter was the Manager of the Ceduna office of Families SA (as it then was) between January 2013 and February 2017.
Detective Brevet Sergeant Scott Price was the Officer in Charge of Ceduna CIB from 2010 until October 2018. In that role his duties included rostering and vetting of files, in addition to his general roles as an investigator.
Detective Senior Sergeant First Class Walter Conte was, at the time of the Inquest, the Officer in Charge of the Multi-Agency Protection Service (MAPS) and had held that position since November 2018. He provided extensive evidence regarding MAPS, an advanced information-sharing model designed to manage domestic violence and related child protection issues across the State.
Fiona Mort was the Director of the Office for Women, of the Government of South Australia. The Office for Women collaborates across government and the community, working towards achieving gender equity and positive change for South Australian women. That work includes developing policy and advice which aids policy makers to make informed decisions on issues that affect women in South Australia.
3.2. In addition to the oral evidence, the Court received into evidence records from AFSS, Families SA, Tullawon Health Service and the Ceduna Hospital. Also tendered into evidence was a Significant Incident Investigation (SII) Report prepared by Inspector Kevin Lawton of SAPOL, some of which has been relied upon for the purposes of this Finding.
3.3. I also received into evidence in excess of 40 affidavits from a number of witnesses who were not called to give oral evidence. I will not list them all, but I have carefully considered each affidavit.
3.4. In this Finding I shall not summarise all the evidence tendered or heard at the Inquest, but refer to it only in such detail as appears warranted by its forensic significance and the interests of narrative clarity. It should not be inferred from the absence of reference to any aspect of the evidence that it has not been considered.
3.5. With the leave of the Court, the following counsel appeared to represent witnesses and interested parties: Mr S Plummer, Counsel Assisting; and • Ms L Gavranich, Counsel for the Commissioner of Police, the Department of Child • Protection, and Ms P Richter.
3.6. Following the conclusion of the Inquest, I received comprehensive oral submissions from both counsel, and written submissions from Ms Gavranich.
4.3. Yalata has a fluctuating population in the vicinity of up to about 350 people and has limited public resources, but does have a police station, medical clinic and educational facilities.
4.4. The Yalata Community is an Aboriginal community comprised of Anangu with a deep connection to the Lands on which they live and who speak Pitjantjatjara language. The Yalata Lands are an Indigenous Protected Area managed by the Yalata Anangu Aboriginal Corporation.
4.5. Joanne Badke, in her evidence, described Yalata as a remote community that has stronger traditional cultural practices compared with rural or urbanised Aboriginal communities.5 She explained that these cultural practices included initiation and ‘sorry business’, but also included some violence towards each other. She said that it was a shock to her as an Aboriginal person.6 In her affidavit tendered at the Inquest, she stated that: ‘Generally prior to the death of (Kunmanara) May the local Aboriginal community did not commonly report domestic violence. Some of this was due to fear of repercussions from the perpetrator and their families, but mainly because of the belief that it was acceptable within the traditional culture, particularly if the male had been initiated as a Wati’.
SK was considered a Wati and was working with and residing with John Mungee in this capacity.
‘Status plays a huge part in the ability and willingness of community members to report any incidents of concern, domestic violence, drug abuse, alcohol abuse and other illegal activities..’. 7 5 Transcript, page 702 6 Transcript, page 702 7 Exhibit C28
4.6. Prior to the death of Kunmanara May there was a reluctance among the Yalata Community to speak to police about issues relating to domestic violence, and a preference to deal with it from a traditional perspective.
4.7. Ms Badke explained that there has been change in the community since Kunmanara May’s death. Her evidence was that the belief that violence towards women is part of culture is changing. She explained that it is a mistaken belief that violence is part of culture, but it has taken this incident and community leaders to initiate a shift in this way of thinking. Ms Badke explained that there is now what she described as ‘a big cohort on community that are fighting to change that for the whole community’.8
4.8. In her opinion, it was Kunmanara May’s death that precipitated this change.
4.9. Police resources at Yalata in 2014 and 2015 4.10. At the relevant time (throughout 2014 and 2015), the Yalata Police Station was staffed by three members – the Officer in Charge, Brevet Sergeant Johnson, together with Constable Marc Hutchins and Community Constable Bronson Laughton.
4.11. Yalata was a satellite station of Ceduna and Yalata officers reported to the Officer in Charge at Ceduna. Yalata was thus one of a number of stations that formed part of the SAPOL Eyre & Western Local Service Area (EWLSA).
4.12. The EWLSA was formed in July 2009 when the West Coast Local Service Area and Mid-West Local Service Area were merged. The EWLSA was divided into three major 24-hour patrol base police stations, including Port Lincoln (headquarters), Whyalla and Ceduna, each with a number of satellite ‘outstations’.
4.13. The distance between stations at Whyalla and Port Lincoln is 260 kilometres, from Whyalla to Ceduna is 460 kilometres and from Port Lincoln to Ceduna is 450 kilometres. Port Lincoln CIB serviced both Port Lincoln and Ceduna, although there were two CIB members based at Ceduna, who reported to the Officer in Charge of the Port Lincoln CIB, Detective Sergeant Robert Humphries.
8 Transcript, page 703
4.14. When it was first formed, there was only one Family Violence Intervention Officer (FVIO) position in the EWLSA; that officer was located at Whyalla and only serviced domestic abuse matters at the Whyalla end of the LSA.
4.15. In mid-2010 Senior Constable Sonya Bryson was seconded into what was initially a temporary FVIO role at Port Lincoln CIB. In August 2012 Senior Constable Carly Wilson commenced in the first substantive FVIO position in Port Lincoln that had been created earlier in the year. When Senior Constable Wilson commenced in her role as FVIO, Senior Constable Bryson ceased in that role and undertook other duties.
4.16. This Port Lincoln FVIO position also included servicing the Ceduna area, as there was no FVIO position there. Due to the distance involved between Port Lincoln and Ceduna, this was primarily done remotely and involved the FVIO conducting enquiries via phone and having uniform staff conduct enquiries to physically locate victims or undertake face to face contact. The FVIO would periodically travel to Ceduna to conduct enquiries which required face to face contact.
4.17. In November 2012 Senior Constable First Grade Mary Octoman was transferred from a part-time general CIB investigator position at Port Lincoln to an FVIO position, after a holding position was created at the request of the then Local Service Area commander.
4.18. In mid-2014 Senior Constable Justine Van Hout was seconded into an FVIO role at Ceduna, which was initially temporary, but became a substantive position towards the end of 2014.
4.19. General Order – Domestic Abuse 4.20. The SAPOL Domestic Violence Strategy outlines SAPOL’s corporate commitment to policing domestic violence and emphasises the importance of intervention, ensuring the safety of victims and delivering effective responses to prevent further harm.
4.21. This strategy underpins General Order - Domestic Abuse, with fundamental philosophies which articulate that ‘employees adopt a professional, curious, questioning and empathetic approach to their duties’ and that members must take ‘positive action’ to ensure the safety of victims and their children, whilst holding offenders accountable for their actions.
4.22. General Order - Domestic Abuse was originally published in 2007 and has been the subject of regular review and update. The versions in question throughout the periods of interaction by police with Kunmanara May were approved by the Commissioner of Police on 17 January 20149 and 22 October 2014.10
4.23. The Family Safety Framework (FSF) 4.24. The FSF is a coordinated service response of the South Australian Government to domestic, family and sexual violence, which was implemented throughout the State in November 2013.
4.25. It was developed under the auspices of the South Australian Government’s Women’s Safety Strategy and Keeping Them Safe - Child Protection Agenda, to drive improved, integrated service responses to violence against women and children in South Australia.
4.26. The FSF seeks to ensure that services to families most at risk of violence are provided in a more structured and systematic way, through agencies sharing information about high-risk families and taking responsibility for supporting these families to navigate the system of services.
4.27. The FSF Practice Manual11 and FSF Practice Manual Modules were developed by the Office for Women. The FSF is underpinned by multi-agency FSF meetings which occur every two weeks to develop coordinated responses for people experiencing a high risk of harm due to domestic, family or sexual violence.
4.28. The purpose of the FSF meetings from SAPOL’s perspective was set out in the General Order - Domestic Abuse12 which states that ‘Family safety meetings are local meetings where relevant agencies gather on a regular basis to share information and implement a positive action plan in relation to high-risk cases of domestic and family violence’.
4.29. FSF meetings in EWLSA 4.30. The FSF commenced in Port Lincoln in June 2012.
4.31. The position of the FSF meeting Chair is, ‘where possible filled by the Sergeant in Charge of the Family Violence Investigations Sections (FVIS) of SAPOL. In country 9 Exhibit C46a 10 Exhibit C46a 11 Exhibit C46i 12 Exhibit C46f, page 29
regions the responsibility rests with the Officer in Charge of the local Criminal Investigation Branch or their delegate, which is generally the Family Violence Intervention Officer’. At EWLSA this role was undertaken by FVIS members at the time preceding the murder.
4.32. When the meetings first commenced in Port Lincoln, the role of Chair was shared between Senior Constable Bryson and Senior Constable First Class Mary Octoman, both general CIB investigators at Port Lincoln CIB.
4.33. In August 2012 the FSF meetings were chaired by Senior Constable Carly Wilson who was appointed to the position of FVIO.
4.34. On 16 July 2013, Senior Constable Wilson was appointed as the SAPOL representative and Chair of the newly established FSF Committee in Ceduna. While she attended the first meeting in person, it was agreed by the Committee that she could fulfill her role remotely via video conference from Port Lincoln Hospital. This decision was made due to the considerable travel time required for personal attendance (a four-hour drive each way). Meetings took place fortnightly at Ceduna Hospital, utilising video conferencing facilities, with minutes being recorded by a representative from Victim Support Services.
4.35. In July 2014, Senior Constable Van Hout, who had previously served in Ceduna Operations (patrols), began assisting Senior Constable Wilson in Port Lincoln while continuing her general duties (patrol) role in Ceduna. Her responsibilities included many tasks typically handled by a FVIO, including participation in FSF meetings.
4.36. Senior Constable Wilson continued to chair the Ceduna FSF meetings remotely from Port Lincoln, with Senior Constable Van Hout assuming an operational FVIO role in Ceduna.
4.37. In the latter half of 2014, EWLSA management identified a service gap in family violence and domestic abuse due to the distance Senior Constable Wilson had to travel and the temporary nature of Senior Constable Van Hout’s secondment. Consequently, a new FVIO position was established and advertised, and Senior Constable Van Hout was appointed to this role on 24 December 2014.
4.38. Senior Constable Van Hout took over the role of FSF meeting Chair at the time she commenced in the substantive FVIO position (December 2014).
4.39. Multi-Agency Protection Service (MAPS) 4.40. In December 2013 the Commissioner of Police established the MAPS project team, partnering with agencies including SAPOL, the Department for Education and Child Development, the Department for Correctional Services, SA Health and the Department for Communities and Social Inclusion. The goal of MAPS was to reduce the incidence and impact of domestic violence and child abuse through effective information sharing.
4.41. MAPS was launched in July 2014 bringing together the staff from SAPOL, Families SA (as it then was – now DCP), SA Health, Housing SA and the Department for Correctional Services in a co-located setting to promote collaboration, information sharing and a coordinated response to high-risk domestic violence cases. Similarly to the FSF, MAPS focusses on information sharing and tasking actions to participating agencies.
4.42. However, unlike the FSF, MAPS only receives referrals from SAPOL (not other agencies) based on daily downloads of Police Incident Reports (PIRs) and Domestic Abuse Reports (DARs). Each report is associated with a risk assessment conducted by the police officer in the field, categorising the referral as standard, medium or high risk.
High-risk referrals undergo a ‘mapping’ process, where information from each agency is shared during a tactical table discussion, and actions are assigned accordingly.
4.43. The effectiveness of the MAPS system depends on police officers in the field submitting PIRs or DARs. If these reports are not submitted, MAPS will not be alerted to the incidents. Additionally, the reports must contain sufficient detail to enable the MAPS triage team to assess the risk factors accurately and be accompanied by a properly completed risk assessment.
4.44. One of the most notable features of the MAPS system is its ability to assign tasks to various agencies throughout the mapping process. This ensures that early intervention actions aimed at breaking the cycle of domestic abuse are prioritised and executed by different government agencies.
Statements of various individuals who witnessed violent and controlling behaviour by SK against Kunmanara were obtained during the SAPOL investigation conducted after Kunmanara’s death and were received as evidence.
5.2. An aunty of Kunmanara May reported that on each occasion that she stayed with the couple, she saw them arguing. On almost every day she saw SK hit Kunmanara with either his fists or a broom stick or some other kind of stick. When he used a stick he would hit her around her back and legs and she would be crying.
5.3. John Mungee13 is SK’s stepfather and Kunmanara May’s cousin. Kunmanara and SK resided with him and SK’s mother, GK. He saw them have some arguments during which he would try to keep them apart. In January of 2015 he had planned to drive SK to Adelaide to give the couple a break from each other.
5.4. Jaleen Miller14 was the Manager of the Mothers and Babies Clinic at the relevant time.
In August 2013, Ms Miller spoke with AFSS and Kunmanara May in relation to forming a case plan as Kunmanara had been abused by SK. In about November 2013 Ms Miller observed Kunmanara with a black eye, and she disclosed that her eye had been hurt in a fight with SK. Ms Miller also heard reports from other people in the community that SK had cut Kunmanara’s hair but Kunmanara denied this.
5.5. Jane H Williams15 was a member of the community and volunteer at the Mothers and Babies Clinic. On one occasion Ms Williams observed Kunmanara May with marks, scratches and very red eyes. She had many conversations with Kunmanara because she believed she was a victim of domestic violence.
5.6. Russell Bryant16 was the Minister of the Yalata Lutheran Church and is married to Doris Bryant, the sister of Kunmanara May. On Christmas Day in 2014 Mr Bryant observed Kunmanara come into the church with her head covered by the hood of her jumper. He knew something was wrong because she was covering her right eye and he saw that her eye was very bruised and swollen. He told his wife, who spoke to Kunmanara, who did 13 Exhibit C10 14 Exhibit C12 15 Exhibit C13 – Now so referred to, for cultural reasons 16 Exhibit C14
not want to talk to Russell because she did not want Russell to contact the police or Families SA (FSA) and she thought she might have to leave the community.
Kunmanara had come running to Mr Bryant’s house four or five times over the two years preceding her death. She was scared and told other family members why she was.
Mr Bryant also observed Kunmanara holding her side as if she was in pain. He knew that SK was hurting Kunmanara but she would often sneak out to see SK.
5.7. Janet May17 is Kunmanara May’s mother. Kunmanara disclosed to her mother that SK would always hit her. She said that John Mungee and GK, whom Kunmanara had also told, would keep it quiet. Janet May also observed Kunmanara to have a black eye on one occasion. When Kunmanara stayed with her grandmother Margaret, SK would go around and throw rocks at the house harassing them. None of this was reported to police. Kunmanara’s mother stated that she kept a lot of things to herself and specifically told her that she did not want people to know about her and SK. She did not want to tell her mother about her problems. Janet May said that every time her daughter would have an argument with SK, she would stay with her mother who would tell her to leave him.
5.8. Marilyn Jebydah18 was a relative of Kunmanara May who had known her since she was little baby. Kunmanara lived with her for a while and so did SK. Ms Jebydah was told several times that Kunmanara was being hit by SK. She heard arguments and, although she did not see any fighting, she thought Kunmanara was hit a couple of times because she heard it. Ms Jebydah reported a number of incidents occurring between Kunmanara and SK to AFSS worker Ms Iversen. Ms Iversen encouraged Ms Jebydah to report these incidents to police, but she sensed a reluctance from her to do so.19
5.9. Juanita May20 was the niece of Kunmanara May. Ms Juanita May saw SK punch Kunmanara around the eyes twice. On another occasion she witnessed SK throw rocks, and a cup which hit Kunmanara in the head. She saw Kunmanara bleed and cry. She informed Ms Jebydah of this incident. She saw SK hurt Kunmanara on two other occasions.
17 Exhibit C15 18 Exhibit C17 19 Transcript, page 851 20 Exhibit C18
5.10. Sometimes Kunmanara May told people close to her of the violence. It was common for her to tell those people and those who saw violence that she did not want anything reported to police and did not want people to know about it. One of the reasons which has emerged is that she was afraid that C would be removed from her care.
5.11. It was not a focus of this Inquest to identify all of individuals who knew of SK’s violence towards Kunmanara May, nor to analyse the reasons and consider how a culture of not bringing incidents of domestic violence in a remote Aboriginal community to the attention of authorities, particularly police, might be changed. For this reason, the individuals were not called as witnesses. Their statements allow me to give an account of the violence endured by Kunmanara during the relationship.
5.12. Between 2013 and 2015, when the violence was occurring, no formal reports were ever made to police.
5.13. During the Inquest it became apparent that there was a reluctance amongst community members to report allegations of domestic violence. Some of the reasons for that reluctance were elucidated although, I acknowledge, not directly by community members.
5.14. Joanne Badke gave evidence that status is relevant. She explained that people within the community can be reluctant to report anything against a member of a ‘leader family’ out of fear of repercussions. Ms Badke said that those leader families are ‘high profile families’ and are usually represented on leader groups, local councils and boards. She said that this issue exists ‘everywhere’, ‘but is more prevalent … at Yalata because of the violence reactions that can happen to families’.21 This violence includes the throwing of rocks. Ms Badke explained that part of the difficulty understanding this issue is that some of the violence comes from cultural traditions and some do not. She said that this violence and reluctance to report also stems from a general fear of people being taken ‘off country’. She explained that is a very real fear for members of the community who have a real connection to country.22
5.15. Brevet Sergeant Johnson explained that when he started as the Officer in Charge, police arrested a lot of males for domestic violence who were subsequently refused bail. This 21 Transcript, page 708 22 Transcript, page 710
had an impact on the victim as the family of the accused would give the victim what he described as a ‘really difficult time’.23
5.16. There were also some challenges for police seeking information or hearing of matters, as a result of cultural constraints, on who could speak on another person’s behalf.
Senior Constable Van Hout explained her understanding that, ‘if you’re not the culturally appropriate person to speak on another person’s behalf you shouldn’t be allowed’.24
5.17. There was also evidence that some service providers based in the community were reluctant to make CARL (Child Abuse Report Line) notifications. Ms Pia Richter said that they, ‘were very well aware that children and families were presenting at clinic but we weren’t receiving any notifications’.25 There was a meeting called with Tullawon Health staff in 2015 at which this issue was raised. Ms Joanne Badke had no memory of the meeting, but did not dispute that it occurred. She explained that this was one of the challenges with living in the community and having obligations to report. Their policy is to involve a staff member who is not connected to the parties to assist with the notification. Nevertheless, Ms Badke conceded that notifying has its challenges and agreed that this was even more difficult for incidents of domestic violence which do not constitute child abuse and are not subject to the same mandatory reporting requirements.26
5.18. Senior Constable Van Hout,27 Kathryn Meier,28 Pia Richter,29 Joanne Badke30 and Fiona Mort31 were all of the opinion that part of the reluctance to report domestic violence was due to the fear that the child would be taken from the mother. Kathryn Meier said that when she started working for Centacare the women would say to her, ‘You want to take our kids away’. Ms Meier explained the difficulty they faced; on the one hand she was encouraging them to disclose allegations of domestic violence, but then she had the obligation to report as well.32 23 Transcript, page 100 24 Transcript, page 370 25 Transcript, pages 497, 498 26 Transcript, page 731 27 Transcript, page 369 28 Transcript, page 394 29 Transcript, page 499 30 Transcript, page 710 31 Transcript, page 764 32 Transcript, page 394
5.19. Senior Constable Van Hout told the Inquest that: ‘Families SA were probably the only organisation more hated than SAPOL on the Lands and there was a concern that if there was violence that … the children were further exposed and the custody would be threatened or further considered’.33
5.20. Despite a general reluctance to involve agencies, some reports of domestic violence by SK against Kunmanara May were made to providers of social services and, occasionally, to police and those reports will be specifically referred to throughout this Finding.
6.2. Allegations of domestic violence first came to the attention of service providers on 29 January 2014 as a result of Rikki Iversen and Natalie Ross of the AFSS attending Yalata and meeting with Kunmanara May.
6.3. AFSS had been contracted by Families SA (FSA) on 27 September 201334 to provide services to Kunmanara May as a result of a CARL notification on 26 August 2013 in relation to housing difficulties. There was a subsequent notification on 16 November 201335 relating to Kunmanara not having nappies or formula for her baby. Neither notification was in relation to domestic violence and AFSS initially provided services relating to housing and parenting assistance. Support from AFSS remained ongoing without a further referral by FSA and, as information emerged about her relationship with SK, became more focussed on supporting Kunmanara as a victim of domestic violence.
33 Transcript, page 369 34 Exhibit C47, page 18 35 Exhibit C47, pages 12, 26
6.4. Facial injuries observed on 29 January 2014 6.5. On 29 January 2014 Ms Iversen and Ms Ross visited Kunmanara May at Cynthia Charra’s house and Ms Iversen had a brief conversation with Kunmanara whilst sitting on the front step. Kunmanara kept her head down and Ms Iversen saw no injuries, but Ms Ross informed Ms Iversen afterwards that she had seen a cut on Kunmanara’s cheekbone just under her eye, and a swollen lip.
6.6. Five days later, on 3 February 2014, Ms Iversen and Ms Ross again travelled to Yalata from their base at Ceduna, where they visited Marilyn Jebydah. Ms Jebydah told them that Kunmanara May had recently resumed her relationship with the father of her baby (then incorrectly understood by Ms Iversen and Ms Ross to have been named (CK)) and that he had forced or convinced Kunmanara to move from Ms Jebydah’s house into the house of Cynthia Charra, a relative of his. In relation to the injuries, Ms Jebydah told them that (SK) had belted Kunmanara and that he ‘does this in front of C’. She also told them SK was very controlling towards Kunmanara and C and that she was worried for them. Ms Iversen asked Ms Jebydah if she would mind talking to SAPOL about what she had just told them and she said she would do so.
6.7. Ms Iversen and Ms Ross then found Kunmanara May and C at the Mothers and Babies Clinic, where Ms Iversen was able to get a look at Kunmanara’s injuries, which she described in the AFSS notes as ‘a scar on her cheekbone and a slightly puffy eye’.
Otherwise, she found Kunmanara ‘unapproachable’ and ‘not her usual happy self’.36
6.8. Observations of the injury, together with the information from Marilyn Jebydah and the change in Kunmanara May’s presentation, clearly indicated to the two AFSS workers that Kunmanara had been the victim of domestic violence, which they considered likely to have occurred in the presence of C.
6.9. Armed with this information, Rikki Iversen and Natalie Ross called into the Yalata Police Station on the way out of Yalata but found it unattended so, upon return to the AFSS office at Ceduna, Ms Iversen telephoned Brevet Sergeant Johnson at the Yalata Police Station.
36 Exhibit C50, page 12
6.12. Ms Iversen’s note in the AFSS case notes stated that when she spoke to Brevet Sergeant Johnson she gave him the information given her by Marilyn Jebydah and that Brevet Sergeant Johnson said he would follow up with Marilyn Jebydah and that he would keep an eye out for Kunmanara May.37
6.13. In her statement, Ms Iversen said that she ‘explained (Kunmanara May’s) injuries and asked if SAPOL could keep an eye on the situation as (Kunmanara) had a young son’.38
6.14. Brevet Sergeant Johnson’s account in his statement39 was that in the phone call he was advised that AFSS were concerned that there was violence in this relationship as (Kunmanara May) had been seen with a graze under her left eye in the last week and that a request was made for Yalata police to keep an eye on the relationship. He said he was advised that (SK) and Kunmanara were residing at a place which he knew as the residence of Leonard Jacobs and Cynthia Charra.
6.15. Brevet Sergeant Johnson gave evidence that he was told in this phone call that Kunmanara May, ‘had been seen in the community with an injury to her face on the Friday prior and that AFSS had some concerns for the relationship she was in with a lad that she named as (CK)40 and they requested us to keep an eye on the relationship in the community’. 41 He elaborated that he was told that an AFSS worker had seen Kunmanara with a graze on her face. He further said that the worker who telephoned him said that they had some concerns that there was possible violence in the relationship.42
6.16. According to Brevet Sergeant Johnson’s account there was no mention by Ms Iversen that Marilyn Jebydah (or anyone) had provided information that (SK) had belted Kunmanara May, that he does so in front of C, that he had forced or convinced 37 Exhibit C50, pages 12, 13 38 Exhibit C64, page 3 39 Exhibit C53, page 6 40 This was not his correct name but nothing turns on it, as under his correct name he was not recorded in SAPOL records with significant relevant history 41 Transcript, page 33 42 Transcript, page 36
Kunmanara to move to Cynthia Charra’s house, or that he was very controlling and that Marilyn Jebydah was worried for Kunmanara and C.
6.17. In oral evidence, Ms Iversen said she believed she told Brevet Sergeant Johnson of the allegations that Marilyn Jebydah had relayed to her, although she could not recall exactly what she said.43
6.18. Ms Iversen made a note at 4:54pm the next day, in the AFSS notes, in which she states, ‘AFSW44 gave Officer TJ45 the information given to AFSW by Marilyn Jebydah and Officer TJ said he would follow up with Marilyn and that he would keep an eye out for (Kunmanara May)’. However, under later questioning by counsel for Brevet Sergeant Johnson, Ms Iversen accepted Brevet Sergeant Johnson’s evidence of the conversation.
She said, ‘I was a bit green at that point in time and I learnt sort of as we went along that people require more information …’.46
6.19. On its face, Ms Iversen’s concession to Brevet Sergeant Johnson’s counsel as to the accuracy of Brevet Sergeant Johnson’s account of the conversation (‘I would say so, yes’) was conceivably too readily made. The concession was not then tested against Ms Iversen’s earlier evidence that although she could not remember exactly what she said, she provided Johnson with an overview of the conversation with Marilyn Jebydah.47
6.20. Brevet Sergeant Johnson’s own notes of the conversation were sparse, to say the least, comprising the name he was given for (SK), Kunmanara May’s name, ‘at Leonard Jacobs’ and ‘graze under L eye’. In no other document did he ever record any further detail of that conversation until, in the context of the murder investigation following Kunmanara’s death, he prepared a statement on 9 June 2015, which he then signed on 24 July 2015.
6.21. I am also mindful that – surprising as it would be if Ms Iversen in fact said nothing to Brevet Sergeant Johnson about her conversation with Marilyn Jebydah – it would be reasonable to expect a police officer receiving advice of such concerns from a provider 43 Transcript, pages 807, 808 44 Aboriginal Family Support Worker 45 Brevet Sergeant Johnson 46 Transcript, page 853 47 Transcript, page 808
of social services, to approach the situation with sufficient curiosity to enquire as to the basis for the informant’s suspicion that there was violence in the relationship, from whom she had received the information and whether she had received any other information.
6.22. I note that the SAPOL General Order - Domestic Abuse in force as at 3 February 201448 stated under the heading, ‘Philosophies’: ‘SAPOL recognises that domestic abuse permeates all structures of society, and crosses all racial, cultural, age and socio-economic groups. It has a damaging impact, often profoundly so, on the victim, their children, family, and friends.
When an employee responds to issues pertaining to domestic/familial violence, the highest priority must be given to the protection and ongoing safety of the victim and their children in family/domestic violence situations.
A member must undertake a risk assessment process for all domestic violence incidents with a view to identifying the level of risk to a victim and their child/children, and take positive action to reduce that risk.
The offender must be held accountable for their actions.
The victim and their child/children should be given the opportunity to remain within their own home unless their safety will be placed in jeopardy.
SAPOL will work collaboratively with government and non-government agencies and the community, recognising that an integrated approach is likely to be the most effective response to victims of domestic violence and their children’. 49
6.23. The General Order - Domestic Abuse - these General Orders are regularly updated by SAPOL - was amended, effective 29 October 2014 adding, under the heading ‘Philosophies’, this paragraph: ‘An employee must adopt a professional curious, questioning and empathetic approach to their duties. They need to listen and reflect to ensure that they are able to fully appraise the risks and threats posed’.
6.24. In my assessment, the need for a curious, questioning and empathetic approach by a police officer responding to information about domestic violence goes without saying.
That is not to criticise the inclusion of this statement in the later version of the General Order. It is appropriate to enunciate such obligations.
6.25. Given the concession by Ms Iversen, I cannot make a finding that she told Brevet Sergeant Johnson what Marilyn Jebydah had told her. Ultimately, I cannot find it 48 Exhibit C46d 49 Exhibit C46d, page 6
proved that Brevet Sergeant Johnson received the information about Ms Jebydah’s knowledge and failed to act on it. However, neither is there any evidence that Brevet Sergeant Johnson took a curious approach and asked Ms Iversen about the basis for her suspicion, or whether she had received any other information. It is reasonable to conclude that, if he had, Ms Iversen would have elaborated and told him of the conversation with Ms Jebydah. That would have left Brevet Sergeant Johnson no sensible option but to speak to Ms Jebydah in an effort to find out what she knew.
6.27. I must proceed on the basis that the information in possession of Brevet Sergeant Johnson was limited to an assertion that an injury had been observed, accompanied by concerns expressed by Ms Iversen that there was possible violence in the relationship between Kunmanara May and SK.
6.28. Brevet Sergeant Johnson talks to Kunmanara May 6.29. Brevet Sergeant Johnson had never heard of any suspected incidents of domestic violence involving Kunmanara May and her partner. Yet, on his own account, he had been told by Ms Iversen of the AFSS concerns that there was violence in Kunmanara’s relationship. Furthermore, it is consistent with Brevet Sergeant Johnson’s evidence, and with what he says he did, that he was open to the possibility. He undertook some investigations.
6.30. Brevet Sergeant Johnson attended the house where Leonard Jacobs and Cynthia Charra lived and spoke to a young male, who gave his name as SK. Brevet Sergeant Johnson asked to speak to Kunmanara May, who then came out. Brevet Sergeant Johnson told her he had received a phone call from AFSS and that she had been seen with a graze or scratch on her face and he wanted to know how she received it, or what happened to cause it. At the time of giving evidence Brevet Sergeant Johnson could not remember seeing any mark or graze on Kunmanara’s face – if there was anything there it was only faint – but she had no obvious fresh injury. It was, by then, the fifth day after the injury was first observed by AFSS workers.
6.31. Brevet Sergeant Johnson told Kunmanara May that he believed the report which he had received from AFSS. Kunmanara told him that she got up during the night, that the power had gone off and she could not see where she was going, that she went to the
bathroom and fell over a piece of furniture in the large living area. Brevet Sergeant Johnson observed that there was a lounge in the area and mattresses on the floor. There was nothing unusual in what she said about the power being out; the community was powered by generators. Brevet Sergeant Johnson found her explanation plausible.
6.32. Brevet Sergeant Johnson asked Kunmanara May if there was any violence going on at home or behind closed doors and she said that there was not and that people in the community were trying to cause trouble for SK because he was not from Yalata. Brevet Sergeant Johnson informed her that if there was anything going on she could come and see him, or let the police know, or flag him down when he was in the community.
6.33. Brevet Sergeant Johnson then went back to the house and spoke to SK. He said, ‘You need to know that we don’t accept any violence here and if you’re violent in the community then we won’t tolerate it’.
6.34. Under further questioning by counsel assisting, Brevet Sergeant Johnson said that he was satisfied with the explanation Kunmanara May gave and believed it was true. He said that in coming to that conclusion he took into account all the factors of which he knew: no-one from the community had called to say there was any abuse going on, something which quite often occurred; he checked police information systems and ascertained that ‘CK’ (the incorrect name, which he had been given) was not known to police; he had no other supportive evidence from any independent person and he had Kunmanara’s own account that the mark was not related to domestic abuse.
6.35. As detailed earlier, the requirements of General Order - Domestic Abuse are that members adopt a professional, curious, questioning and empathetic approach to their duties. They need to listen and reflect to ensure that they are able to fully appraise the risk and threats posed. If Brevet Sergeant Johnson had been told by Ms Iversen – whether at her initiative or following questioning by Brevet Sergeant Johnson as to the basis for her concerns – that Marilyn Jebydah had said that (SK) belted Kunmanara May and that he did it in front of the child, it would not have been available to Brevet Sergeant Johnson to accept without further enquiry what Kunmanara told him. An appropriate investigation would then have required, at a minimum, that he speak to Ms Jebydah to ascertain what information or evidence she could provide.
6.36. Unfortunately, Brevet Sergeant Johnson did not exercise sufficient curiosity to question Ms Iversen along those lines and conducted no further investigation or enquiry.
6.37. Apart from his own very brief note, Brevet Sergeant Johnson made no other note in his notebook or anywhere else about his conversation with Ms Iversen and his subsequent visit to and discussion with Kunmanara May. He made no formal record in SAPOL information systems of what he had been told. Instead, the only written SAPOL record remained as Brevet Sergeant Johnson’s couple of lines of notes in his own notebook, and no further police action was initiated. I will return to this issue of appropriate documentation later in the Finding.
6.38. Families SA informed by AFSS 6.39. On the same day, Ms Iversen advised her manager Helen Dunn, who was also Kunmanara May’s AFSS case manager, of her observations and concerns. Ms Dunn made notes of that conversation which she emailed back to Ms Iversen and which were retained in the AFSS notes.50 Reference was made in this note to Ms Iversen telling Ms Dunn about Kunmanara having cuts and scratches to her face. Ms Dunn recorded that Marilyn Jebydah was concerned about Kunmanara moving out of her house to Cynthia Charra’s house with (CK) and that he could be very controlling.
6.40. It is recorded that Ms Dunn spoke to Trudy (supervisor) at FSA (FSA) and was advised to ask Ms Iversen to make a report to the Child Abuse Report Line. Ms Dunn recorded that ‘Trudy (FSA) said that she was happy that Rikki (Iversen) took safety measures to try to eliminate the safety risks for (Kunmanara May) and C’.
6.41. Report to the Child Abuse Report Line (CARL) 3 February 2014 6.42. That evening, a report was made to the CARL activating a requirement for a formal response by FSA. Details are contained in the FSA Familial Intake Report.51 Among other details it records the notifier, stating that (C’s) father had not been in the picture for the last three or five months, that Kunmanara May was observed on 29 January 2014 to have a cut under her eye on the cheekbone and bruising, and also that her bottom lip was swollen and cut inside. Further, it recorded that, according to the notifier, ‘(CK)52 (father) had gone to the house and forcibly took (Kunmanara) and C (her son) from the house and took them to where his family lives (also at Yalata). It was reported that the notifier had advised police. It was also reported that (Kunmanara) was seen again on 50 Exhibit C50, page 13 51 Exhibit C49, page 2 52 SK’s incorrect name was still being used
3 February 2014 and was reluctant to talk and the notifier took a good five minutes to get a smile from her son, who would normally engage with her spontaneously. It is then recorded, ‘Notifier has no further information in relation to whether C was present when the domestic violence occurred’.
6.43. The report was initially classified as a Notifier Only Concern (NOC), a classification not requiring further action as there was ‘no information as to what actually occurred’.53 I observe that this might have been different if Ms Iversen disclosed that Marilyn Jebydah told her that SK belted Kunmanara May and that he does it in front of C.
6.44. Nevertheless, the notification was promptly reassessed once the Crisis Response Unit member who took the call accessed the FSA case management systems, C3MS, and ascertained that there had been prior NOC referrals in relation to C. Accordingly, C was classified as an Infant at Risk (IAR) and the notifications classified as Tier 2, requiring a FSA response within three days.
6.45. FSA investigation in response to the Tier 2 notification 6.46. On 5 February 2014 a FSA worker, Jacqui Perry, contacted Rikki Iversen to discuss Kunmanara May. Among other things, Ms Iversen told the FSA worker that although Kunmanara generally engaged well with the AFSS workers and the baby C was usually bright and responsive, in the previous days when they had seen her, the mother ‘shutdown’ and did not engage well, and the baby was withdrawn, unusually taking five minutes to smile. Ms Iversen said that she was very concerned about the safety of mother and child.54
6.47. The FSA worker advised Ms Iversen they would be visiting Kunmanara May and Ms Iversen asked to be kept informed by email of their investigations.
6.48. Ms Perry contacted police officer McCormack at Yalata and was advised that Kunmanara May had been spoken to about her injuries but stated that she ‘fell over inside the house’ and was reluctant to speak further about her appearance.
6.49. The following morning, Ms Perry and another FSA worker went to Yalata and spoke to a nurse at the Yalata Clinic (Tullawon Health) as to C’s welfare. In short, they were 53 Exhibit C47, page 32 54 Exhibit C47, page 36
told that Kunmanara May had been vigilant in attending to and following up on C’s medical needs.
6.50. The FSA workers then attended the Mothers and Babies Clinic and did not find Kunmanara May there, but they were told of daily visits to the clinic by Kunmanara and, in effect, that she was properly attending to her baby’s needs.
6.51. The FSA workers then went to Cynthia Charra’s home, where they spoke with Kunmanara May. They observed a slight scratch to her face on the right cheek and a swollen area of the top lip. They asked how the marks occurred and she said the lump on her lip was from chewing tobacco and, as to the scratch, she said she had caught her skin as she zipped up her jacket. Ms Perry knew that this was inconsistent with the explanation which Kunmanara had given to Brevet Sergeant Johnson.
6.52. The FSA workers spoke to Kunmanara May about domestic violence, emphasising the risk it presented to C. Kunmanara did not admit the occurrence of domestic violence but did not dispute it. Strategies for dealing with domestic violence and keeping C safe were discussed, particularly ‘safe places’ she could go within community and, if necessary, the option of contacting police. They also discussed that she could ring her godmother Julieana Smart in Adelaide, who was known to local social workers to be available to assist Kunmanara.
6.53. The FSA workers noted the inconsistency of Kunmanara May’s explanation (with what Kunmanara had told Brevet Sergeant Johnson) about the cause of her injuries and that Kunmanara was particularly receptive to the safety plan which was discussed.
6.54. Marilyn Jebydah was not spoken to by the FSA workers. The notifier had advised FSA in the CARL notification that (SK) had forcibly removed Kunmanara May and C from her previous home (which was Ms Jebydah’s home), but had not advised of Ms Jebydah’s assertion that (SK) had belted Kunmanara and that he does it in front of C. It is unfortunate that this information was not provided to FSA. Had it been, there could be no justification for FSA not talking to Ms Jebydah, who might have provided confirmatory evidence of abuse by SK. However, given what was conveyed to FSA about SK removing Kunmanara from Ms Jebydah’s home, an act in its terms capable of amounting to physical and emotional abuse, a proper investigation required FSA to seek out and speak to Ms Jebydah in any event, which did not occur.
6.55. After their investigation, such as it was, FSA concluded, ‘Emotional abuse could not be confirmed due to lack of information pertaining to the alleged incident’ and then referred to the extensive discussion with Kunmanara May about safety and the impact to children and babies exposed to domestic violence.55
6.56. Statement of Marilyn Jebydah 6.57. I have made observations critical of Ms Iversen for not conveying to Brevet Sergeant Johnson a full account of what Marilyn Jebydah told her, of Brevet Sergeant Johnson for not enquiring of Ms Iversen as to the basis for her concern that there was violence in the relationship, and of FSA for not having spoken to Ms Jebydah despite having been advised that Ms Jebydah asserted that SK forcibly removed Kunmanara May from her home, and not telling Brevet Sergeant Johnson of the inconsistency in the account of how she suffered injury. Accordingly, I must mention Ms Jebydah’s statement dated 11 August 2016.56 This statement was received as evidence in the Inquest but given the focus of the Inquest on the institutional responses to Kunmanara’s circumstances, she was not called as a witness to give oral evidence elaborating upon it.
6.58. The statement itself records that it was first provided to Constable Holmes on 2 June 2015 at the Ceduna Police Station, and it was clearly obtained in furtherance of the police criminal and coronial investigations.
6.59. In this statement Ms Jebydah, who was related to Kunmanara May, stated that after C was born, Kunmanara first stayed in Adelaide with her godmother Julieana, and then came to live with her at Yalata, where she helped Kunmanara with her newborn and showed her how look after him, until C was able to sit up by himself, after which Kunmanara and C moved out to live with SK. For a little while, while Kunmanara was living with her, SK was living with them as well. She said that SK was controlling of Kunmanara and made her and C move out when C could sit up. She said there was never any fighting that she saw. One time there was an argument in their bedroom and she did not see any fighting, but thought Kunmanara was hit a couple of times because she could hear it. She did not like the arguments and told them to stop and would growl at them. She tried to get into the room but the door was locked from the inside.
55 Exhibit C47, page 45 56 Exhibit C17a
6.60. Ms Jebydah’s statements, made long after the event she was talking about, that SK was controlling, that he made Kunmanara May and C move out, and that she thought Kunmanara was hit a couple of times because she could hear it, were not detailed but provide some support for what Ms Iversen stated Ms Jebydah told her. They suggest that if Brevet Sergeant Johnson or FSA had spoken to Ms Jebydah in February 2014 in search of detail, they may well have obtained information confirmatory of abuse by SK of Kunmanara.
6.61. Further DV and child welfare concerns lead to CARL notification 21 February 2014 6.62. On 20 February 2014 AFSS workers Ms Iversen and Ms Ross travelled from Ceduna to Yalata there they spoke to Ms Jebydah. She told them that Kunmanara May and C would be welcome to move back to her house. Ms Jebydah told Ms Iversen and Ms Ross of her ongoing concerns about domestic violence and that (SK) was taking all Kunmanara’s money and was controlling towards her. She said Kunmanara had been around with C knocking on her door asking for food and that she would cook them up a feed.
6.63. The AFSS workers then went to the Mothers and Babies Clinic and saw Kunmanara May, who asked if they had any nappies they could give her for C. She said she was nearly out of formula and asked for their help about when her next Centrelink payment was due.
6.64. Ms Iversen made comprehensive records in the AFSS notes about her subsequent contacts,57 firstly with FSA case worker Jacqui Perry about what she had learned about Kunmanara May’s shortage of nappies and formula. She recorded telling Ms Perry about what Ms Jebydah had said and that Ms Perry asked her to inform the police and to mention in a child protection report that police were aware.
6.65. Ms Iversen also spoke to Kunmanara May about the safe house in Ceduna which she could use if she needed to. As requested by Ms Perry, she arranged for some nappies to be provided for C.
6.66. Ms Iversen went to the police station but there was no officer in attendance. Back in Ceduna she rang Yalata police and asked officer ‘David’ to get either ‘Daryl’58 or 57 Exhibit C50, page 16 58 McCormack
‘Tim’59 to call her back. Her records disclose that ‘Daryl’ returned the call and she ‘filled him in on’ Kunmanara May’s situation. She told ‘Daryl’ that she would be making a child protection report.
6.67. On 21 February 2014 Ms Iversen called the CARL and made a notification, details which are recorded in a FSA Familial Intake Report.60 It is recorded that the notifier stated that police and FSA Ceduna had been advised.
6.68. It is also recorded: ‘The notifier has been informed by community members that there is DV occurring in the home perpetrated by father (SK). The notifier was advised that the father is controlling and has been preventing mother from leaving or going anywhere. He also has been taking her money. The notifier states that until the relationship commenced the mother also had money and had provided for C.’
6.69. FSA response to 21 February 2014 CARL notification 6.70. FSA workers attended Yalata on 28 February 2014 and spoke with Kunmanara May who said she understood the need to buy baby’s nappies first, and then her own food, without having to rely on support from other agencies. She seemed to engage readily and smiles of mother and baby were noted. The FSA workers noted Kunmanara was working well with AFSS. Regarding domestic violence, Kunmanara consented to work with AFSS domestic violence workers, but indicated everything was ‘pulya’61 (sic) and that her partner sometimes wanted her money. She said she talks with AFSS about financial management. The note concludes ‘DV not substantiated’.
6.71. Marilyn Jebydah was not spoken to; she was not named in the CARL report and on the evidence I cannot conclude whether or not she was identified by Ms Iversen in her earlier conversation with Ms Perry.
6.72. There is no evidence that this CARL report was brought to the attention of Yalata police by FSA; indeed, the evidence is that it was not.
6.73. 6 March 2014 – Ms Iversen is advised of a further incident of violence 6.74. On 6 March 2014 Ms Iversen was in Yalata with Ms Ross and social worker, Michele Naylon, and, at the Aged Care Centre, Ms Jebydah asked to have a yarn. She told 59 Johnson 60 Exhibit C49, page 7 61 ‘good’
Ms Iversen and Ms Ross that Kunmanara May ‘had come to church the other day crying and looking for Doris Bryant (her sister) because (SK) had grabbed her around the throat and punched her in the heart. She was asking Doris to go and get C from Cynthia Charra’s house’.
6.75. Ms Iversen was not able to meet with Doris Bryant that day but found Kunmanara May at her house (Cynthia Charra’s) and, after Kunmanara picked up her baby, she shared lunch with them. Ms Iversen offered to arrange on the spot for Kunmanara to go to stay with her godmother Julieana in Adelaide, but Kunmanara said she was content at that moment to think about it.
6.76. After returning to Ceduna that day, Ms Iversen emailed Ms Perry at FSA conveying this information. She also advised that Ms Jebydah had told her that Kunmanara May was asking her sister to go and get C from her house and that when a fight is happening at Cynthia’s house between Kunmanara and SK, GK (SK’s mother) leaves the house.
She mentioned steps which were being taken for locals to keep an eye on Kunmanara and advised that she had offered for Kunmanara to go to Adelaide to stay with her godmother. Kunmanara was told that if she wanted to take up that offer, AFSS workers could pick her up the following Thursday.
6.77. FSA supervisor Trudy Smith responded, requiring Ms Iversen to make a CARL report, even though it was ‘third hand’.
6.78. Ms Iversen did so, leading to formal documentation of it within FSA. This report or ‘intake’ was classified as No Grounds for Intervention (NGI) ‘as it is a current open case with Ceduna who have not closed the case seeking updates and ongoing information regarding this child’.62 It was noted that the information was ‘third hand and does not identify if the child witnessed the abuse’, but that in conjunction with recent history it meets criteria for further action. It was noted that the mother was connected to DV workers by AFSS and Centacare and that FSA had recently completed a risk assessment which was ‘HIGH’.
6.79. Ms Iversen later obtained a mobile phone for Kunmanara May, which she gave to her on 20 March 2014 when they again attended Yalata. It contained phone numbers for 62 Exhibit C47, page 107
AFSS and Kunmanara’s Centacare DV worker, as well as police. She was told she could dial 000 even without phone credit. A Case Planning Review was completed.
6.80. No SAPOL officer was advised, either by AFSS or FSA, of the information which Ms Iversen had obtained and reported to FSA.
6.81. April 2014 – AFSS continues to support Kunmanara May 6.82. AFSS continued making regular visits to Yalata, usually weekly, and caught up with Kunmanara May on each occasion. The AFSS workers kept Kunmanara’s case manager and others at FSA apprised of detailed information regarding Kunmanara’s and the baby’s progress.
6.83. On 10 April 2014, three AFSS workers including Ms Iversen and Kunmanara May’s Case Manager, Ms Dunn, attended a Partnership Meeting with FSA, represented by Trudy Smith (Supervisor, Family Support and Child Safety Team). AFSS staff advised, among other things, that Kunmanara’s situation was being closely monitored and there appeared to have been no further incidents in relation to domestic violence.63
6.84. On 16 April 2014 Ms Iversen forwarded to FSA the detailed AFSS Monthly Progress Report Targeted Intervention64 advising that in March AFSS had spent 3½ hours working directly with Kunmanara May and 23½ hours indirectly (case recording and file management, case planning, attending meetings without the family, travel time without the family and report writing).
6.85. On 28 April 2014 Ms Iversen was advised by Ms Perry at FSA that they had closed their case and were happy with AFSS overseeing management of Kunmanara May’s case. During this period Ms Iversen learned that Kunmanara had moved and, on 8 May 2014, located her living with SK and C, at Russell and Doris Bryant’s house.
6.86. CARL notification 15 May 2014 6.87. It is recorded in the detailed AFSS notes,65 mainly written by Ms Iversen, that she and Ms Ross arrived in the Yalata Community on 14 May 2014. They found Kunmanara May at the Mothers and Babies Clinic, where they were informed by Jaleen Miller 63 Exhibit C50, page 26 64 Exhibit C47, page 111 65 Exhibit C50, pages 31, 32
(Manager and Kunmanara’s auntie) and Jane H Williams (community member and volunteer) that (SK) allegedly threw Kunmanara against a wall, causing her to run away from Russell and Doris’ house to Sorry Camp where she found Jane H Williams and told her, shaking and crying, what had happened.
6.88. Ms Iversen and Ms Ross spoke to Kunmanara May, who did not want to talk about it, but said she would like to leave the community with C. She declined to get police support to get personal property from her house before leaving. Ms Iversen and Ms Ross made calls to put Centacare DV services in Ceduna on notice that Kunmanara and C would be arriving. They then drove Kunmanara and C back to the AFSS offices at Ceduna where they also met with FSA Care and Protection worker, Ebany Holmes.
6.89. It is recorded in the notes that Kunmanara May was trying to play down the incident and, in the presence of Ms Holmes, Ms Iversen related what she had been told that Kunmanara had told Jane H Williams about what occurred. It is further recorded that after Kunmanara was confronted with the allegation, she stated she was the victim of domestic violence at the hands of SK. Ms Holmes talked with Kunmanara about how it is her job to keep herself and C safe from DV and stated that if Kunmanara was unable to keep herself and C safe, FSA would have no choice but to remove C from her care.66
6.90. Six nights in Ceduna 6.91. The following morning Ms Iversen telephoned the CARL67 advising of the information provided to her on the previous day and that Kunmanara May had allegedly left the house, leaving C behind. She advised that a number of community members were aware of the incident, but she thought it had not been reported to police. The FSA intake report reveals that there was a current child protection case, in the Protective Intervention phase, which had been opened on 21 February 2014. FSA assessed this report as Tier 2, requiring investigation within three days. In the assessment ‘Decision and Rationale’ it was noted: ‘There have been two or more episodes of physical assaultive behavior in the last six months in which the father has assaulted the mother by throwing her against a wall and grabbing her by the throat and punching her in the heart. The mother on both occasions has left the father with C after being assisted by DV services’.
66 Exhibit C50, page 31 67 CARL Familial Intake Report, Exhibit C49, page 12
6.92. Centacare DV Services arranged for Kunmanara May and C to stay in a Ceduna motel as the Ceduna safe house was full. She stayed there for six nights.
6.93. Return to Yalata Community, to live without SK 6.94. On 19 May 2014, with Kunmanara May’s agreement, arrangements were made for her and C to go back to Yalata to stay at Ms Jebydah’s house, on the basis that SK would not be living there.68 The AFSS note also records that FSA supervisor Trudy Smith was present at the AFSS office participating in the making of this plan. On the same day, Centacare workers took Kunmanara and C back to Yalata and left her at Ms Jebydah’s house.
6.95. Back to SK – Another report of violence 6.96. The next day it was reported to AFSS workers that Kunmanara May had left Ms Jebydah’s house and gone to stay at Russell and Doris Bryant’s. They were also told that on the night of Kunmanara’s return to Yalata she had been locked in a car by SK and hit repeatedly. Ms Jebydah, who provided the information, was invited to provide details of these allegations to FSA supervisor Trudy Smith.
6.97. Ms Iversen’s AFSS note records that she later left a message for Ms Smith providing information about these allegations and enquiring whether she had been able to catch up with Ms Jebydah.69
6.98. Ms Iversen recorded in the AFSS notes that the next day she telephoned Ms Smith, who said she had been unable to contact Ms Jebydah. Ms Iversen provided Ms Jebydah’s information and asked Ms Smith whether she would be making a child protection notification. Ms Smith said to leave it with her.70
6.99. No Family Care Meeting 6.100. I am unable to ascertain from the FSA records exactly what action was taken in relation to this information provided to Ms Smith. There is a record, apparently made by Ms Smith that, following a meeting between DV services, AFSS and FSA, ‘FSA will 68 Exhibit C50, page 33 69 Exhibit C50, page 34 70 Exhibit C50, page 34
make a referral to a Family Care Meeting (FCM), given the level of concerns’.71 There is no evidence that a referral to a FCM was made.
6.101. Ms Iversen enquires whether police are aware of allegations relating to Kunmanara May’s return to Yalata on 19 May 2014
6.102. The AFSS records make it clear that Ms Iversen remained concerned about Kunmanara May’s return to Yalata and whether the plan for her to live with Ms Jebydah, without SK, had come to pass.
6.103. On 27 May 2014 after an absence in Adelaide for a week, Ms Iversen emailed a Centacare DV support worker asking to be advised whether Yalata police were advised of the situation with Kunmanara May.
6.104. The response was that Yalata police were informed that she was returning to Yalata and that she would be staying with Ms Jebydah as that was the safest option for Kunmanara May and C. It was further advised that Kunmanara ‘ran away and went back to his (SK’s) house’. Finally, Ms Iversen was advised that the Centacare DV team would not be able to visit Kunmanara whilst at her partner’s house, due to work policies, related to the fact that the alleged perpetrator was at the house.72
6.105. I have not been able to find any evidence - there is no written record - that police at Yalata were advised that, yet again, a member of the public had provided information to a service provider about another assault by SK against Kunmanara May. Having regard to the advice from Centacare to AFSS that police had been advised, it may well be that a Yalata police officer was informed and no record was made.
6.106. May – June 2014 AFSS continues close involvement 6.107. AFSS case notes provide, as at all relevant times, considerable detail about the AFSS team’s extensive and ongoing contact with, and provision of support services to, Kunmanara May. AFSS case manager Ms Dunn, as well as caseworker Ms Iversen, were aware that she was again living with SK, and that FSA was aware of this. Further, as noted above, AFSS workers believed that Yalata police were aware of the incident which led to Kunmanara being provided domestic violence shelter in Ceduna from 14 to 71 Exhibit C47, page 121 72 Exhibit C50, page 35
19 May 2014 and were aware of the allegation that, upon her return to Yalata to live separately from SK, SK had coerced her to return to residing with him.
6.108. Referral to Family Safety Framework June 2014 6.109. On 19 June 2014 Ms Iversen referred Kunmanara May to the FSF. She completed paperwork provided by Senior Constable Carly Wilson, at the time the Port Lincoln FVIO, whose responsibility encompassed the Ceduna region, including Yalata.
6.110. This referral commenced a second period of engagement by SAPOL with Kunmanara May, comprising fortnightly FSF meetings from 1 July 2014 until 28 August 2014 inclusive and, during that time at least one verifiable personal contact by a police officer with Kunmanara.
6.111. In the referral, Ms Iversen included under the heading ‘Background and Risk Issues’: ‘Case Worker was informed on 3 February 2014 that [Kunmanara] May had entered back into a relationship with the father of her child [SK] and had moved with [C] into Cynthia Charra’s house.
On the same day (3 February 2014) Case Worker put on a Child Protection Report for suspected Domestic Violence between [Kunmanara] and [SK] in front of baby [C].
On 21 February 2014 another Child Protection Report was made by Case Worker due to [Kunmanara May] having no formula or nappies for baby or any money to buy any formula or nappies. It is believed that [SK] takes [Kunmanara May’s] money.
Another Child Protection Report was made by Case Worker on 11 March 2014, again for suspected Domestic Violence between [Kunmanara May] and [SK] in front of baby [C].’73
6.112. As the form required, Ms Iversen completed a Risk Assessment Form together with Kunmanara May. The risk assessment produced a score of 39, in the medium category.
6.113. There were a number of critical matters which Ms Iversen did not mention in the referral, namely:
6.113.1. That Kunmanara May had been observed on 29 January 2014 with injuries on her face, together with the information provided by Ms Jebydah on 3 February 2014 that Kunmanara had recently resumed her relationship with the father of her baby, that he had forced or convinced Kunmanara to move from Ms Jebydah’s house into his relative Cynthia Charra’s house, that (SK) had 73 Exhibit C58, Appendix 1
belted Kunmanara and that he ‘does this in front of C’ and that SK was very controlling towards Kunmanara and C and Ms Jebydah was worried for them.
6.113.2. That Kunmanara May had given inconsistent accounts to police and FSA about the cause for these injuries (I note, however, that Ms Iversen might not have been aware of this).
6.113.3. The Child Protection Report made on 21 February 2014 which made reference to Ms Jebydah’s ongoing concerns about domestic violence between the couple and that SK was controlling towards Kunmanara May.
6.113.4. That on 6 March 2014 Ms Iversen was told by Ms Jebydah that Kunmanara May ‘had come to church the other day crying and looking for her sister Doris Bryant because (SK) had grabbed her around the throat and punched her in the heart and she had run away, so she wanted Doris Bryant to go and collect C from the house’; also, that Ms Jebydah told Ms Iversen that when a fight is happening at Cynthia’s house between Kunmanara and SK, GK (SK’s mother) leaves the house; further, that this had been the subject of advice by email to FSA and of a CARL report.
6.113.5. That on 15 May 2014 Ms Iversen made a CARL notification regarding having been told on 14 May 2014 that (SK) allegedly threw Kunmanara May against a wall, causing her to run away from Russell and Doris’ house to Sorry Camp where she found Jane H Williams and told her, shaking and crying, what had happened.
6.113.6. That as a result, Kunmanara May was given domestic violence shelter accommodation in Ceduna for six nights.
6.113.7. Pursuant to a plan which involved FSA, Kunmanara May was relocated back to Yalata to stay at Ms Jebydah’s house and, as Ms Iversen was told on 20 May 2014, upon returning to Yalata, despite agreeing to move away from SK, she immediately returned to live with him; and on the night of her return to Yalata she had been locked in a car by SK and hit repeatedly.
6.114. Ms Iversen appropriately conceded in evidence that this information should have been included on that form. Harsh criticism is not warranted. Ms Iversen was new to the
role and had received no formal training as to the completion of the referral, risk assessment, or what she should do and disclose at the FSF meeting. Formal reporting to police of the various matters of which she had heard was not something that she considered, and it was not a practice within AFSS itself.74
6.115. Senior Constable Wilson brought the referral to the attention of Brevet Sergeant Johnson by email on 30 June 2014, advising him that Kunmanara May and SK had been referred to the FSF as a high-risk DV couple and requesting information in relation to them.
6.116. According to Brevet Sergeant Johnson, that was the first he had heard of them in a domestic violence context apart from his contact in relation to the mark seen on Kunmanara May’s face in February 2014, when he had accepted her account of having injured herself tripping over furniture during the night.
6.117. Brevet Sergeant Johnson responded immediately, advising that he was pretty sure this was about [CK]75 and that they had some DV issues together in the past, but nothing reported recently to the best of his knowledge. He said he thought they were not at Yalata at the time and that he would keep an eye out for them and let Senior Constable Wilson know if there are any issues with them.
6.118. The reason he wrote about ‘DV issues together in the past but nothing reported recently’ was not explained in his evidence, given his assertion that he had discounted in his own mind that Kunmanara May’s February injury was domestic violence related and that he had never heard anything else.
6.119. FSF meeting 1 July 2014 6.120. The first FSF meeting to consider Kunmanara May’s case was held on 1 July 2014 in the meeting room at the Ceduna District Health Service. The meeting was chaired by video link by Senior Constable Wilson, the SAPOL FVIO based in Port Lincoln, with responsibility for Ceduna and Yalata. Those present included Ms Iversen as well as, among others, Ms Meier of Centacare, Pia Richter, the Manager of the Ceduna office of FSA and Ms Dunn, Kunmanara’s case manager at AFSS.
74 Transcript, pages 853-868 75 He remained unaware of SK’s correct name
6.121. Perusal of the minutes and consideration of the evidence heard at the Inquest revealed that the meeting fell well-short of presenting that Kunmanara May was a young woman who appeared to be the subject of regular and ongoing reports of domestic violence.
6.122. From the minutes, in relation to the AFSS representative (Ms Iversen), it is reported as being stated ‘last incident was in March, no recent incidents, but are monitoring incidents’. This was simply wrong. Ms Iversen explained in evidence that she would have been very nervous and would have rushed through her dot points.76 It must also be said that there were representatives of other agencies at the meeting, who knew or ought to have known, that the information provided in the referral was incomplete and who ought to have said so.
6.123. From SAPOL it was recorded that no [CK] was found on the SAPOL system. There was no record of any discussion about whether SAPOL had been informed of the various incidents of which other service providers were or may have been aware. This was an obvious question to be asked by the SAPOL representative, and there were participants present who could have provided significantly more information about what was known to them, but not to SAPOL. Police would then have been aware, through Senior Constable Wilson, that there was a substantial body of evidence that Kunmanara May was, in all likelihood, enduring regular domestic violence and that she and her child were at high risk of harm.
6.124. The contribution to the meeting from FSA was recorded as ‘[Kunmanara May] is an open case, if anything further happens it could result in family care meeting’. There is no record of any mention of the fact that Ms Smith recorded in May that FSA was to arrange a family care meeting following the report which led to Kunmanara’s domestic violence crisis care in Ceduna. Also, there is no record of any observation on behalf of FSA that other incidents had been reported to it.
6.125. From Centacare was recorded that there had been ‘no contact with [Kunmanara May] since 21 May 2014, she was put in accommodation for a few days until Centacare took her back to Yalata where she was going to stay with Marilyn Jebydah but received a call from Marilyn the following day to say [Kunmanara] had gone back to the house where (SK) is staying’. At least this must have alerted those present to the likelihood 76 Transcript, page 829
that there was a recent incident, but there appears to have been no action to rectify the lack of information delivered to and received by the meeting.
6.126. Actions to be taken, as recorded in the minutes, were for AFSS to continue to engage with Kunmanara May and a SAPOL officer in Yalata to speak to her regarding options to keep her safe.
6.127. Having regard to the accumulated knowledge of Kunmanara May held by the various agencies which were represented at the meeting, it is clear that the FSF meeting was almost entirely ineffective in operating to protect Kunmanara from further domestic violence because, from the outset, those agencies, through their representatives at the meeting, failed to share information which would have led to a full and shared understanding of Kunmanara’s dire situation.
6.128. FSF meeting 15 July 2014 6.129. This meeting was again chaired by video link by Senior Constable Wilson.
6.130. Ms Iversen and Ms Ross were present on behalf of AFSS and Ms Iversen advised that they had seen Kunmanara May on 10 July 2014 and she had been skinny and unkempt.
C had been with SK’s mother who was on her way back from a trip to Adelaide.
Ms Iversen advised that Kunmanara had not disclosed, and AFSS were not aware of, any further incidents of domestic violence. AFSS workers had not had contact with any of the community members they were aware had been keeping an eye on Kunmanara because they were not in the community at the time. Kunmanara was still residing in SK’s mother’s house.
6.132. At this meeting it emerged that SK’s correct name had finally been ascertained; until then he had been referred to as (CK). This is not a matter which had any adverse impact on services which were provided, or could have been provided, for Kunmanara May, as SK had no recorded history of criminal offending either.
6.133. Actions from the meeting were: that AFSS was to report back regarding a family case plan review scheduled for the next day and of any disclosure of abuse; the SAPOL officer at Yalata was to speak to Kunmanara May regarding options to keep her safe
and the possibility of an intervention order; and all agencies were to update SK’s name and conduct a new search for any relevant information about him.
6.134. Brevet Sergeant Johnson speaks to Kunmanara May again 6.135. On 26 July 2014 Brevet Sergeant Johnson went to Debra May’s house (a relative of Kunmanara May) and spoke to Kunmanara. He asked if there was violence in the relationship and she said she was staying with family most of the time at Debra May’s.
She said that SK was not being violent towards her. Brevet Sergeant Johnson gave her a domestic violence information package supplied by the Family Violence Legal Service Aboriginal Corporation SA, Ceduna and also a SAPOL Information about Intervention Orders booklet. He asked Kunmanara to come and see him at the police station if there were any problems with SK and also asked Debra May to call him if there were any issues she was aware of between SK and Kunmanara.
6.136. Brevet Sergeant Johnson emailed Senior Constable Wilson: ‘Have caught up with (Kunmanara May) this morning. She advises there have been no issues between the pair and that if anything comes up then she can contact me. I don’t think there is much more to do with this at this point.’ This email lacked detail and did not address establishing or investigating potential allegations in accordance with guidelines to focus on alternative lines of enquiry, rather than solely relying on the victim, including interviewing others within the close-knit community.
6.137. Brevet Sergeant Johnson said in evidence that having spoken to Kunmanara May there was nothing which led him to believe that something else was going on that she was not disclosing. Again, I must observe that if in the FSF process Senior Constable Wilson had enquired about what was known by other agencies, or if those agencies had in any event disclosed to SAPOL what they knew, then this information ought to have been conveyed to Brevet Sergeant Johnson and he, in turn, would not have been so readily persuaded.
6.138. Also at that meeting was Nicole Leonette from the Office for Women, who attended to assist participants in the way the FSF meetings should be conducted.77 77 Transcript, page 323
6.139. FSF Meeting 29 July 2014 6.140. This meeting was chaired by Senior Constable Wilson, but was also attended by Senior Constable Van Hout, who had just commenced assisting Port Lincoln FVIO, Senior Constable Wilson, in relation to family violence matters in the Ceduna region.
6.141. The meeting was brief in relation to Kunmanara May, with SAPOL reporting that Kunmanara had been spoken to regarding her safety and possible intervention orders and that she would contact Brevet Sergeant Johnson if she needed to. FSA reported they were still working with Kunmanara and that a family care meeting may be held regarding C. The only action raised from the meeting was for AFSS to report back to the FSF regarding a family case plan review which had been scheduled for 16 July 2014, and any disclosure of abuse.
6.142. The 16 July 2014 scheduled meeting had in fact taken place and involved Ms Dunn and Ms Iversen spending 1½ hours with Kunmanara May at the Mothers and Babies Clinic at Yalata, which was later comprehensively noted in the AFSS records.78
6.143. Ms Dunn and Ms Iversen saw Kunmanara May again for 45 minutes at Yalata on 23 July 2014 and for half an hour on each of 30 July and 6 August 2014. Kunmanara confirmed she would move into SK’s mother’s new house once it was allocated to her.
The workers questioned Kunmanara carefully, seeking indications that she was being subjected to domestic violence. They encouraged her to take up the offer of FSA to pay for her to take a holiday to see her godmother Julieana in Adelaide. They spoke sensitively of strategies she might employ in the event of abuse by SK. They discussed the support she had in the community.
6.145. FSF Meeting 12 August 2014 6.146. The AFSS report on this occasion was recorded as: ‘No further incidents between (Kunmanara May) and (SK). (Kunmanara) has moved in with (SK’s) Mum so another safety plan will be done. The community are happy to be part of (Kunmanara’s) safety plan. Have been discussing with (Kunmanara) the impact it can have on C while being in DV relationship. (Kunmanara) seems to be a lot happier and 78 Exhibit C50, page 44
taking more care of herself. She states that (SK) hasn’t been getting as cheeky or bossy to her lately.’
6.147. It was mentioned at the meeting by SAPOL that Yalata police had caught up with Kunmanara May a few times in the previous fortnight to discuss how things were going with her and SK. Apart from the evidence of Brevet Sergeant Johnson about his discussion with Kunmanara on 26 July 2014, there was no evidence or detail provided to this Inquest of what those occasions were. There was no official record of any such contacts having occurred.
6.148. The only action from the meeting was that AFSS was to complete and finalise a safety plan with Kunmanara May.
6.149. AFSS workers talk with SK’s mother 6.150. On 13 August 2014 Ms Iversen met up with SK’s mother and questioned her about what happens when SK gets a bit cheeky with Kunmanara May. Ms Iversen was told by SK’s mother that it had not been happening very much anymore and that when it happens, she speaks with him about it. Ms Iversen spoke about the risk to Kunmanara if SK mistreats her and to C if he witnesses it. SK’s mother agreed to talk to SK.
6.151. Safety plan 22 August 2014 6.152. On 22 August 2014 Ms Iversen prepared a safety plan for Kunmanara May and C, taking care to make it inconspicuous by incorporating it into a Centacare booklet which, it was thought, would be inconspicuous and readily hidden (from SK) if necessary. It contained plans for a safe place for Kunmanara to go if necessary, and phone numbers such as Yalata SAPOL and domestic violence services after hours telephone.
6.153. FSF Meeting 26 August 2014 - end of referral 6.154. At this meeting AFSS advised, as recorded in the minutes: ‘A safety plan has been completed and will be given to Kunmanara May tomorrow 27 August 2014. Kunmanara May, C and SK have moved in with SK’s mother.
Community members are keeping an eye out on the couple.’
6.155. SAPOL is recorded in the FSF minutes as having advised of further visits to Kunmanara May and offering support. Again, there is no documentation of these in police records.
6.156. A Domestic Abuse Report (DAR) is submitted 16 September 2014 6.157. On 16 September 2014 Senior Constable Justine Van Hout prepared and submitted DAR 15/Q30814.79 6.158. She explained in her statement,80 and in evidence,81 that it came to her attention that there was not a current (police) report to record the family violence that was referred to in the FSF meetings. By this time, Senior Constable Van Hout had attended three FSF meetings and obviously had realised that there was no information on SAPOL systems about Kunmanara May at all.
6.159. The narrative in the DAR outlined that May had disclosed to AFSS workers that she was a victim of domestic abuse. The investigation diary had an entry that a Yalata member had spoken with Kunmanara on two occasions to ensure her safety. It stated, ‘Nil reported, nil assistance engaged. Nil offences reported and substantiated at this time’.
6.160. Ongoing engagement of services following the closure of the FSF referral 6.161. Following the closure of the FSF referral on 28 August 2014, AFSS workers continued their close engagement with Kunmanara May. The focus was on assisting her with the setup of the new house and obtaining financial assistance for white goods. Kunmanara seemed to be struggling to have money from week to week and financial counselling through FSA was arranged. Kunmanara expressed interest in going on the Income Management Scheme. Despite these concerns, the AFSS workers perceived that C was happy and healthy, and well looked after.
6.162. There were difficulties obtaining funding for white goods, but on 22 October 2014 the AFSS workers told Kunmanara May that once her furniture was arranged it was likely that AFSS would close her case, although she would still be welcome to contact them.
A grant for the furniture came through on 23 October 2014.
6.163. Another CARL notification – 24 October 2014 6.164. On 24 October 2014 Kunmanara May’s mother Janet visited the Ceduna FSA office and expressed concern to Leon Schultz, FSA social worker that Kunmanara was still 79 Exhibit C46ad 80 Exhibit C58 81 Transcript, page 247
experiencing domestic violence at the hands of SK, which she felt was occurring on a daily basis. It was also stated that the child C witnesses domestic violence.
6.165. Mr Schultz telephoned Ms Iversen to advise her of this and she told him that Kunmanara May still denies that anything is going on and that she was reluctant to see the domestic violence services in Yalata, as they work out of Yalata which is where SK’s mother spends a lot of time.
6.166. This report was allocated as a Tier 2 requiring a FSA investigation within 10 days.
6.167. FSA social worker Kirsty Lawrence had a conversation about this on 30 October 2014 with Ms Dunn of AFSS and advised Ms Dunn that FSA workers had been unable to speak to Kunmanara May in Yalata the previous day and were going to close this latest case, but would like AFSS to continue working and addressing the impact of domestic violence on C. Ms Dunn was asked to make a report if they received any further information when they attended Yalata the next day.
6.168. AFSS attend Yalata 31 October 2014 and see Kunmanara May 6.169. Ms Dunn and Ms Iversen attended Yalata and went to SK’s mother’s house where they saw Kunmanara May. Once they were in private, they said they had heard from community members that SK was being cheeky with Kunmanara again and she nodded.
She said he growls at her and makes her cook dinner, but denied that she was being pushed or hit. The AFSS workers talked with Kunmanara about the escalation of domestic violence from growling to black eyes and beatings. She said she did not want to be like a relative of hers, who got ‘smashed up’. The workers talked about the risk that C could be removed from her if he should see domestic violence. This and the workers were quite sure that she well understood the impact that witnessing domestic violence had on little children. They reassured her that she had done a wonderful job with C. They asked her to come to Ceduna as she had previously done, to learn more about domestic violence and to talk to Centacare DV services. Kunmanara agreed to come to Ceduna. She said she wanted to be a stronger woman and not be scared of SK, and to be strong for C.
6.170. Ms Dunn telephoned Ms Lawrence at FSA, informing her of the conversation and that Kunmanara May had acknowledged that there was domestic violence. Ms Dunn
advised Ms Lawrence that AFSS had agreed to keep an eye on the situation and report findings back to FSA.
6.171. Arrangements were then made for accommodation and transport for Kunmanara May to get to Ceduna, and for appointments with Centacare DV services and an appointment with the financial counsellor at FSA about getting onto the Income Management Scheme. This was to occur after a further week had passed, as AFSS staff were to be away at training.
6.172. Another child protection report 12 November 2014 6.173. On 11 November 2014 at Yalata, AFSS case manager Ms Dunn spoke with Ms Jebydah, as a result of which Ms Dunn telephoned Ms Lawrence at FSA to advise of what she had been told.82 Then, on 12 November 2014, Ms Dunn made a CARL report.83 Ms Jebydah told Ms Dunn that she had heard lots of violence in Kunmanara May’s home, including SK slapping and pushing her. Ms Jebydah said she was highly concerned for C’s wellbeing and wanted to care for him. Ms Dunn advised Ms Lawrence at FSA that she had spoken to Kunmanara, who continued to deny domestic violence, but was willing to come to Ceduna to access services. It was also mentioned that SK’s mother was reportedly not taking any action to ensure the child’s safety and wellbeing.
6.174. Ms Dunn advised in the CARL report she then made that, according to the informant, the father ‘pushes the mother around’ and also ‘slaps’ her, that he yells at her and ‘makes her do things’, for example she would be in trouble if dinner is not on the table or if she does not cook for him. Ms Dunn advised that she had known Kunmanara for about one year and had suspected domestic violence for some time and that about two weeks earlier Kunmanara admitted domestic violence by SK towards her.84 Ms Dunn expressed concern that although Kunmanara had some insight, she was young and although she did not like what was happening, she may not leave SK. Ms Dunn referred to Kunmanara’s small frame.
6.175. Under the heading ‘Additional Information’ it was recorded that Ms Dunn was aware that Kunmanara May was going to Ceduna that day to liaise with AFSS and to be 82 Exhibit C47, page 159 83 Familial Intake Report, Exhibit C49, page 23 84 This was the admission made on 31 October 2014
referred to domestic violence services, ‘however it is unclear at this stage how things will pan out and whether the mother will want to leave the father’.
6.176. The assessment of FSA in relation to this report was recorded as ‘Significant risk of emotional abuse due to domestic violence’ and ‘Today’s report in conjunction with recent CP history indicates that the DV is chronic’.
6.178. The FSA casenotes85 provided to the Court do not indicate an outcome of this report, but it may be gleaned by reference to the AFSS notes.
6.179. Kunmanara May travels to Ceduna 12 November 2014 6.180. Kunmanara May travelled by bus to Ceduna on 12 November 2014 and stayed at the Step Down Unit, where Ms Dunn and Ms Iversen visited her. She told them in conversation that John Mungee stands up for her if SK gets mean/rough with her, but she admitted that SK’s mother does not step in to help.
6.181. After a meeting with the FSA financial counsellor, Kunmanara May told the AFSS workers that she had thought about a suggestion they had made and decided she would like to go to Adelaide and stay with her godmother Julieana.
6.182. During a later conversation with Centacare DV workers, when asked if she was safe at home, she said she was safe sometimes and that if feeling unsafe she would go to her grandmother Margaret May’s or to Ms Jebydah’s house. She confirmed she wanted to go to Julieana’s in Adelaide to have a break from SK.
6.183. To Adelaide for a break 6.184. Kunmanara May left Ceduna for Adelaide on 14 November 2014 and on 17 November 2014 her godmother telephoned Ms Iversen to say that Kunmanara had decided to stay in Adelaide for a couple of weeks, that when she returned she would like to live at Oak Valley with her Mum Janet and that she would definitely not be going back to Yalata.
On 21 November 2014 Ms Iversen was advised that Kunmanara would be catching the bus back to Ceduna on Monday 24 November 2014. Ms Iversen spoke to Kunmanara 85 Exhibit C47
advising that she would need a new safety plan before she could return to (Yalata) community.
6.185. On the morning of 24 November 2014, Ms Lawrence at FSA telephoned Ms Iversen to discuss Kunmanara May’s impending return. Ms Iversen advised that Kunmanara had decided not to return home to SK and that she would like to live with her Mum between Yalata and Oak Valley. Kunmanara had told Ms Iversen she did not want to be like her auntie who had all her children removed. Ms Lawrence said that if another child protection report was made it would be very serious for Kunmanara, and Ms Iversen assured her that AFSS would have hard conversations with Kunmanara about this, and were hoping to keep her in town (Ceduna) for a few days, in order to have these conversations. Centacare advised that Kunmanara could be accommodated at the Ceduna safe house for a few extra days before she returned to Yalata.
6.186. Kunmanara May returns to Ceduna and a safety plan is made 6.187. Soon after arriving by bus at Ceduna on 24 November 2014, Kunmanara May told Centacare DV worker Chloe Carr that she wanted to return the next day to Yalata, to live with a family member. Nevertheless, she remained in Ceduna for a couple of days, where AFSS and Centacare DV workers spent time with her working on a safety plan.
She agreed she would live with Debra May, not with SK, and that she might take C to see SK sometime during the day, if Ms Jebydah or someone was at the house. She agreed SK would not come to the house she was living in. She was regarded as willing to be part of the case plan and offered ideas about how she was going to keep herself and C safe from SK when he is angry. She was told that if she went back to SK’s house and lived with him, and there was another domestic violence report, FSA would take C away, and Kunmanara said she did not want that to happen. Ms Carr was to continue to work with Kunmanara as her Centacare DV worker. AFSS and Family Violence Outreach committed to helping Kunmanara get her things out of the house SK was living in. Ms Dunn, as her AFSS case manager, was impressed with Kunmanara’s commitment to the plan. The safety plan was agreed on 26 November 2014.
6.188. Ms Iversen telephoned Mark Hutchins at Yalata Police Station and informed him that Kunmanara May was returning to Yalata after nearly a two week break from her current domestic violence situation with SK. She told him about the safety plan. She told him AFSS would continue to monitor the situation and that Centacare DV was involved.
Senior Constable Hutchins agreed that Yalata police would monitor the situation as well.
6.189. Ms Iversen suggested to Ms Carr that Centacare might refer Kunmanara May again to the FSF. Ms Carr advised it was her last day and that she would advise Tracy Cox, who would be taking over as Kunmanara’s Centacare DV worker.
6.190. FSA case closed - referred to other agency 6.191. On 24 November 2014, FSA closed the case arising from the child protection report on 12 November 2014, Supervisor Ms Lawrence recording that it was being ‘referred to other agency’ (AFSS).
6.192. The following was recorded: ‘There is an ongoing pattern of DV between the mother and her partner which the child is likely being exposed to. Mother is currently engaged with AFSS who have supported mother and child to go to Adelaide for two weeks. Mother is due to return today and has indicated she does not wish to return to reside with her partner. AFSS will be assisting mother to stay in Ceduna for a few days prior to her returning to reside with her own mother. AFSS have agreed to continue to follow up and address the DV concerns with the mother via their ongoing engagement.
FSA will close the case at this time, however should further information be received regarding the child being at risk or unsafe due to DV between the mother and her partner, then strong consideration should be given to allocating this intake for investigation’. 86
6.193. Referral to FSF 2 December 2014 6.194. On 28 November 2014 Centacare DV worker Ms Carr completed a Domestic Violence Risk Assessment in relation to Kunmanara May, who was then referred by that agency to the FSF.
6.195. Kathryn Meier from Centacare DV Service completed the FSF referral, which was submitted together87 with the risk assessment (Risk Rating - 37 medium risk). This referral outlined the belief that Kunmanara May was the subject of emotional and physical abuse. Ms Meier cited two specific examples of violence - on 14 May 2014, Kunmanara complained of hurting on the inside after being thrown against a wall by SK and, on 20 May 2014, she was allegedly locked in the car and hit repeatedly by SK.
86 Exhibit C47, page 172 87 Exhibit C59, Appendix B
6.196. Domestic violence concerns re-emerge 6.197. Within days of Kunmanara May’s return to the Yalata community, Ms Dunn and Ms Iversen heard gossip from different sources in the community that Kunmanara was spending time with C and SK at SK’s mother’s house, that SK was locking her in a room, and that SK was getting money from Kunmanara. They spoke to Kunmanara who said that she was there sometimes (at SK’s house), and the AFSS workers discussed the assistance which could be arranged to get her things from SK’s house.
6.198. A couple of days later Ms Cox, the new Centacare DV worker, spoke to Kunmanara May about going to Oak Valley to stay with her mother and assured her that she could arrange a ride for her. By 5 December 2014, Kunmanara told Ms Cox that her mother would be returning to Yalata so she could not go to stay with her at Oak Valley.
6.199. On 9 December 2014 Kunmanara May’s AFSS case manager and two care workers went to Yalata and at Debra May’s house were told that Kunmanara had not been staying there for about a week. They found Kunmanara at SK’s mother’s house and she told them she was sleeping at Debra May’s and going to SK’s mother’s in the morning. She was then asked to be honest, and she admitted that she was staying with SK. AFSS told Kunmanara they would have to prepare a new safety plan and invited her to ask SK to be involved. They informed Ms Cox of what was occurring.
6.200. On 11 December 2014 Kunmanara May did not turn up for a meeting with Ms Cox, the Centacare DV support worker.
6.201. On 11 November 2014 Ms Dunn telephoned Ms Lawrence at FSA, who advised that the available information indicated that Kunmanara May was not following the safety plan and a child protection report would need to be made.
6.202. CARL report 11 December 2014 6.203. AFSS made a report by telephone on the afternoon of 11 December 2014. A description was given of what had occurred since the report in November 2014 and how, when she returned to Yalata, Kunmanara May appeared not to be complying with the safety plan and was living with SK. The belief that Kunmanara was being locked in a room by SK was conveyed. It was stated that C had appeared to be happy and healthy. Information
was provided that Kunmanara had not attended her appointment with Centacare the previous day.
6.204. The AFSS worker advised that Kunmanara May had a further appointment with AFSS on 17 December 2014 and AFSS would continue to have contact with the family. They were advised by FSA that if further concerns arose about the mother’s safety a welfare check could be requested from SAPOL.
6.205. This report was assessed as a Tier 2 but was closed the following day (12 December
6.206. AFSS Partnership meeting with FSA 16 December 2014 6.207. On this day Kunmanara May’s case manager, Ms Dunn, and three other AFSS caseworkers including Ms Iversen, met with Ms Lawrence from FSA. Although the Court was provided with no note of this meeting from FSA, AFSS documented that FSA was updated that:
6.207.1. Kunmanara May was back living with SK; 6.207.2. AFSS intended to go to Yalata the next day to prepare a safety plan, hopefully including SK;
6.207.3. AFSS had notified SAPOL of the situation; and 6.207.4. To community members it appeared that there was no DV going on at the moment but ‘we all know it will happen again’ and were watching out for Kunmanara May.
6.208. FSF Meeting 16 December 2014 6.209. This was the first Family Safety Meeting which considered Kunmanara May under the new referral and was chaired by Senior Constable Van Hout.
6.210. Ms Meier was present as the Program Manager for the Regional Domestic Violence and Aboriginal Family Violence for Centacare Catholic Family Services, the referring agency. She gave evidence that she presented the referral to the meeting but there was much more said than is recorded in the minutes. The minutes noted that Centacare had organised for Kunmanara May to go back to Oak Valley, but that her mother had moved back to Yalata and family members stated that Kunmanara is not safe. It was also noted that in the previous week Centacare was unable to make contact with Kunmanara.
6.211. It was recorded that nothing had come to SAPOL in relation to Kunmanara May.
6.212. The AFSS contribution (Ms Dunn and Ms Iversen were present) was recorded in some detail in the minutes. It referred to Kunmanara May moving with C back into SK’s mother’s house to be with him, contrary to the safety plan. AFSS intended to prepare a new safety plan at Yalata on 17 December 2014. They had notified SAPOL and asked them to keep an eye on the situation. Kunmanara had told AFSS at Yalata the previous week that things had settled down with SK and his parents had spoken to him about treating her better. AFSS had received no further information in relation to recent incidents.
6.213. Actions recorded were: AFSS to develop a Safety Plan; • FSA to investigate to ensure that (C) is safe (Do not have the capacity to investigate • now); and SAPOL to raise DVR (Domestic Violence Report).
•
6.214. Ms Iversen provided SAPOL with detail of Kunmanara May’s known domestic violence history.
6.215. On 18 December 2014, in response to a request made by Senior Constable Van Hout at the FSM, because she had realised SAPOL had no records in relation to Kunmanara May,88 Ms Iversen prepared and sent to Senior Constable Van Hout a detailed email89 summarising Kunmanara’s history, as known to AFSS.
88 Transcript, page 256 89 Exhibit C50, page 98
6.216. It first referred to the late January 2014 observation by AFSS workers of the injury under Kunmanara May’s eye, and her swollen lip. To recap, this is the injury which had been accepted by Brevet Sergeant Johnson as a result of falling over, and which he had not recorded in SAPOL information systems.
6.217. It referred to various other incidents, most of which thereby came to the attention of SAPOL for the first time: a) the CARL report on 20 March 2014 about Kunmanara May having no nappies or formula for C; b) the information received on 6 March 2014 and reported to FSA that Kunmanara May had come to church crying and looking for her sister because SK had grabbed her around the throat and punched her in the heart; c) the information received on 14 May 2014 and reported to FSA the following day that Kunmanara May arrived at Sorry Camp in the middle of the night shaking and crying, having left the house with C in it, after SK threw her against a wall; d) that as a result of this Kunmanara May had gone to Ceduna for four nights and returned to Ms Jebydah’s house, with SAPOL at Yalata being informed; e) that AFSS were informed that Kunmanara May returned to SK immediately and that he locked her in a car and hit her repeatedly; f) after the June to August referral to the FSF, Kunmanara May’s mother telephoned FSA on 24 October 2014 expressing concern that domestic violence was still taking place; g) AFSS workers were informed on 11 November 2014 (CARL report 12 November
6.218. In relation to three particular incidents of violence (Kunmanara May grabbed around the throat and punched in the heart, being thrown against a wall, and being locked in a
car and hit repeatedly) the email advised Senior Constable Van Hout of the identity of the informants.
6.219. The email also referred to Ms Dunn’s conversation with Jaleen Miller in which she referred to the community knowing that the domestic violence would happen again and that they were all watching out for Kunmanara May and for C.
6.220. Senior Constable Van Hout forwarded this email to Brevet Sergeant Johnson at Yalata asking him to ‘keep a close eye and we will try to visit and follow up on myself’.
6.221. Brevet Sergeant Johnson was on leave and on 24 December 2014, Constable Marc Hutchins responded, by email, ‘Wow! That’s a big email! I haven’t had any dramas from that house’.
6.222. Senior Constable Van Hout responded asking if someone could catch up with Kunmanara May and ensure she cannot be encouraged to report anything and that ‘supposably (sic) she got a fairly big hiding on the weekend…’. This was a reference to information which Senior Constable Van Hout received on 22 December 2014.
6.223. Information received on 22 December 2014 about violence on the weekend of 20 December 2014
6.224. On 22 December 2014 an AFSS care worker advised Deb Swan, Project Officer, FSA that AFSS had not been able to get to Yalata the previous week, so Ms Iversen asked Ms Swan if she could check on Kunmanara May’s situation. Ms Swan quickly got back to Ms Iversen advising that she had spoken to a community member who told her that Kunmanara had not had a good weekend and that she has a black eye.
6.225. Ms Iversen brought this allegation to the attention of Ms Cox at Centacare DV Services and advised that she would be on holidays from 24 December 2014, returning to work on Monday 5 January 2015.
6.226. As has been noted under the previous heading, Senior Constable Van Hout asked police at Yalata if they ‘could catch up with Kunmanara May and ensure she can’t be encouraged to report anything’ but there was no request to Yalata police to speak to the known informant by way of investigation, and there was no evidence before the Court of what, if anything, was done by the Yalata police. If anything was done there was apparently no record made of any action.
6.227. CARL report 22 December 2014 – closed no action 6.228. Ms Swan made a CARL report advising of this information. A FSA case note the following day records that, although it was acknowledged that an investigation was required to assess the risk and safety of the child, which supervisor Ms Lawrence had committed to doing when capacity allowed, there was no capacity to allocate this intake and it was to be forwarded to the Ceduna FSA manager, Pia Richter to approve that it be CNA.
6.229. Ms Dunn emailed90 Ms Richter, before the case was closed, expressing concern about the closure plan. She expressed that she was deeply worried about this. She did not think C could be protected in that household. She pointed out that (Kunmanara May) ‘is a very small timid young woman’.
6.230. SAPOL advised 6.231. This report of violence was brought to the attention of SAPOL, which is evident from correspondence between Ms Iversen and Senior Constable Van Hout, about whether there were witnesses to the incident on the weekend. Senior Constable Van Hout commented to Ms Iversen that she ‘was going to personally try to get a statement and try to achieve something’ and ‘it is a regular occurrence that no one ever sees anything … even when we know everybody does …’. Senior Constable Van Hout commented that she had kept the ‘Yalata crew’ up-to-date.91
6.232. Senior Constable Van Hout gave evidence that she heard of the incident when she bumped into Ms Iversen at Foodland.92
6.233. Domestic Abuse Report prepared relating to Ms Iversen’s extensive email 23 December 2014
6.234. On 23 December 2014 Senior Constable Van Hout prepared and submitted DAR number 15/Q9281693 using the extensive information which Ms Iversen had sent her on 18 December 2014, cut and pasted into the report.
90 Exhibit C47, page 206 91 Exhibit C50, page 102 92 Transcript, page 262 93 Exhibit C58, Appendix 11
6.235. Senior Constable Van Hout explained in the investigation diary that the matter had been referred to the FSF at Ceduna via AFSS, and that she had requested details of the matter as (SAPOL) had nothing reported/recorded since the prior referral. She also recorded: That the email had been forwarded to the Yalata officers; and • That she was aware that previously Yalata members (requested by her) have • approached Kunmanara May but she has not reported incidents.
6.236. Senior Constable Van Hout concluded: ‘This situation will need to be closely monitored. If Kunmanara May does want to report any of these incidents, the matters can still be investigated. Have sent a request to (reporting person) to ascertain if any persons have witnessed the assaults, because at this time victim has not come forward (even when spoken to by police)’.94
6.237. In Senior Constable Van Hout’s evidence she appeared to misread the investigation diary, as if it said, ‘If (Kunmanara May) does not want to report any of these incidents, the matters can still be investigated’.95 She went on in evidence to say that her reaction at the time was that the matter needed to be investigated with or without the support of the victim. It was my impression that she was honest about this (as was my clear impression about Senior Constable Van Hout generally), and that she had intended to say in the investigation diary that it could be investigated even if Kunmanara did not want to report anything.96
6.238. Indeed, that was the fact of the matter. SAPOL was by then in a position to make specific inquiries, knowing who the informants were, in order to ascertain in relation to each incident whether any person might give a statement and, if so, what they might say.
6.239. Senior Constable Van Hout gave evidence that it would ordinarily be her responsibility to undertake further investigations, but given that she was in Ceduna, the file should probably have been electronically sent to Yalata patrols to investigate, and it would be meant to go through a supervisor as part of the vetting process.
94 Ibid, page 17 95 Transcript, page 258 96 Transcript, page 260
6.240. Senior Constable Van Hout said did not prepare a risk assessment because she had not had the opportunity to see the victim herself to do so.97
6.241. FSF Meeting 30 December 2014 6.242. SAPOL’s contribution at this meeting was recorded as, ‘Various comments have been made within community of abuse, but nothing reported. Yalata police are monitoring’.
6.244. Actions recorded were: Centacare to contact (DV worker) in Yalata and to visit weekly.
• FSA to investigate abuse allegations and to speak to AFSS on Monday 5 January • 2015.
Yalata police to monitor.
•
6.245. Although both Ms Lawrence (FSA) and Senior Constable Van Hout were present at the meeting (as well as a representative of Centacare), and both knew of the information that ten days earlier Kunmanara May had ‘not had a good weekend and had a black eye’, there was no record in the minutes of this having been specifically discussed.
There was no record from SAPOL of the informant from the community having been approached for information, or of the Yalata police having been specifically asked to do so.
6.246. An active and effective engagement by the FSF in the ongoing protection of Kunmanara May required that this recent reported incident be regarded as a potential opening for further investigation which might reveal sufficient evidence to support perpetrator focused action, such as an intervention order, if not a criminal charge.
6.247. Brevet Sergeant Johnson returns from leave and reads Ms Iversen’s email 6.248. Brevet Sergeant Johnson returned from leave on 1 January 2015 and saw Senior Constable Van Hout’s email of 24 December 2014 providing the detail of AFSS knowledge of violence from SK against Kunmanara May. He responded to Senior Constable Van Hout by email, ‘Just FYI re these guys, I haven’t heard much at all re these 2’.
97 Transcript, page 257
6.249. One might think that a careful reading of that email might inspire Brevet Sergeant Johnson to consider how the apparent extent of abuse could have flown under his radar, and how he could address this. There were, after all, three incidents referred to by Ms Iversen in which there were informants who had never, to Brevet Sergeant Johnson’s knowledge, been approached by police. There is an echo here of his failure to make the specific inquiries which would have led him to Ms Jebydah in relation to the injuries about which he made enquiries in February 2014. That is not to say, of course, that these enquiries would have borne fruit. Neither is it the case that Brevet Sergeant Johnson did nothing; he attended Debra May’s house on 7 January 2015 with a view to speaking to Kunmanara May. He then spoke to Debra May and she said that Kunmanara had not been seeing much of SK and that she thought they were separated at the time. She said that Kunmanara had been largely staying with her at her house.
She said Kunmanara had been out with Russell Bryant camping and that she was not aware of any issues between Kunmanara and SK. Brevet Sergeant Johnson asked Debra May that if anything happens between the pair, to do him a favour and contact police at the station to let them know.98 She said she would do so. On the same day Brevet Sergeant Johnson sent an email to Senior Constable Van Hout advising of this information. 99
6.250. AFSS contact with Kunmanara May and Russell Bryant 6.251. AFSS workers spoke with Kunmanara May on 7 and 8 January 2015 during brief visits to Yalata while she was camping, and then on 9 January 2015 they spoke to her on the phone while she was camping, and also spoke to Russell Bryant. At this time Kunmanara stated she was unsure whether, when she came back from camping, she would be staying with Russell and Doris Bryant, or would be going back to live at SK’s house.
6.252. On 13 January 2015, AFSS workers received a phone message to call Russell Bryant and shortly before the FSF Meeting they called him back. The notes of the call to Mr Bryant make ominous reading: ‘Returned from camping at Colona Station yesterday; Russell and Doris have been caring for (Kunmanara May) and C while camping and keeping them safe; 98 Transcript, page 53; Exhibit C53 99 Exhibit C53, page 11
Since returning to Yalata, (Kunmanara) has been spending time during the day with her Mum (Janet May) and her grandmother (Margaret May) then returning to Debra May’s house in the late afternoon; (Kunmanara) has been sneaking out of Debra May’s after dark and going to stay with
(SK); (Kunmanara) has a lot of scars from SK and also had a black eye from Christmas; Russell feels that (Kunmanara) is hiding the issues from family and that she keeps secrets; Russell would like a Restraining Order taken out against (SK) to keep (Kunmanara) and C safe, family try to keep (Kunmanara) safe but (she) continues to see SK; Debra May and Alison May talk to (Kunmanara) and tell her to keep away from SK; Russell is really worried about (Kunmanara) getting sick or SK really hurting her.’
6.253. FSF Meeting 13 January 2015 6.254. On this occasion, Senior Constable Van Hout was an apology and Senior Constable Wilson chaired the meeting.
6.255. On behalf of SAPOL it was recorded that Yalata patrols were well aware of Kunmanara May’s situation, referring to Brevet Sergeant Johnson’s recent email: ‘(Kunmanara May) is said to be separated from (SK) now. She is residing with Debra May at her house here in Yalata. I have spoken with family to get in touch if there are any further issues between her and SK. She has been camping with Russell Bryant for the last week or so and has just returned, so we will keep an eye out up here.’
6.256. The AFSS report to the FSF meeting detailed what Russell Bryant had said to them in the earlier telephone conversation: ‘Russell (brother-in-law) said that he was watching and trying to protect (Kunmanara May) from (SK); The family have all spoken to (Kunmanara); (Kunmanara) knows that FSA will become involved if there is another CP report; (Kunmanara) is still seeing (SK), and the community are scared for her safety; Russell said that (Kunmanara) needs to keep away from (SK’s) house; Russell asked if the police can put a restraining order on (SK); It appears that (Kunmanara) is visiting (SK).’
6.257. Actions from the meeting were rolled over from the previous meeting, for Centacare to speak to Bianca Mitchell (Centacare in Yalata) for weekly visits and for FSA to investigate abuse allegations and speak to AFSS.
6.258. There is no suggestion in the oral evidence, or in any record produced to the Inquest, that there was any action or follow-up arising from Russell Bryant’s request to police for a restraining order, or that anyone considered whether and how this might be achieved.
6.259. New Safety Plan 14 January 2015 6.260. On this day AFSS convened a meeting at Russell and Doris Bryant’s house for the purpose of discussing a new safety plan. In attendance were Ms Dunn and Ms Iversen, Kunmanara May, Russell Bryant, Kunmanara’s grandmother and her cousins Debra and Fiona.
6.261. The AFSS workers praised the family’s protective actions while acknowledging Kunmanara May’s right to make her own decisions. Ms Dunn asked Kunmanara if, when she sneaks out to SK’s, she could organise for a responsible family member to watch over C instead of taking him with her. She agreed. Russell stated that he could not talk directly to SK as they were of the wrong skin group. He said he could speak to SK’s mother and stepfather John Mungee, but asked AFSS to have a conversation with them instead.
6.262. Russell Bryant stated that Kunmanara May had been getting tougher on SK when he got cheeky/rough with her and had been telling him to stop because he was hurting her.
6.263. Importantly, Russell Bryant asked if AFSS had let SAPOL know about the situation and Ms Iversen said that SAPOL had been advised what was going on and were keeping an eye out for Kunmanara May and C.
6.264. It was ascertained that Kunmanara May’s grandmother was going back to Oak Valley, and she agreed to take Kunmanara and C with her for a break. Ms Dunn said she would speak to Centacare to try to arrange transport to Oak Valley.
6.265. Finally, Case Manager Ms Dunn then spoke about how FSA would become very involved with Kunmanara May’s case should another child protection notification be made and reminded the family of other children in the family that have been removed and how hard a fight it had been for those children to be returned to community/family.
6.266. I make no criticism of Ms Dunn for saying this. She was trying sincerely to convey to Kunmanara May, and persuade her of the reality of, FSA’s obligation to protect children
from harm. In doing so, she was attempting to persuade Kunmanara to take the actions necessary to protect C from harm, preferably by terminating her relationship with SK but, in any event, by ensuring that C was not exposed to violence perpetrated by SK.
6.267. The reality may be that Ms Dunn was simply reinforcing in Kunmanara May a desire not to be secretive about violence which was going on in her relationship. However, it cannot be imagined that anything Ms Dunn said about the possibility of C being removed if she exposed him to the risk of harm, by exposing him to domestic violence, was not something Kunmanara well knew.
6.268. At the end of the meeting the safety plan was signed, and a copy was delivered to the manager of the Mothers and Babies Clinic for their records.
6.269. The AFSS workers then went to speak to SK’s mother at her home. She said she had been talking to SK about returning to his country to stay with his grandmother. She said she knew everyone in the community was talking about SK and she had been praying for SK, Kunmanara May, C and for the community members who had been talking about them. She was told, when she asked, that she would still be allowed to take C away on trips with her and John Mungee if appropriate plans were made. SK’s mother said she would rather Kunmanara did not sneak over to her house as it puts her in a difficult spot, and it was suggested she could tell her to go home, and she could say that AFSS said that, if it made it easier for her.
6.271. AFSS quickly learns the new Safety Plan is not working 6.272. On 19 January 2015 a family member informed AFSS workers that Kunmanara May was still going to SK’s house at night and taking C with her (instead of leaving him with responsible family members as agreed in the Safety Plan).
6.273. On 22 January 2015, another family member told an AFSS worker that the family was sick of welfare coming around and asking questions about Kunmanara May. It was also said that the family was sick of helping Kunmanara as she does not listen and does her own thing anyway.
6.274. On the same day, Kunmanara May initially denied to Ms Iversen that she was staying with SK and wanted to know who was telling her where she was staying. She then
admitted that she was staying at SK’s ‘for a while’. Ms Iversen reminded her of the risk that FSA would become heavily involved, in the event of another child protection report and reinforced to her that she was a good Mum and was doing a fantastic job bringing up C.
6.275. On 23 January 2015, Ms Iversen informed Centacare DV worker Ms Cox, and Supervisor Ms Lawrence at FSA, that Kunmanara May was again living with SK. To Ms Cox, Ms Iversen expressed the view that the family being sick of welfare visiting was an attitude held by her extended family, but that Kunmanara’s sister Doris Bryant, who at the time was in Adelaide, was believed to be likely to continue to support Kunmanara when she returned.
6.276. FSF Meeting 27 January 2015 6.277. On this occasion Senior Constable Van Hout chaired the meeting.
6.278. AFSS was recorded as reporting – ‘Russell (brother-in-law) is not happy with agencies continually visiting. Three safety plans have been put in place. (Kunmanara May) may go back to Oak Valley with (her grandmother) Margaret May. Outreach visit scheduled for tomorrow 28 January 2015 to catch up with (Kunmanara)’.
6.280. Actions from the meeting were that SAPOL was to be advised of any injuries presented for (Kunmanara May) and C in the previous six months and AFSS was to continue to follow up and engage Kunmanara.
6.281. Relevant contacts leading up to the next (10 February 2015) FSF Meeting 6.282. On 28 January 2015 Ms Dunn visited Kunmanara May and her sister Doris at Ms Jebydah’s house and was informed by Kunmanara that she was finished with SK and that she was staying there with her sister and Russell Bryant. She said SK had been cheeky with her and that his Mum had asked her not to come to the house. She said she was happy staying with her sister Doris because she looks after her and C.
6.283. Ms Iversen informed Ms Lawrence at FSA of this, and also Ms Meier at Centacare.
She also turned her mind to how to assist in getting Kunmanara May’s whitegoods out of SK’s house.
6.284. Kunmanara May discloses violence to Senior Constable Van Hout 4 February 2015 6.285. On this day, Senior Constable Van Hout attended Yalata and spoke with Kunmanara May at the Mothers and Babies Clinic for about 20 minutes. Kunmanara was reluctant to speak and had to be supported by some women in the community. She said she was leaving that day to live with her mother at Oak Valley. She said that SK was getting rough with her and that was why she was leaving. She said that SK punched her on Christmas Day and gave her a black eye, but she refused to provide further details.
Senior Constable Van Hout offered Kunmanara the opportunity to make a statement and offered her assistance to stop SK from ‘being around her again’ which she declined.
She said SK does not assault the baby, that she was taking C with her to Oak Valley, and she was confident he would not follow.
6.286. Senior Constable Van Hout stated that she completed an electronic CARL notification100 but no reference to this appeared in the FSA intakes101 or the FSA casenotes102 produced to the Court for the purpose of the Inquest.
6.287. Senior Constable Van Hout did not submit a PIR in relation to the incident of which Kunmanara May told her and she agreed in evidence that she ought to have done so.
She added it to the investigation diary relating to the DAR 15Q92816. She also notified AFSS of this by email.
6.288. Senior Constable Van Hout also sent an email on 6 February 2015 making patrols in Yalata aware of the situation and requesting that they monitor SK’s movements. This was to ensure that SK did not interfere with her safety plan and her plans to move to Oak Valley.
6.289. By 10 February 2015 it was known to AFSS and Centacare DV workers that Kunmanara May’s mother and grandmother had not yet gone to Oak Valley and that Kunmanara could not stay with her grandmother in the aged care unit. Ms Iversen expressed the thought to Ms Cox that Kunmanara was saying she was going to Oak Valley because it was what she thought the agency workers wanted to hear.103 100 Van Hout statement, Exhibit C58, page 8 101 Exhibit C49 102 Exhibit C47 103 Exhibit C50, page 123
6.290. FSF Meeting 10 February 2015 6.291. Senior Constable Van Hout was present on behalf of SAPOL and chaired this meeting.
6.292. The minutes record that Senior Constable Van Hout advised that Kunmanara May stated that SK did assault her on Christmas Day and did not want to make a report, and that she is moving to Oak Valley.
6.293. AFSS is recorded as having reported that Kunmanara May was still in Yalata until her mother goes to Oak Valley, that she was spending time at Mother and Babies group, and that SK’s mother has stated that she does not want Kunmanara to come over to her house. It was also reported that other living arrangements are available to Kunmanara in Oak Valley. This was a reference to the fact that Kunmanara would not be able to live with her grandmother Margaret May, as referred to by Centacare.
6.294. Centacare reported that although transport had been arranged for Kunmanara May to Oak Valley they were currently unable to do so because of extreme temperatures. It was also reported that Kunmanara will be unable to reside with Margaret.
6.295. I observe that it appeared from the contributions of this meeting that although Kunmanara May was stating an intention to go to Oak Valley it was not clear that there was accommodation for her there.
6.296. Relevant contacts with Kunmanara May prior to next (24 February 2015) FSF meeting 6.297. On 12 February 2015, Ms Iversen saw Kunmanara May at the Mothers and Babies Clinic and Kunmanara said that she was still going to Oak Valley when the weather cooled down, but in the meantime had been camping with her grandmother. She said she was not seeing SK.
6.298. FSF Meeting 24 February 2015 6.299. This meeting was chaired by Senior Constable Mary Octoman, in the absence of Senior Constable Van Hout, who was on leave.
6.300. AFSS reported that when they attended Yalata the previous week, Kunmanara May was staying with her mother and grandmother and stated she had finished her relationship with SK and still wanted to go back to Oak Valley. She was attending Mothers and Babies regularly.
6.301. By Centacare it was reported that on 18 February 2015 Kunmanara May attended the Mothers and Babies group and was doing well. Then, on 20 February 2015 at midnight, she presented to the safe house (Ceduna) seeking accommodation.
6.302. Actions from the meeting were that AFSS would continue to work with Kunmanara May and Centacare and AFSS were to investigate travel to Oak Valley and accommodation.
6.303. Relevant contacts with Kunmanara May prior to next (10 March 2015) FSF meeting 6.304. On 25 February 2015, Ms Iversen spoke with Kunmanara May, who was staying in Ceduna at the Foreshore Motel with a friend. On this occasion she advised that she did not want to go and live at Oak Valley, so Ms Iversen made arrangements for her to go to Housing SA in the morning to put her name on the waiting list for housing in Yalata.
6.305. The next day, Kunmanara May advised Ms Iversen that her sister Doris and brother-inlaw Russell were getting the keys to a house in Yalata that day, and she and C would be moving in with them.
6.306. At this stage C was having some health issues, to which Kunmanara May was apparently diligently attending. By 3 March 2015 Kunmanara wanted to go back to Yalata and a seat was arranged for her on the bus the next day. AFSS workers made enquiries to confirm that she had somewhere to live and that members of the community were aware of her return and were going to look out for her.
6.307. On 10 March 2015 AFSS workers received news that Kunmanara May and C were back living at SK’s mother’s house with SK. Russell Bryant told them that he had tried to stop Kunmanara but that any time SK rang, Kunmanara went running to him.
Mr Bryant expressed to Ms Iversen that the family was concerned for Kunmanara’s safety.
6.308. Ms Iversen telephoned Ms Lawrence at FSA and advised of this. Following that, Ms Iversen made a CARL report. It is also apparent from the AFSS records that Ms Iversen informed SAPOL.
6.309. Final CARL report 10 March 2014 6.310. Ms Iversen telephoned the CARL and made a notification that Kunmanara May had returned to live with SK contrary to the protective arrangements which had been made.
The report was assessed as a Tier 2 with there being a risk to the child of emotional abuse due to domestic violence.104
6.311. FSF Meeting 10 March 2015 6.312. On this occasion, Senior Constable Mary Octoman chaired the meeting and Senior Constable Van Hout was present, back from leave.
6.314. SAPOL’s contribution was recorded as ‘Willing to ascertain a statement any time from (Kunmanara May)’.
6.315. AFSS contributed, according to the minutes, ‘(Kunmanara May) living away from (SK); community supported this. (Kunmanara) was in Ceduna last week. It is now believed that (Kunmanara) has gone back to (SK)’.
6.316. Centacare is minuted as contributing, ‘Willing to assist (Kunmanara May) with transport to Oak Valley, if required’.
6.317. FSA’s contribution was that Kunmanara May’s mother Janet was in Yalata/Ceduna for native title; unsure when she was returning to Oak Valley (the point apparently being made was that Kunmanara could not stay with her mother at Oak Valley because she was not there).
6.318. Relevant contacts with Kunmanara May leading to 24 March 2015 FSF meeting 6.319. Police welfare check 12 March 2015 6.320. The day after the FSF meeting, Hedley Richards (Project Officer FSA), conveyed to Ms Iversen concerns expressed by Russell Bryant that Kunmanara May had not come to stay with Doris and him upon returning from Ceduna, but went straight to SK’s.
104 Exhibit C47, page 234
6.321. On 12 March 2015, Hedley Richards again rang Ms Iversen; this time Russell Bryant was with him. Mr Bryant said that he and Doris had not seen Kunmanara May for a few days and the family was concerned for her safety. Ms Iversen agreed to request a welfare check. There was some discussion about whether SK’s mother was there, as she had previously agreed not to let Kunmanara stay at her house. Mr Bryant said that the community have been talking and saying that SK even gets rough with (his mother).
Mr Bryant said that he had talked with SK’s mother, but she was not listening.
6.322. On this date, Senior Constable Van Hout received an email from Ms Iversen regarding her concerns as to Kunmanara May’s whereabouts. As a result, Senior Constable Van Hout contacted Yalata patrols and requested that they do a check on welfare.
6.323. Senior Constable Hutchins105 attended John Mungee’s house, where Kunmanara May was apparently living with SK. Senior Constable Hutchins made no notes, and he telephoned Senior Constable Van Hout soon afterwards. His statement recorded that he had never met Kunmanara, who came outside. As he recalled the gist of the conversation, he asked her ‘Are you okay?’ and ‘How are things between you and (SK)?’, and ‘Have you been hurt by SK?’. He said she stated she was fine and that she and SK were getting along well. Senior Constable Hutchins saw no injuries and found her to be in good spirits and appearing to be happy. He said he had no cause for concern for her welfare.
6.324. Senior Constable Hutchins advised Senior Constable Van Hout of the outcome of his enquiries, and AFSS, Centacare and FSA staff were also advised by email. This email also reported that Senior Constable Hutchins had been able to speak with John Mungee, who said there had been no incidents for a while and that they have been getting along well.
6.325. This was the last interaction that police had with Kunmanara manoeuvre prior to her death.
6.326. AFSS speaks with Kunmanara May 17 March 2015 6.327. On 17 March 2015 Ms Dunn was in Yalata and spoke to Kunmanara May, who said that she was back living with SK and his mother and her partner. She said SK did not hit her anymore and she felt safe when his parents were home. She appeared happy.
105 Exhibit C30
SK’s mother said that her partner had a good talk to SK and that she would be looking out for Kunmanara and C. Kunmanara said she knows she can go to Doris and Russell’s house or Marilyn’s house to be safe. Ms Dunn told Kunmanara and SK’s mother that in the event of another report of violence, FSA could take C away. This was acknowledged and she said he would be protected. Ms Dunn told Kunmanara that AFSS would be closing her case, ‘as she has done all the right things and that C has developed into a strong healthy little boy’.
6.328. AFSS case closure 6.329. Despite FSA’s repeated case closures AFSS maintained their support until, and only until, the caseworker was due to take maternity leave on 20 March 2015.106 Instead of transferring the client to another case worker, which I suggest would have been the appropriate decision, the case was closed. Ms Iversen agreed, with the benefit of hindsight, that this should not have occurred.107 The one organisation that had the most contact and provided the most support to Kunmanara manoeuvre was no longer there to support her.
6.330. On 19 March 2015, AFSS forwarded a completed Monthly Progress Report for March regarding its case with Kunmanara May and a Family Closure Form108 in order to formalise the closure of the FSA referral. One of the stated purposes of the form was ‘To formalise and mark the end of AFSS Stronger Families Intervention with the family’.
6.331. Several sections of the Closure Form warrant specific mention here. The first was an enthusiastic assessment of Kunmanara May and her parenting capacity under the heading, ‘What is going well now? What has changed? Why?’: ‘(Kunmanara May) is an amazing mother to (C). She is attentive to his needs, he is well fed and always appropriately dressed. (Kunmanara) attends the clinic when (C) is ill and administers medicine to (C) consistently, on time and in line with the doctor’s instructions.
(Kunmanara) manages her finances quite well on her own since joining up to the Income Management Scheme. The Scheme has made it possible for (Kunmanara) to budget for things such as food and clothing and her payment now stretches to cover the whole fortnight’.109 106Transcript, pages 791, 845 107 Transcript, page 845 108 Exhibit C50, page 339 109 Ibid. page 341
6.332. Under the heading, ‘What am I still worried about? Why?’, Ms Dunn wrote, leaving no room for misunderstanding: ‘AFSS are worried about (Kunmanara May) and C as SK is a perpetrator of Domestic Violence. (Kunmanara) is only a petite woman and AFSS are concerned that SK could really hurt (Kunmanara) or possibly even kill her.’
6.333. Ms Dunn stated in the form a willingness to accept another referral to work with Kunmanara May regarding domestic violence should this be deemed necessary.
6.334. FSF Meeting 24 March 2015 6.335. This meeting was chaired by Senior Constable Van Hout.
6.336. SAPOL’s contribution was recorded as follows: ‘(Kunmanara May) was contacted and conversation had satisfied staff that C was not in danger. Through speaking with (Kunmanara’s) mother and mother-in-law it was acknowledged that (Kunmanara) is living with her partner (SK) but is aware of the Safe House option if needed. Email information – Yalata patrol also had the opportunity to (speak) with Mungee who said that there had been no incidents for a while and that (Kunmanara) and (SK) have been getting along well. – Appeared no imminent concern.
Tullawon Health has been contacted by police to update if they had any concerns.’
6.337. The Centacare representative is recorded as reporting that Kunmanara May and C had been sighted with other family members in Yalata and appeared very happy.
6.338. There was no other update from any agency, including FSA. It is clear that by then FSA had closed the most recent intake, although the documents produced to the Inquest by FSA did not record the formal approval of that by the Manager, Pia Richter, who gave evidence that she closed it due to a lack of staff to investigate.
6.339. The minutes from the meeting record no agency experiencing any concerns at that time.
6.340. From that point until her death Kunmanara May, as a victim of domestic violence, was no longer under the scrutiny of FSA, AFSS, SAPOL or the FSF.
6.341. Two months later, Kunmanara May was killed by SK in a domestic violence attack.
The concern raised in the AFSS closure form became a reality.
7.2. I first wish to mention a submission made by counsel assisting, with which I broadly agree, that the police witnesses presented as truthful witnesses who were trying their best to assist the Court with its inquiry, and gave their evidence in a way that was frank and forthcoming with suggestions for improvement. Appropriate concessions were made, and each witness acknowledged shortcomings or oversights they made during their involvement with Kunmanara.
7.3. Failure to submit documentation 7.4. There were a number of instances where police failed to submit appropriate documentation about information obtained in relation to Kunmanara May. As well as breaching General Orders, in some instances failures to submit documentation prevented further investigations being undertaken by police, and also prevented information coming to the attention of MAPS.
7.5. In relation to the first information that came to SAPOL about DV in February 2014 7.6. Apart from his own very brief note, Brevet Sergeant Johnson made no other note in his notebook or anywhere else about his conversation with Ms Iversen and his subsequent visit to and discussion with Kunmanara May. He made no formal record in SAPOL information systems of what he had been told.
7.7. An issue for consideration was what police documentation if any Brevet Sergeant Johnson should have submitted following this interaction.
7.8. SAPOL General Order - Crime Reporting, in force at the time,110 governed the use of the different types of reports. An ancillary report is described in the General Order as ‘the primary point of collection for information relative to SAPOL’s intelligence business process’. The General Order distinguishes between ‘an offence PIR’ and ‘a domestic abuse PIR’. It states an offence PIR ‘should be submitted for reports of an offence involving a victim, and the employee taking the report is satisfied that a prima 110 Exhibit C46v
facie breach of the law involving a victim has occurred’ and a domestic abuse PIR ‘must be submitted for domestic abuse incidents where a substantive offence has not been committed. Where a substantive offence has been committed an ‘offence’ PIR will be submitted’. Domestic Abuse Report (DAR) is common police parlance for ‘a domestic abuse PIR’.
7.9. When asked at Inquest what he should have done, Brevet Sergeant Johnson said that the report he received from AFSS, together with the investigation he conducted by attending and speaking to Kunmanara May and SK was probably most suitable to be recorded as a ‘street check’ (also known as an ‘Ancillary Report’), a means of recording on the (then) Police Incident Management System (PIMS) details of persons spoken with and details of the interaction, together with his observations. No such report was made. No such collection of information occurred.
7.11. His description of a Domestic Abuse Report was a report ‘completed when the officer has concerns that domestic abuse is present but there’s no offences that have been disclosed at that time’. He also said such a report would be appropriate if it was a suspected incident of domestic abuse, reported by a third party or otherwise, but with no evidence to corroborate it. Once Brevet Sergeant Johnson had been persuaded by Kunmanara May’s account to him of having injured herself falling over, and he then failed to enquire any further about it, it is unsurprising that he did not complete a DAR.
He distinguished the DAR from a PIR as being required to be completed if there was evidence to substantiate the commission of an offence.
7.12. If Brevet Sergeant Johnson had been advised by Ms Iversen of what Ms Jebydah had said to her, the matter would likely have met the criteria to be recorded as a DAR, which would have triggered other police requirements and reviews. In particular, a risk assessment would have been required to be undertaken and the report would have gone for review to a supervisor.
7.13. The requirements for a member who receives a ‘third person report’ are set out section 9 of General Order - Domestic Abuse under the heading ‘Third Party Reporting of Domestic Abuse’.125 General Order - Domestic Abuse states that if ‘prima facie’ evidence of a substantive offence exists, a ‘PIR should be raised for that offence ... and
a statement taken from the third party reporter ... where their evidence may provide corroboration of an offence’.
7.14. Notwithstanding Kunmanara May’s claim that she had fallen over a piece of furniture, it is arguable that the information given by AFSS, together with Brevet Sergeant Johnson’s conversation with Kunmanara, gave rise, or at least should have given rise, to a ‘prima facie’ suspicion that an offence had been committed within the domestic relationship such that a PIR should have been raised.
7.15. In any event, Brevet Sergeant Johnson failed to record any offence or conduct any investigation (and, equally importantly, failed to document this) by way of the submission of a PIR or, at the very least, a DAR together with a PD438 - Domestic Violence Risk Assessment.
7.16. Although this report of likely domestic violence came to the attention of SAPOL, and was in fact the first information that came to police about Kunmanara May being an alleged victim of domestic violence, no record was ever made on PIMS.
7.17. As a consequence, Kunmanara May and SK were not brought to the attention of EWLSA FVIS members at this time.
7.18. In relation to the DAR submitted on 16 September 2014 7.19. The first DAR submitted was that completed by Senior Constable Van Hout on 16 September 2014 as detailed in the chronology above.
7.20. That DAR contained minimal information in the narrative, namely: ‘Victim May has been referred to the FSF meeting in relation to disclosing to AFSS workers that she is a victim of violence. They also have a young child. Nil reported by victim’.
7.21. In the investigation diary, Senior Constable Van Hout wrote that Kunmanara May had declined all services when AFSS and FSA engaged with her, that the matter had been investigated by FSA, ‘child involved nil substantial’.
7.22. It was also recorded that Brevet Sergeant Johnson had spoken with Kunmanara May on two occasions to ensure her safety.
7.23. Although the preparation of a DAR required a police officer to undertake a risk assessment, Senior Constable Van Hout did not do so, and recorded a risk assessment score of ‘39, Medium’ based on the assessment undertaken by Ms Iversen when she referred the matter to the FSF.
7.24. Senior Constable Van Hout explained in evidence that she had had no contact with Kunmanara May, so it would not have fallen to her to complete the risk assessment, but she said she should have noted in the investigation diary that it needed to be forwarded to an investigating officer, through her supervisor, in order to have a risk assessment completed. If this had occurred, it might have led to some more incisive police enquiries having been made at this stage.
7.25. Whilst I acknowledge Senior Constable Van Hout’s lack of experience in relation to FSF meetings (an issue which I will return to later in this Finding), it must be observed that this DAR was so devoid of information that it did not advance the cause of Kunmanara May’s safety at all. It lacked all of the information that had been available to Brevet Sergeant Johnson, because it was not recorded by him, and it lacked all of the information which could have been drawn by Senior Constable Wilson and Senior Constable Van Hout from the other participants in the FSMs that precipitated the creation of this DAR. Senior Constable Van Hout was in a position to include a detailed synopsis of the circumstances leading up to the entry of this DAR, including the recent history of Kunmanara as reported at the FSF meetings, but failed to do so.
7.26. On the same day the DAR was prepared, it was vetted by Senior Sergeant Matthew Steinbeck, Officer in Charge, Ceduna Operations, who noted ‘DV report only. Nil offence disclosed. Suggest file’. He forwarded the report to Ceduna Criminal Investigation Branch Supervisor Detective Brevet Sergeant Scott Price for review.
7.27. The vetting process at the relevant time involved two stages. First, it was to go to the immediate supervisor whose responsibility it was to ensure that all avenues of investigation were complete. This included reviewing the report and looking at all facets of the report, including all documents such as the investigation diary, statements and PD438s. Second, it was transferred to the Officer in Charge for further vetting.
The Officer in Charge had similar responsibilities with respect to vetting as the
supervising officer had but was essentially responsible for ensuring the matter had been properly investigated.111
7.28. The DAR was filed on 17 September 2014. Detective Brevet Sergeant Price explained in his statement112 that the narrative and the investigation diary indicated that Kunmanara May was the subject of violence that she had reported to support services and as a result was referred to the Ceduna FSF, but that she had not reported any matters directly to police. Detective Brevet Sergeant Price gave evidence that although he could not specifically remember vetting the report, he would have understood that it had been referred to the FSF and from the investigation diary would have understood that follow-up action had been taken at Yalata level by Brevet Sergeant Johnson.
7.29. On 18 September 2014 a note was made on the investigation diary that this DAR was reviewed by MAPS at a meeting on 17 September 2014 and an action recorded for SAPOL to send a summary document to EWLSA FVIS. The MAPS summary document was tendered at the Inquest.113 Due to the scant detail included in that DAR the mapping process was all but useless. The entry of this DAR was a significant opportunity to inform MAPS of the matter so that MAPS could provide corporate oversight as it was designed to do. The information simply was not there and so the process failed.114
7.30. In relation to the DAR following the incident on 23 December 2014 7.31. Senior Constable Van Hout completed another DAR in relation to the incident on 23 December 2014. I have detailed the contents of this DAR earlier in the chronology.
7.32. Again, this DAR was of poor quality in that it was lacking in important information which needed to be drawn to the attention of any reader.
7.33. The abuse type should have been listed as ‘physical abuse’ instead of ‘emotional/psychological’, and it should not have included the entry of ‘no - insufficient evidence’ alongside the row querying whether there had been an arrest or report of the suspect.
111 Transcript, pages 287-289 112 Exhibit C39a 113 Exhibit C46af 114 Transcript, pages 334-340
7.34. This DAR was particularly deficient in that Senior Constable Van Hout did not complete a PD438 (risk assessment) and instead entered the risk assessment score as being zero. She accepted that a PD438 should have been completed and that even if she could not have attended Yalata herself, she could have recommended to her supervisor that someone from Yalata patrols complete the PD438.
7.35. Senior Constable Van Hout further accepted that it was her responsibility for the investigation of those alleged offences and that a recommendation should have been made by herself or her supervisor that those offences be further investigated. This could have occurred through either the transfer of the file as part of the vetting process, or she could have forwarded it on for investigatory purposes.115
7.36. The result of the deficiencies in this DAR was that it was not triaged as a matter of particular significance when received by MAPS. Detective Senior Sergeant Conte told the Inquest in relation to 15/Q92816116 that although this was included in the daily download for MAPS, it was not subjected to the mapping process. Senior Sergeant Conte explained that there is strong possibility that this document was not brought to anyone’s attention due to the absence of the keywords that were searched for at the time.117
7.37. It must be observed that at that time the processes for analysing the downloaded reports at MAPS was rather basic, with the risk that many reports that needed MAPS oversight were in fact missed. The evidence was that an analyst would include the downloaded information on a spreadsheet and perform a keyword search for certain alarm bells. If there were hits for words such as ‘strangulation’ or ‘risk of separation’ then it was those matters that would have been sent to the Detective Sergeants.118 Detective Senior Sergeant Conte’s evidence was even if the DAR had been completed properly, the DAR would not have been subjected to the mapping process due to the absence of the keywords that were searched for at the time. That does raise some concerns about the effectiveness of the MAP's daily downloads at that time. However, Detective Senior Sergeant Conte did say that with the subsequent changes to the keywords that are 115 Transcript, pages 257-258, 261, 349 116 Exhibit C46AE 117 Transcript, page 909 118 Transcript, page 657
searched he was ‘very confident’119 that this DAR would been selected for mapping if received today.
7.38. There were also errors in the vetting of this DAR which effectively meant that no more senior investigator turned their mind to what needed to be done to advance any potential investigation.
7.39. The vetting responsibility initially fell to Senior Constable Daniel Palmer,120 an acting sergeant at the time who was performing the role of the day shift patrol supervisor at Ceduna. He had a long list of reports to vet because there had been a missing person search in the previous couple of days.
7.40. In his statement he said he must have understood the report to be linked to an apprehension report and before transferring the file to Ceduna CIB/Ceduna Crime Management Unit (supervisors for Ceduna FVIS), he erroneously marked the file before transferring it, ‘Created and completed by FVIS member - appears that an arrest has also been made’.
7.41. He forwarded the file to Detective Brevet Sergeant Scott Price who entered on 24 December 2014 ‘Victim follow-ups have been conducted and PIR suitable for filing.
Cleared by ARREST’.
7.42. Detective Brevet Sergeant Price explained in evidence, in summary, that his job was to ensure the matter had been properly and fully investigated and everything had been forwarded with the brief. Although he was not able to specifically recall vetting this report, he said there were several factors which would explain why he did what he did:121 the victim had already been referred to the FSF; • FSA had already engaged with the victim and she had declined all services; • FSA had investigated reports of child concerns of which nil were substantiated; • a case plan had been conducted; • 119 Transcript, page 671 120 Exhibit C37 121 Exhibit C34b, page 3
Brevet Sergeant Johnson had engaged with Kunmanara May on two occasions to • ensure her safety; nil offences had been reported at the time.
•
7.43. In his evidence he conceded that his vetting decision was likely to have been influenced by the notation by Senior Constable Palmer that it appeared an arrest had been made, which would indicate that a possibility of reoffending had been dealt with. He pointed out indications in the document that this endorsement was an error. The document was not endorsed with an apprehension report number. It ordinarily would have been. He agreed that there should have been a risk assessment score other than zero.122
7.44. Detective Brevet Sergeant Price stated that despite the errors, he was satisfied that the DAR was nevertheless suitable for filing.
7.45. I disagree with this assessment, particularly in relation to the three particular incidents of violence in relation to which Senior Constable Van Hout had been advised of the identity of the informants. There was nothing in the DAR to indicate they had been spoken to in furtherance of the investigation of these alleged incidents, which had now been brought to the attention of police. It was not sufficient to note that the victim was unwilling to provide a statement. It was incumbent on police to ascertain whether there was a third-party avenue through which evidence might be obtained to support the commission of an offence, or an application for an intervention order.
7.46. Detective Brevet Sergeant Price also pointed out that despite the erroneous vetting, the file remained open and Senior Constable Van Hout undertook further investigations.
Counsel for SAPOL submitted that the administrative vetting error did not affect the conduct of the investigation for this reason. Again, I disagree; by the vetting failure, Senior Constable Van Hout was deprived of the benefit of supervision and guidance in the conduct of her investigation and was left to her own devices, without support which should have been forthcoming.
7.47. Also of concern is that Senior Constable Van Hout did not submit a PIR in relation to this incident. General Order - Domestic Abuse required that where a member receiving 122 Transcript, page 568
a ‘third party report’ is satisfied that a prima facie evidence of a substantive offence exists, then a PIR should be raised for that offence.
7.48. There was sufficient detail to support a ‘prima facie’ allegation that Kunmanara May was the victim of offences at the hand of SK and the raising of a PIR. The submission of a PIR would have initiated a proper and thorough investigation with a degree of oversight, and also may have come to the proper attention of MAPS.
7.49. Senior Constable Van Hout’s conversation with Kunmanara May on 4 February 2015 7.50. Senior Constable Van Hout did not submit a PIR for the substantive offence disclosed to her by Kunmanara May in person at Yalata on 5 February 2015. On that occasion Kunmanara disclosed that she had been punched on Christmas Day and received a black eye, but did not want to disclose any more than that and did not want any police action.
This was corroborated by members of the community and an AFSS worker who saw the injury.123
7.51. The SII says of this information that ‘Up until this time, all the information was from a third party, but at this point SAPOL were the closest it had come to the “prima facie” evidence case against (SK) that should have prompted immediate action to hold (SK) accountable’.124 Quite plainly, a PIR should have been submitted and an investigation initiated. In her evidence at the Inquest, Senior Constable Van Hout correctly agreed that should have been done.
7.52. Senior Constable Van Hout also accepted that in terms of the practical options available to her, she could have contacted Yalata police and an option would have been to take steps to locate SK and interview him with respect to the alleged offence. She said with the benefit of hindsight that she would have applied for an intervention order, but in her opinion she would have been unlikely to receive approval, given that the offender was not present at the time, the offence had occurred over a month earlier, Kunmanara May had moved away from SK and had plans to move further from him to Oak Valley, and she had a safety plan in place and support from her family. It was therefore Senior Constable Van Hout’s view that there was not an imminent threat to Kunmanara at the relevant time. That may be the case, but it is nonetheless surprising and unsatisfactory 123 Transcript, page 357 124 Exhibit C46a
that this option was seemingly not considered at any time. If I am wrong and it was considered, that consideration was not documented.
7.53. Issues with staff training, experience, attitudes and workloads 7.54. The evidence revealed that these various occasions of lack of appropriate documentation occurred in the context of the responsible officers having little to no prior experience with domestic violence, a lack of sufficient training in relation to important domestic violence processes and being generally burdened by large workloads with limited resources.
7.55. Lack of experience and training 7.56. Brevet Sergeant Johnson had never worked in family violence and received no specialist training in family violence, either at Yalata, or prior to commencing at Yalata.
He had a vague memory of some training about MAPS but could not remember whether he attended.125
7.57. Senior Constable Justine Van Hout had no experience or training in family violence investigations, nor did she have any training or experience relating to chairing meetings of the FSF, when she took over the chairperson role.126 She explained that there was no pre-requisite that a FVIO has any training in family violence. She was given an induction by Senior Constable Wilson on 2 September 2015 at the Port Lincoln Police Station. Senior Constable Wilson stated, ‘I showed her a few of the processes I used; including case management updates ... showed her the high risk management folders ...
I explained my processes when a domestic violence report gets allocated to me and answered questions she had’.127
7.58. Senior Constable Wilson had previously worked in the FVIS at Holden Hill from 2009 to 2012 but had no formal training.128 She had ‘on the job’ training and induction at Holden Hill where she was also provided with a folder containing documents regarding the role of a FVIO and the General Order - Domestic Abuse. Senior Constable Wilson also received no training in how to chair the FSF meetings, although she was provided 125 Transcript, pages 74, 75 126 Transcript, page 309 127 Exhibits C46 and C46a 128 Transcript, page 176
with the FSF Manual. Prior to chairing meetings, she had attended a number of FSF meetings at Holden Hill.
7.59. The lack of training in family violence was commented on previously by former State Coroner Johns in the Inquest into the deaths of Wyatt and Wyatt. His Honour said: ‘It is the responsibility of each member agency to ensure that its staff are knowledgeable of, and properly trained to, identify high or imminent risk of harm and that internal processes and procedures are in place within the agency to that end.’ 129 Unfortunately, in this instance, it was clear that the officers dealing with Kunmanara May were lacking in experience and training in relation to family violence.
7.60. The lack of training and experience goes some way to explaining individual police officers’ approach towards not commencing a PIR or DAR, as well as a failure to pursue available lines of inquiry or investigation. The failure to not commence a PIR or DAR at certain key points is perhaps the clearest example of where SAPOL officers were not knowledgeable of, or properly trained to identify, the risk of harm and take appropriate steps - and steps required of them under a General Order - to appropriately mitigate that risk.
7.61. The evidence also revealed a surprising lack of understanding of MAPS and the importance of PIR/DAR documentation in relation to the MAPS process.
7.62. Detective Senior Sergeant Conte gave evidence about the extent of training of police relating to MAPS.130 Whilst there was clearly some training, the evidence suggests the extent of training the officers interacting with Kunmanara May had had in relation to MAPS was insufficient.
7.63. Brevet Sergeant Johnson did not specifically remember any training in MAPS.131 Senior Constable Wilson gave evidence that that, ‘I remember not having a good understanding of what their role was, so if there was some sort of training then it wasn’t very detailed’.132 She could not recall interacting with MAPS or MAPS ever making her aware that they had reviewed any of her matters. Detective Brevet Sergeant Price, who has considerable experience with the FSF and as a supervisor of members 129 Inquest 19/2011 into the deaths of David James Wyatt and Jakob James Wyatt, State Coroner Johns, 20 February 2012 130 Transcript, page 686 131 Transcript, page 75 132 Transcript, page 231
performing family violence investigations, admitted that even at the time of the Inquest he was not particularly familiar with MAPS, or how they receive referrals.133 He told the Court frankly, ‘straight up I really – to this day I still don’t fully understand the role of MAPS. I haven’t had anything to do with MAPS in my career, haven’t had a lot of cross over so I’m not 100% sure’.134 Even at the time of the Inquest he had had no training in MAPS.
7.64. MAPS can only work effectively if workers within the participating agencies know about it and are aware of the referral process, and in particular the critical importance of the submission of detailed and accurate DAR/PIRs. That was clearly lacking in relation to Kunmanara May.
7.65. Attitude of police 7.66. The evidence provided examples of where police seemingly demonstrated an attitude that action in relation to domestic violence was non-urgent, and even futile.
7.67. Regarding the SAPOL action arising from the first FSF meeting, that Yalata police should seek to speak to Kunmanara May about the concerns, Senior Constable Wilson did not advise Yalata police of that action for two weeks, until late on the morning of 15 July 2014, shortly before the next FSF meeting that afternoon.
7.68. At that time Senior Constable Wilson emailed Brevet Sergeant Johnson advising him that the action from the meeting two weeks earlier was, ‘SAPOL officer in Yalata to speak to (Kunmanara May) regarding options to keep her safe’. Senior Constable Wilson wrote in her email: ‘I know there isn’t probably much we can offer, advice about intervention orders, the services in Ceduna that can assist her with safety and counselling. It’s just something we need to at least say we have told her about and asked if she wants any assistance with. The latest from the services in Ceduna is that they are back in Yalata. Let me know how you go’.
7.69. Senior Constable Wilson gave evidence that when she sent this email she expected to be met with negativity.135 She did not know Brevet Sergeant Johnson, but she spoke of a culture over many years where she experienced police not taking domestic violence 133 Transcript, page 585 134 Transcript, page 584 135 Transcript, page 222
as seriously as she wanted it to be. Senior Constable Wilson described that with some people (police) domestic violence was not being prioritised. She could not remember what had been said but some police officers’ reactions were negative. That included what they said, body language, sometimes things were not done at all. Senior Constable Wilson thought that the negative culture was possibly more pronounced in Aboriginal communities, ‘because of their reluctance, at times to speak to police, so I don’t know whether that created a culture of the reluctance to approach them’.136 The impressions of a FVIO like Senior Constable Wilson that such a culture existed cannot be ignored or dismissed; she was simply saying that this was her experience. Unfortunately, although the framing of her email may be seen to be borne of frustration, if that culture did exist, she was doing nothing about it and was effectively allowing herself to become part of it.
7.70. The fact that this action arising out of the first meeting - to ask police to follow up with Kunmanara May - was not actioned until two weeks later, some two hours prior to the next FSF meeting on 15 July 2014, also highlights a lack of urgency in dealing with Kunmanara.
7.71. The SII concluded that, ‘this reflects poorly on SAPOL in terms of commitment to the SAPOL Domestic Violence Strategy and General Order - Domestic Abuse’ a conclusion with which I agree.
7.72. Workload issues 7.73. The evidence indicated that Brevet Sergeant Johnson and the other police in Yalata were considerably overworked. There were only two police and one community constable (with another community constable position vacant). They would have two police on at once and the nearest backup was in Ceduna, two hours away. Brevet Sergeant Johnson agreed that the job was effectively a 24 hour one.137 They would be on call any time of the day or night. He might receive a call every half hour during the night, but then the phone might not ring for three or four days. After being awake most of the night he would then be expected to work the next day.138 He agreed that he could 136 Transcript, page 223 137 Transcript, page 119 138 Transcript, page 119
work for days without getting any good sleep. This would sometimes get so bad that he would have to turn the on call phone off so they could get some rest.
7.74. With limited staff in Yalata there were periods of time that the station was unmanned.
Brevet Sergeant Johnson explained that this would occur when they were out on patrol and also, with only two police officers and a community constable, it was inevitable that there were periods of time that the station was not manned. This was generally after midnight.139
7.75. Joanne Badke was critical of police response times prior to Kunmanara May’s death.
She described living in Yalata at night time. She would hear screams and women crying out. She stated that, ‘it’s hard to explain but if you were living there you would understand the severity of it’.140 She described kids running around the community, damage being done and this was just accepted by the community without calling the police.141 A night patrol was set up to try to get children back in their houses. She explained that situation was improved with the presence of a community constable living in the community142 as well as when Brevet Sergeant Johnson was on shift.143
7.76. Chief Superintendent Dean Miller referred to the night patrols in his affidavit, stating: ‘SAPOL encourages community safety programs that are accountable to the local community. The Yalata Community is, in collaboration with SAPOL, attempting to establish community night patrols.’ 144 The implementation and efficacy of community night patrols at Yalata was not investigated in this Inquest.
7.77. Brevet Sergeant Johnson gave evidence that domestic violence in Yalata was ‘quite common generally’.145 He said that sometimes they would speak to domestic violence victims two or three times a week, and other times we might not see an incident for ‘maybe several weeks’, that there were ‘two or three dozen names of offenders in the 139 Transcript, page 78 140 Transcript, page 716 141 Transcript, page 716 142 Transcript, page 717 143 Transcript, page 719 144 Exhibit C68, paragraph 34.6 145 Transcript, page 73
community’ but that they would only respond to incidents about once or twice per week.146
7.78. Senior Constable Van Hout commenced assisting Senior Constable Wilson with performing family violence policing tasks in Ceduna from July 2014. Prior to that date there had been no police officer west of Port Lincoln with responsibility for family violence. For the first five or so months of reports of domestic violence by SK, the closest FVIO was in Port Lincoln. It was an entirely inadequate level of service to a large area of this State.
7.79. Senior Constable Van Hout was appointed to the substantive family violence position on 24 December 2014 and commenced in that position in January 2015 when she returned from leave. She had responsibility for a vast portion of the State that included Yalata. She gave evidence that it was her understanding that Yalata, or the broader west coast region, had the third highest rate of reported domestic violence in the State.
She explained that it was under-reported prior to her commencement. She explained, ‘I think when we commenced the prior year we only had something like four reported incidents in Yalata and then suddenly it just rolled on and rolled on’.147 There is no reason to think that family violence had not occurred prior to Senior Constable Van Hout’s arrival; it seems likely that her appointment as an extra FVIO, responsible for that area, had a positive impact on the rate of reporting. Until then, there was very little that Senior Constable Wilson could do from Port Lincoln, 600 kilometres away. This will no doubt be borne in mind as SAPOL continues to consider police staffing in remote areas.
7.80. Detective Brevet Sergeant Price was asked whether he considered there to be too much work in family violence for one FVIO. His response was ‘Yes I did, 100%’.148
7.81. He also expressed the opinion that the family violence victims dealt with by Ceduna were predominantly from Yalata. He clarified that answer by saying that a lot of the inquiries that Senior Constable Van Hout was conducting were in Ceduna, due to the transient nature of the victims; however, ‘as a percentage of her clients who are genuine 146 Transcript, page 74 147 Transcript, page 315 148 Transcript, page 589
Yalata residents and spend the majority of their time in Yalata, I would suggest 95%, and I would suggest to this day it probably remains the same’.149
7.82. Senior Constable Van Hout also explained that performing an arrest in Yalata was problematic. The police station is a secure facility and she did not have access to it without recalling to duty a member of the permanent Yalata police staff, which would have its own complications depending on who was on shift and where they were.150 However, Senior Constable Van Hout went on to say that this situation had evolved and resolved.151 I think it is fair to assume that the situation was an administration oversight, or an administrative accident which coincided with the introduction and consolidation of the Ceduna FVIO position.
7.83. Senior Constable Van Hout also explained that as the FVIO, she was not allocated a vehicle. The drive to Yalata takes two hours but she explained that she was ‘grounded in a location like Ceduna without a vehicle’.152 Senior Constable Van Hout told the Court that at some point she had access to a vehicle, but it was shared and ‘rarely available for our use’.153 She made the point to the effect that for practical purposes it had to be an unmarked vehicle, so that the FVIOs could safely visit individuals in the community without signalling their presence with a police car outside the house. This meant that she could not get access to places like Yalata because she quite simply did not have the means of getting there. Evidence was heard that an extra unmarked vehicle later became available for FVIOs and CIB. Although there was evidence of CIB requirements sometimes rendering that vehicle unavailable to FVIOs, that appeared to have been resolved by the time of this Inquest.
7.84. None of these resourcing issues excuse the lack of a more proactive police approach to dealing with the domestic violence SAPOL was alerted to, or should have been alert to, in relation to Kunmanara May. However, they do provide important contextual information about the broader situation for the police who were involved with Kunmanara.
149 Transcript, page 591 150 Transcript, page 358 151 Transcript, page 361 152 Transcript, page 359
7.85. Conclusions about police involvement 7.86. Counsel on behalf of SAPOL submitted that whilst there is evidence before the Court of some administrative type errors by individuals within SAPOL in following approved protocols and policies, as well as resourcing issues, none of these matters had any bearing in causing or contributing to the death of Kunmanara May.
7.87. Counsel for SAPOL has also submitted that, despite being approached by police on a number of occasions and encouraged by police to report any incidents of domestic abuse, Kunmanara May was uncooperative and declined police assistance. It was submitted that it is difficult to see what more police could have done by way of ‘positive action’ without the support of the community, service providers or indeed Kunmanara herself. To the contrary, it was submitted, there was a significant response by SAPOL officers, such as by Brevet Sergeant Johnson and Senior Constable Van Hout, in their attempts to help Kunmanara, and that unfortunately, she was not willing to provide the assistance required by the police that was necessary to deploy the full measure of resources available to SAPOL to protect her from SK.
7.88. This submission contradicts the conclusion of the SII undertaken by Inspector Lawson which states: ‘It is apparent that opportunities existed for a greater level of intervention in the investigation of the reported domestic abuse by [SK] on May. There are instances where DARs were not entered on the SAPOL PIMS system, or were entered late, contrary to General Order - Domestic Abuse and General Order - Crime Reporting. There were also instances where supervisors made mistakes in the vetting of these DARs which were cleared or finalised in error. It can also be argued that there was sufficient information/evidence to support the submission of a PIR for an offence, which would have provided the opportunity to take ‘positive action’ and hold [SK] accountable for his actions, either by way of delivering him an intervention letter, investigating him for an offence, or making him the subject of an Intervention Order application. The reluctance by police who became involved with May, [SK] and individuals from other agencies, to act in a manner that sought to hold [SK] accountable may be attributed to a lack of understanding about what ‘positive action’ was required in circumstances involving third party reporting that were not supported by the victim.’
7.89. In my view, the response by police was significantly lacking. There was a lack of positive action by police to investigate what they did hear, to deepen their knowledge by approaching discussions about Kunmanara May at FSF meetings with an inquisitive mindset, to secure the support of the community and service providers, and to consider all potential means of holding the perpetrator, SK, to account. Effective policing of
domestic abuse demands uncompromising diligence throughout every phase. There can be no tolerance for complacency or laxity in investigating alleged offences, documenting incidents, or enforcing orders. The potential outcomes are profoundly serious and in some cases fatal, as was the case here.
8.2. Changes to General Order 8.3. General Order – Domestic Abuse was reviewed in 2016, well in advance of this Inquest, to include the need for FVIS members to submit a PIR or DAR for every FSF referral.
This became effective on 15 February 2017 and also provided the need for a PIR or DAR to be submitted for psychological and/or emotional abuse, which was not clear in the previous version of this General Order. This ensures that MAPS could provide investigative oversight over third party referrals of that nature. The General Order was also amended to ensure that instruction was provided for the course of action to be taken when reports of suspected domestic abuse are made to police by a third party and particularly to recognise ‘a service provider or other professional assisting/supporting the victim’ as a valuable source of information for a third party.
8.4. FVIS officers 8.5. The employment of two FVIS officers at Ceduna was another significant change. The first Ceduna FVIO position was created in September 2014 and filled in January 2015 by Senior Constable Van Hout. Prior to that, domestic violence matters in that location were managed by the Port Lincoln FVIO. In May 2017, an experienced FVIO was transferred temporarily into that position, backfilling that role. In December 2017, a second Ceduna FVIO position was created and those two positions were filled permanently since January 2018. In July 2018, EWLSA requested a holding position be established which allowed a third person to be placed into the role of FVIO.
Although the third position was not, at the time of the Inquest, a permanent position, I was advised that the LSA had committed to this level of staffing for family violence.
8.6. I was advised that having three members working as FVIOs allows a weekly attendance at Yalata. This facilitates regular personal contact with the Yalata Community to provide victim support, the opportunity for victims to report matters directly to police without having to travel to Ceduna, and to build a rapport between the community, victims and police. Two FVIOs will attend when practicable to do so, supported by Yalata patrol members when necessary, and ensure if possible that the visit to Yalata coincides with the attendance of other agencies to enable joint responses. An extra vehicle was added to the CIB / FVIS unit for use by FVIS to attend Yalata on a regular basis and to assist them with their personal victim contact duties. There were wider benefits perceived to flow from the employment of these officers within the Ceduna region. This included the increased reporting of incidents of domestic violence and, in particular, women reporting to and gaining the trust of those officers; officers forming a good rapport with victims, especially in the Yalata area; an increase in the numbers of perpetrators being placed on intervention orders; and statements being provided to police by the victims themselves. The employment of the FVIOs was of great benefit to the uptake of Centacare DV Services, in that SAPOL was the top referral agency to the service; communications between SAPOL and Centacare would occur on a daily basis which in turn led to stronger case plans for victims being developed and access to more information relating to perpetrators.
8.7. Training 8.8. The SAPOL Family and Domestic Violence Section (FDVS) was tasked with the development of a Domestic Abuse Investigators Course, a five-day course designed to enhance knowledge and skills, including investigative techniques and understanding of collaborative approaches, and to improve responses to and outcomes for domestic violence victims. These courses commenced after the death of Kunmanara May. Five courses were run in 2016 with a total of 136 members trained. These were predominantly existing family violence staff and their supervisors who were brought up-to-date with practices and policy. Training with respect to FSF and MAPS was included. Two courses were run in 2017 with a total of 31 members trained. These course members were staff new to the family violence specialist areas, and those who
were interested in transferring into those areas in the future. Those courses continued through 2018 and 2019.154
8.9. An annual Domestic Abuse Investigators Training Day for all family violence staff commenced in 2015 to enable information and training to be provided on topical issues.155
8.10. Since 2019 a further training package has been provided by SAPOL to all police in relation to the recording by video of domestic violence evidence in chief. This was permitted by the commencement on 1 September 2019 of sections 26A and 28A of the Intervention Orders (Prevention of Abuse) Act 2009 and section 13BB of the Evidence Act 1929.156 It is a 1½ hour package157 which, although specifically directed towards equipping police to take video statements which may be used in court, provides extensive detail about domestic violence and the SAPOL expectation of responding police, which includes to be inquisitive (i.e. to find out what is actually happening), to be victim focused, to take positive action proportionate and appropriate to the circumstances and to hold offenders to account for their actions. It also includes information in relation to MAPS.
8.11. Cross Borders Indigenous Family Violence Program 8.12. In 2018 Ceduna FVIOs, in coordination with Ceduna CIB and Prosecution, and with external agency support, implemented a program for participation by repeat Aboriginal domestic violence offenders called the Cross Borders Indigenous Family Violence Program. This is a multi-jurisdictional local approach to address family violence in remote Aboriginal communities, providing a service to male victims and offenders.
Under the Cross Borders Indigenous Family Violence Program, programs are available to male domestic violence perpetrators and appropriate housing support may be available in their local community where they can retain family support. This Inquest did not examine the effectiveness of the Program.
154 Exhibit C67, page 22 155 Exhibit C67, page 22 156 Exhibit C67, page 34 157 Exhibit C67, Annexure IH21
8.13. Vetting 8.14. The State Crime Assessment Centre (SCAC) took over responsibility for reviewing all crime occurrences where the occurrence nominates a victim. Previously, the function was undertaken at a local level as was the case in relation to the DARs vetted in relation to Kunmanara May. SCAC now is responsible for conducting an assessment of all victim reported crime and a stringent assessment process is undertaken with respect to that victim including criteria assessing as to whether the victim is safe and whether the perpetrator has been held to account.158
Notifications to FSA and subsequent scrutiny of such notifications and sharing of information obtained was one means by which the true extent of the domestic violence occurring between SK and Kunmanara May have come to light.
9.2. There were nine notifications made to FSA about Kunmanara May and SK’s child, C, many of which related to concerns of domestic violence within the home. Of those notifications, some were closed with no action by FSA.
9.3. Notification of 12 November 2014 9.4. As previously referred to, the CARL notification made on 12 November 2014 was rated tier 2159 (with a response time of 10 days). It followed concerns expressed by Marilyn Jebydah to AFSS workers Ms Dunn and Ms Iversen about violence she had heard in Kunmanara May’s home, including slapping and pushing. Ms Jebydah was highly concerned for C’s wellbeing.160
9.5. Subsequently Ms Dunn made the CARL notification and AFSS arranged for Kunmanara May to travel to Ceduna with C by bus where they stayed at 158 Exhibit C67, pages 36-37 159 The tier and response times are explained by Ms Richter at Transcript, pages 469-470 160 Exhibit C47, page 159
accommodation provided for them, before having a bus ticket arranged to travel to Adelaide to stay with Kunmanara’s godmother.161
9.6. A FSA case note on 24 November 2014 refers to the case being closed as it was ‘referred to other agency’. It stated, ‘There is an ongoing pattern of DV between the mother and partner which the child is likely being exposed to’. It also mentions AFSS providing support and that Kunmanara May, ‘does not wish to return to reside with her partner’.
9.7. Ms Richter explained in evidence that closing the cases is ‘not normal practice’ but was due to the capacity issues they were experiencing.162 She said that it concerned her and the other staff and that they struggled with the high client load and not managing their clients as well as they would have liked to.163
9.8. Ms Richter admitted that they were closing cases which had ‘elements of risk’. She said that it was not something she had experienced before, but they had no ability to investigate. Ms Richter gave evidence that they closed other cases for the same reason and that she would bring this to the attention of her supervisors in Adelaide at their fortnightly meetings. She conceded that she has no records of these meetings.
9.9. Notification of 11 December 2014 9.10. On 11 December 2014, there is a file note made by Ms Lawrence of FSA relating to a telephone call with Ms Dunn.164 During this call Ms Dunn raised her concerns about Centacare not making a CARL report after they attempted to visit Kunmanara May but could not locate her. She had missed appointments and a member of the community reported being concerned that she was locked in the home by SK.165 Ms Lawrence advised that, ‘FSA do not currently have capacity to allocate this for investigation due to staff going on leave over Christmas’.
161 Exhibit C47, page 171 162 Transcript, page 539 163 Transcript, page 541 164 Exhibit C47, page 181 165 Exhibit C47, page 183
9.11. Nevertheless, on 11 December 2014 a CARL notification was made and rated Tier 2 and not investigated. The lack of capacity to investigate was documented by Ms Richter and other staff.166 In particular, Ms Lawrence noted: ‘FSA have referred previous intakes to AFSS who are engaging the mother and whom have been addressing CP concerns re DV. It is concerning that there is a pattern by the mother of returning to the relationship and continuing to expose the child to DV. FSA have previously conveyed to AFSS the intention to allocate this matter for investigation if it is reported again. However, at this time there is no capacity to allocate this matter for investigation.’ 167
9.12. Notification of 22 December 2014 9.13. Another notification was made 10 days later on 22 December 2014 relating to Kunmanara May being seen in the community hiding her face but sighted with a black eye. This notification was rated Tier 2.
9.14. On 23 December 2014, the day after the notification, a case note authored by Ms Lawrence and sent to Ms Richter includes the reasons for suggesting the closure of the case. Again, the closure was due to no capacity to allocate the intake within the FSA office in Ceduna.
9.15. It states that staff have full caseloads and that both staff members are ‘currently on leave until 5 January … in addition there is a permanent vacancy’. The case note also referred to the child continuing to: ‘… be placed in a risky situation as alleged in the CARL reports. A FSA investigation is required to assess the risk and safety of this child and Supervisor Ms Lawrence has committed to doing this when capacity allows for this.’
9.16. Ms Dunn then emailed Ms Richter on the same day stating that she was ‘deeply worried’ about the case being closed.
9.17. Notification of 10 March 2015 9.18. A further, and final, notification was made on 10 March 2015 that included information that Kunmanara May had left SK on 25 December 2014 after he gave her a black eye but that by 4 March 2015 she had returned to live with him again.
166 Exhibit C47, page 192 167 Exhibit C47, page 192
9.19. This intake was given a response rating of Tier 2 (10 days). However, it was recommended for closure three days later on 13 March 2015 due to no capacity to allocate. This is despite the caseworker, Ms Lawrence, noting that AFSS were considering closing their case and despite no recent reports of violence ‘it is highly likely that there will be further incidents of violence in the future, making Kunmanara May unsafe and likely exposing C to this violence’.168
9.20. On 13 March 2015 it was recorded in the FSA case note that there was no capacity to allocate this intake within the FSA Ceduna office, referring to there being three casework positions vacant in the Assessment and Support and Protective Intervention Team and that all current cases were being managed by the supervisor and the office senior practitioner. It was noted that the intake would be sent to Manager Pia Richter for a decision of CNA.
9.21. On 17 March 2015, a FSA case note made by Ms Lawrence referred to the recent meeting between Ms Dunn and Kunmanara May and that Kunmanara looked very well, as did C. Ms Lawrence noted that AFSS: ‘… are considering case closure as currently they have done all they can for this family and (Kunmanara May) continues to be in a relationship with (SK). Currently there are no reports of violence, however it is highly likely that there will be further incidents of violence in the future, making (Kunmanara) unsafe and likely exposing C to this violence’.
Ms Lawrence noted that AFSS would be happy to accept a rereferral if necessary in the future.
9.22. On 18 March 2015 there was a meeting between FSA and AFSS relating to the case closure. The notes from that meeting show that the attendees discussed that Kunmanara May was back with SK, the ‘DV likely to continue’ and ‘original referral [from AFSS] was for parenting not DV’.
9.23. AFSS closing their case should have heightened concern within FSA in terms of the protection of C, due to the ongoing and heavy reliance FSA had placed on AFSS until that time to monitor and intervene. Even more concerningly, the AFSS case closure which was provided to FSA on the same day includes the predictive and particularly troubling comment: ‘AFSS are worried about [Kunmanara May] and C as [SK] is a perpetrator of Domestic Violence, [Kunmanara] is only a petite woman and AFSS are concerned that [SK] could 168 C47, p250
really hurt [Kunmanara] or possibly even kill her. AFSS are also concerned that C is a possible witness to domestic violence’.
Despite that concern, recorded in communication to FSA, neither AFSS nor FSA had an open case from that time.
9.24. Reason for closing notifications with no action 9.25. Ms Richter was the Manager of the Ceduna office of FSA between January 2013 and February 2017. She gave evidence of the lack of capacity to investigate notifications due to a shortage of staff. Ms Richter explained that ‘recruiting social workers into Ceduna was not easy’.169 In June 2015, there were three social work vacancies in the Assessment and Support team – the team responsible for managing and responding to notifications.
9.26. The practice of FSA, and then DCP, closing notifications with no action under the Children’s Protection Act 1993 has been the subject of much criticism by the Nyland Royal Commission, the State Ombudsman,170 and this Court in the Inquests into the deaths of Chloe Valentine, Ebony Napier, Amber Rigney and Korey Mitchell, and Caleb Evans. I shall not here repeat those criticisms. However, it must be said that the involvement of FSA with Kunmanara May unfortunately provides yet another case study of how FSA did not fulfill its statutory mandate due to resourcing issues.
9.27. Lack of flow of information from FSA 9.28. As the Department charged with the protection of children, it was not the role of FSA to protect Kunmanara May from the domestic violence she was experiencing; it was their role to protect her child. But FSA was armed with important information about the situation in which Kunmanara was living.
9.29. A significant issue was that none of the notifications FSA received about violence by SK towards Kunmanara May were ever formally communicated to SAPOL.
9.30. The procedure and requirement at the time for communicating CARL notifications to SAPOL was that it was only required when there were notifications regarding sexualised behaviours. This was the practice in the Ceduna Office at the time. Despite 169 Transcript, page 467 170 SA Ombudsman report entitled ‘Department for Child Protection - Wrongful failure to share information concerning the care and protection of two deceased children (2018/02813), Redacted Final Report (Ombudsman SA)
the fact it was not a requirement, Ms Richter agreed that it would have been best practice to formally communicate these notifications at the relevant time.
9.31. There were a number of occasions where that exchange of information from FSA to SAPOL may have been vital in leading to further enquiries being made, and avenues for protecting Kunmanara May being pursued.
9.32. For example, when FSA spoke to Kunmanara May on 6 February 2014, FSA workers did not inform any local police officer that Kunmanara gave an explanation for her lip injury which was different to that which they knew had been given to Brevet Sergeant Johnson. This is unfortunate and seems an obvious thing for FSA to have done. Brevet Sergeant Johnson would immediately have known that what Kunmanara had told him was unlikely to be true and he would necessarily have reassessed his response.
9.33. In relation to the 21 February 2014 CARL notification, Brevet Sergeant Johnson gave evidence that he was unaware of it and of Ms Iversen’s concerns and what Ms Iversen had learnt from Ms Jebydah. However, on the basis of Ms Iversen’s notes, there is no reason to doubt that she told officer McCormack of her concerns and particularly having regard to Ms Perry’s request that police be informed, and there is no reason to think that Ms Iversen would not have told officer McCormack of Ms Jebydah’s claimed knowledge, whether or not she identified Ms Jebydah to officer McCormack. It is apparent that no police record was kept of Ms Iversen’s contact with officer McCormack and there is no evidence that he told Brevet Sergeant Johnson. There is no evidence that officer McCormack spoke with Ms Jebydah or took any other action in relation to anything Ms Iversen told him.
9.34. In relation to the report of domestic violence on 6 March 2014, no SAPOL officer was advised of the information which came to the attention of Ms Iversen and was then reported to FSA.
9.35. Communication of the child protection notifications from FSA was one opportunity to expand police knowledge and perhaps instigate further police investigations into the domestic violence Kunmanara May was experiencing. Whilst I accept it was not a requirement at the time that FSA did communicate these matters to SAPOL, I do find that it should have occurred. I say that bearing in mind that SAPOL and FSA were frequently in a forum together (FSF meetings) discussing Kunmanara, and had that forum facilitated a more effective exchange of information between participating
agencies (an issue which I discuss in more detail below), formal communication from FSA to SAPOL of notifications may not have been so important.
9.36. Relevant changes in DCP since 9.37. An affidavit was provided by Lucy Wade, Regional Director Far North Far West, DCP.
She was appointed to this position on 2 February 2019. Her affidavit detailed a number of developments and improvements in relation to procedures, resourcing and staffing since Kunmanara May’s death in 2015.
9.38. Of particular relevance is that DCP guidance, that had been implemented prior to the Inquest, required that all notifications reporting domestic and family violence are shared with SAPOL. Whilst the formal sharing of notifications where domestic and family violence was a feature considered best practice in 2013-2015, it was not explicitly contained in any guidance. This has now been included as a specific requirement in the Manual of Practice - Investigation and Assessment.
9.39. To ensure ongoing communication between interagency partners, the new Practice Approach (introduced in 2019), adopts a care team approach to working with children and their families. As a result, when a case is open in the protective intervention phase (as C’s was between 21 February 2014 and 8 September 2014), staff would be required to form a care team of family members and relevant professionals who are involved with, or who may be able to contribute to, assessment and intervention that supports the safety and wellbeing of the child. In Kunmanara May’s contact with FSA, discussions with other agencies occurred but often these occurred individually with separate agencies. Care team meetings provide systematic mechanisms for relevant agencies to communicate collectively, regularly and consistently.
9.40. I was also advised that in Ceduna, the implementation of a number of recruitment and retention efforts and other improvements in areas such as case allocation and supervision resulted in the Ceduna office providing a response to all notifications (i.e.
no CNA outcomes) since mid-2018. Recruitment efforts had also been successful in filling the vacant supervisor position in the DCP Ceduna office in addition to filling a Senior Social Worker and Aboriginal Family Practitioner position. These positions are critical in providing practice leadership and oversight. Two of these positions had been vacant for some time prior to appointments in 2019/2020. Recruitment and retention of staff is a significant focus for the DCP more broadly. Improvement initiatives
resulted in a reduction in the DCP vacancy rate in the Far North Far West Region from 19.8% in July 2017 to 5.2% in December 2019.
10.2. It has been acknowledged by all witnesses who gave evidence in relation to their attendances at the FSF meetings that, whilst some domestic violent concerns may have been discussed with respect to Kunmanara May, the details of the actual incidents of domestic violence were not discussed.
10.3. Counsel for SAPOL submitted that as a result it appears the true nature of the domestic violence perpetrated by SK against Kunmanara May was not fully appreciated by the FSF participants. Whilst I accept that may be the case, it does beg the question why SAPOL, and indeed all of the agencies present, did not seek more information in relation to the concerns that were being raised. This was an information sharing forum, but the information exchanged was seemingly scant.
10.4. No agencies were sharing written documentation at the meetings. Many of the agencies did have extensive documentation relating to their dealings with Kunmanara May. In particular, the AFSS notes are very comprehensive and detail their many interactions with Kunmanara, and what information was relayed to other agencies and when.
However, these records were not shared at FSF meetings, and Ms Iversen conceded that she did not provide all relevant information at the meetings, due in part to her being inexperienced in the FSF meetings, and feeling nervous. When she was asked specifically why she did not share more information and why she did not provide more
detail to the first FSF meeting on 1 July 2014, she answered that ‘I would have been very nervous and I probably just would have rushed through the dot points that I had’.171
10.5. This was a continuing theme throughout the evidence. Police, AFSS, Centacare, and FSA were all independently of one another having contact with Kunmanara May, or making decisions about their service to her, but the whole of the information was not being communicated to the other relevant parties as no written documentation was being shared. Another example of this was the child protection notifications FSA received - it was Ms Richter’s practice to review the most recent notification on the C3MS system prior to attending the meetings. However, it was not her practice at the time to print the notifications and bring them to the meetings. Ms Richter cannot recall discussing the notifications at FSF meetings. Whilst she said it was her practice to advise the FSF if a notification had been received, she cannot recall the details of these notifications being discussed.172 Quite simply, information was not being shared in a sufficiently thorough and accurate manner.
10.6. The meetings were to be as much about information sharing as about working collaboratively to develop positive action plans for high-risk domestic violence victims, and yet the actions assigned to attendees of the FSF relating to Kunmanara May were, for the most part, suggestions to continue with the status quo. This was despite the fact that sometimes there were hints of a role for more positive action – for example, at the FSF meeting on 13 January 2015 AFSS representatives Ms Dunn and Ms Iversen attended and the minutes reflect that they advised the meeting that ‘Russell asked if the police can put a restraining order on [SK]’. This was an example of what would have been ‘positive action’. Interestingly, it was positive action that was proposed by a member of the community and not by any of the participants at the meeting. However, there was no action relating to the entry and no follow-up. The information was shared but the sharing of that information was seemingly fruitless.
10.7. Despite being discussed at 13 FSF meetings, SK was never interviewed, investigated, or were steps taken towards placing him on an intervention order. A very significant deterrent to any further violent act by SK - the use of police powers - did not occur. He 171 Transcript, page 829 172 If she was specifically asked about a notification, her practice would be to provide the detail at that point
was never properly confronted with the allegations of domestic violence. The participating agencies were focussed on the victim and not the perpetrator.
10.8. Even on the occasions where possible options for positive action were considered, there was also a lack accountability for implementing any actions that did arise. For example, there was the suggestion of a possible Family Care Meeting at the meeting on 29 July
10.9. A lack of positive action was considered by former State Coroner Johns in the Inquest of Zahra Abrahimzadeh. In that Inquest, the then Deputy Police Commissioner gave evidence in relation to the lack of police action. He expressed the opinion that if FSMs had been in place under the FSF at Elizabeth in 2009, there would have been a vastly different response. He said that he thought that if police officers attending a FSM became aware that there had been no action to apprehend an offender in a case such as the Abrahimzadeh case, that would ‘trigger activity’.
10.10. The Former State Coroner Johns made the following comment in his finding: ‘I must say I have difficulty accepting his confidence that the result would be different.
There were many occasions when the lack of activity in apprehending Ziaolleh came to the attention of various police officers who were not directly responsible for ensuring his apprehension. None of them noted the lack of progress and none of them instigated activity. Just because they happen to be attending a family safety meeting does not fill me with confidence that the result will be different in future’.
10.11. Unfortunately, Kunmanara May’s case is a demonstration that mere attendance at a FSF meeting - at least in 2014/2015 - would not necessarily be the catalyst for an appropriate police response. I understand that the FSF process was relatively new at the time Kunmanara May was discussed at these meetings. But the unavoidable conclusion is that the FSF process did nothing to keep Kunmanara safe. The FSF was entirely ineffective in this case.
173 Exhibit C47, page 121 174 Transcript, page 215
Documentation was often poor and there was a lack of appropriate services, both for the victim and for the perpetrator. The result was only a superficial understanding of the domestic violence relationship and an offender who continued to inflict violence over many months without interference or positive action.
11.2. In the course of this Finding, I have identified various shortcomings on the part of agencies and individuals which occurred in the context of the issues which I have described.
11.3. I cannot conclude that the various shortcomings I have identified caused or contributed in any substantial way to the tragic death of Kunmanara May. To suggest otherwise would be to ignore the complexity of the relationship between Kunmanara and SK and the impact of her determination to keep the authorities out of it, or the ability of the authorities, and in particular SAPOL, to protect her from harm.
11.4. Sadly, SAPOL was overly reliant on Kunmanara May’s cooperation and willingness to produce evidence in order to hold SK accountable for his actions rather than to seek evidence from other sources. Neither Kunmanara nor any other victim of domestic abuse should be criticised for not disclosing their abuse or cooperating with authorities.
The factors which may have led Kunmanara to reject the involvement SAPOL and other agencies are varied and complex and include both complex cultural and psychological factors which were not explored in this Inquest. The repeated references to her fear of losing her child and the authorities’ references to the possibility or likelihood of that are ample evidence of why she would not report or cooperate.
11.5. I do find that the response of the agencies involved with Kunmanara May, both individually and collectively, was ineffective in ensuring her safety. It cannot be known whether a more effective response may have played a role in preventing Kunmanara’s death.
12.2. The domestic violence was well-known to the Yalata Community. Many members of the community were reluctant to involve the police. Kunmanara May specifically told people she did not want the police to become involved.
12.3. A number of agencies were aware of the domestic violence in the relationship, including AFSS, Centacare, SAPOL, and Families SA, though the extent of that knowledge varied between agencies.
12.4. Kunmanara May was discussed at 13 Family Safety Framework meetings. None of those meetings were effective in resulting in positive actions to protect her from the violence being perpetrated against her by SK.
12.5. Communication between agencies was lacking. Important documents were not being shared, nor relied upon for knowledge to bring to Family Safety Framework meetings.
12.6. There were a number of shortcomings in the police response given what the police were aware of, explicable to an extent by issues surrounding training and expertise in the area of domestic violence.
12.7. There were shortcomings in the Families SA response, explicable to an extent by issues surrounding a lack of resources.
12.8. Whether or not Kunmanara May’s death could have been prevented had agency involvement been more inquisitive, persistent, and protective can ultimately not be concluded.
13.2. I was informed throughout the Inquest of a number of significant developments which occurred since Kunmanara May’s death. I will not repeat them here. I have taken each of those developments into account when considering any recommendations I should make.
13.3. Royal Commission 13.4. When considering any recommendations I may make in relation to this matter, I now also bear in mind that the South Australian Government has established a Royal Commission into Domestic, Family and Sexual Violence.
13.5. The Royal Commission Terms of Reference require and authorise the Commissioner to inquire into:
13.5.1. How South Australia can facilitate widespread change in the underlying social drivers of domestic, family and sexual violence by addressing the attitudes and systems that drive all forms of domestic, family and sexual violence and particularly violence against women and children, to stop it before it starts (prevention);
13.5.2. How South Australia can improve effective early intervention through identification and support of individuals who are at a high risk of experiencing or perpetrating domestic, family and sexual violence and preventing the recurrence of such violence (early intervention);
13.5.3. How South Australia can ensure best practice response to family, domestic and sexual violence in South Australia through the provision of services and supports, such as crisis support, health services, police intervention and a trauma-informed justice system that will hold people who use violence to account, to intervene in and address existing violence, and support victimsurvivors experiencing violence (response);
13.5.4. How South Australia can embed an approach that supports recovery and healing within South Australia through reducing the risk of re-traumatisation, and supporting victim-survivors of family, domestic and sexual violence (including children) to be safe and healthy and to be able to recover from
trauma and the physical, mental, emotional and economic impacts of violence (recovery and healing);
13.5.5. How government agencies, non-government organisations and communities can better integrate and coordinate efforts across the spectrum of prevention, early intervention, response and recovery, including through whole of system approaches and information and data sharing systems.
13.6. The terms of reference specifically direct that regard must be had a number of things including specifically to the lessons from implementing previous innovations in family, domestic and sexual violence response in South Australia, such as the Multi-Agency Protection Service, the provision of services across rural, regional and remote South Australia, and the views and experiences of First Nations communities.
13.7. The terms of reference also dictate that the Commission must recognise a number of features including the unacceptable rate of family, domestic and sexual violence in South Australia with a strong focus on the rates of violence experienced by Aboriginal women and children and the over-representation of Aboriginal people in current service systems, that the response to family, domestic and sexual violence is complex and will require coordination across government and the community, including courts, police, correctional services, legal services, housing, child protection and family services, schools, health and non-government organisations, and that preventing and responding to family violence, domestic and sexual violence is a shared responsibility across government, media, business, community organisations, communities, families, and individuals.
13.8. I anticipate that the Commission’s findings will offer a robust foundation for any necessary reforms, allowing for a well-considered approach to addressing a number of the issues that were illuminated in this Inquest. Thus, it is prudent to await the outcomes of this authoritative review of the current landscape before proposing any specific actions or changes. With that in mind, I will not make any recommendations, however will summarise evidence relative to the recommendations I have considered making, for the attention of the Royal Commission.
13.9. Safe house 13.10. All the witnesses called at the Inquest were asked whether they would consider there to be a benefit in having a safe house in the community.
13.11. Kathryn Meier of Centacare Domestic Violence Services saw a real need for a safe house facility in Yalata,175 highlighting the difficulty of keeping a victim of domestic violence safe as a crisis response, from 200 kilometres away (in Ceduna). She pointed out that this places the domestic violence victim in a very lonely situation ‘like a prison itself’.176
13.12. Pia Richter said that having lived in Yalata, and ever since she lived there the community has asked for a safe house for women and children’.177 She said she would support the establishment of a safe house but it would need to be carefully managed, in partnership with services and the community. She pointed out that Yalata is a scary place when domestic violence is taking place and there is nowhere to go, and she referred to the strain on social services staff harbouring people out of their own goodwill, because there is no other choice’.178
13.13. SAPOL witnesses were supportive of the idea. Senior Constable Wilson said that the safe house in Port Lincoln was ‘definitely’ a benefit and that victims of domestic violence ‘knew there was that safe place to go to and get ongoing support’.179 Senior Constable Van Hout said she expected that such a facility, where women could present at any time if they were in a situation of violence, or could see a potential for violence, would be used daily if it was secure and no shame was associated with it. She said that it would depend on how the community supported it.180
13.14. Joanne Badke said that there was definitely a need for something like a safe house ‘but it would definitely need to be a different model of service’.181 Ms Badke told the Court that safe houses are generally at an undisclosed location. In a small community like Yalata that would be impossible. She referred to the Ceduna safe house, the fact that because the location is known, the program needs to be bigger and the building needs to be more fortified.182 Ms Badke also explained that, in her opinion, it is not as simple 175 Transcript, page 384 176 Transcript, page 385 177 Transcript, page 552 178 Transcript, page 553 179 Transcript, page 235 180 Transcript, page 364 181 Transcript, page 711 182 Transcript, page 712
as taking a safe house model from elsewhere and replicating it in Yalata. She said there would need to be a facility that also focuses on the perpetrator and allows them to sober up, in circumstances where alcohol or drugs are involved.
13.15. Fiona Mort of the Office for Women raised similar concerns relating to the location of the safe house being known in a small community but she referred to feedback, ‘particularly from certain communities, that just having a place to go where there is a bit of distance from what’s going on can be of great assistance…’.183 Ms Mort said that what is required is a ‘serious conversation’ about the issue and the appropriate model.
13.16. I find that there is a need for a service or facility in Yalata that provides crisis care for victims of domestic violence. Consultation of service providers and the community would assist in determining what is required. It has become quite clear, based on the evidence heard in this Inquest, that any strategies need to be community driven and generated.
13.17. Perpetrator Services 13.18. The Inquest identified a clear gap in the availability of perpetrator services. It was agreed amongst all witnesses who provided front line services to Kunmanara May that there was at the time of Kunmanara’s death, and still at the time of the Inquest, a gap relating to services for perpetrators of domestic violence. This gap was referred to by Senior Constable Van Hout as a ‘big downfall’.184 Kathryn Meier explained that Centacare has, as part of its funding agreement, no capacity to work with perpetrators of domestic violence.185 This was confirmed in the affidavit of Dr Jen Cleary.186
13.19. Fiona Mort agreed that there are gaps in perpetrator responses across the State and the Office for Women was seeking an evidence base of what works.187
13.20. I received into evidence information about the Cross Borders program. The program is a multi-jurisdictional approach to address family violence in remote Aboriginal Communities in the NPY communities in the Northern Territory, Western Australia and South Australia. The program is designed to apply local cultural content and is based on a community development approach. The program offers an option as an alternative to custody, however is open to all community members and estimates that 183 Transcript, page 785 184 Transcript, page 366 185 Transcript, page 407 186 Exhibit C65, page 4 187 Transcript, page 783
15% of the participants are voluntary. The non-custodial program is delivered in local communities and where participants live.
13.21. A number of witnesses gave evidence about this program and its strengths. Pia Richter told the Court that, in her experience, the court-referred clients get priority ‘and if there is space they will take extras’.188 Ms Richter said that the program is ‘proving to be beneficial to some men, some men have really changed, in fact one man that went through the first program is now a mentor, employed, and is working now with the men doing the program’. She went on to say that for other men it does not work and they breach on day two. Joanne Badke told the Court of her experiences with the program and that ‘…it happens probably once a year, we’re looking to how we’re going to get that more often, and looking at something that’s equivalent for females as well’.189
13.22. Ms Badke explained that engagement with any program depends on the involvement of the community and community leaders in its development. She used the Cross Borders program as an example of such a program. She told the Court that it was the local men’s group that initiated the conversation about engaging with the program and so it is community led and a ‘really successful program, whereas if it’s just a program that has been developed by Centacare or even ourselves without that community lead, it’s just not successful’.190
13.23. It was outside the scope of this Inquest to consider the Cross Borders program in detail.
However, it was apparent that it was one of very few anger management or family violence services currently being provided to Aboriginal men. In my view, there needs to be a thorough analysis of perpetrator services currently available to those in Aboriginal communities including Yalata.
13.24. Information sharing 13.25. Counsel Assisting urged me to make a recommendation that significant documents including, but not limited to, FSF minutes, CARL reports, closure reports (Families SA/AFSS/Centacare), police incident reports, criminal histories, risk assessment forms, mapping documents and safety plans should be distributed amongst participants at the FSF meetings. The suggestion was that the Office for Women and participating agencies should consider the introduction of an online portal which would allow access 188 Transcript, page 551 189 Transcript, page 706 190 Transcript, page 732
to such information by attendees.191 It was noted during the Inquest by Fiona Mort that that proposal was at that time being considered by the Office for Women.192
13.26. At my request, the current Director of the Government of South Australia, Office for Women, Sanjugta Vas Dev, recently provided me with an update as to developments since the then Director, Ms Mort, gave evidence. I was informed that the Office for Women are continuing discussions with SAPOL to formalise information sharing between MAPS and the Family Safety Framework. Currently agency representatives can upload documents, including mapping documents, to the new Family Safety Portal.
The Family Safety Portal (the Portal) was launched on 14 June 2022 in select regions and has been live in all 17 regions since December 2022. The Portal is a digital solution which has transitioned the FSF from a manual, paper-based process to a secure online platform. As a digitised secure online solution for the FSF, the Portal is used to: Undertake common risk assessment and referrals to the FSM; • Manage meeting records, process, information sharing, case management; and • Develop and track status of Positive Action plans.
•
13.27. The portal enables representatives to share information immediately with other agencies. This feature can be used outside of FSM times to facilitate timely information sharing.
13.28. A further recommendation I was urged to make by Counsel Assisting was that the minutes of the FSF meeting should be kept in real time and uploaded immediately to a portal, as this would assist participants to proactively record tasks undertaken by them and the outcomes prior to the meeting, to contribute effectively to the formulation of additional actions which may mitigate risk or promote safety, as well as actioning tasks assigned to them. The recent update from Ms Vas Dev includes information that through the Portal, meeting reports are automatically generated. These reports are created when each FSM ends and are automatically and immediately distributed to all representatives for that region. Meeting reports include attendance records as well as all actions and case notes added by representatives and chairs since the last meeting.
13.29. Implementation of the online Portal has enabled improved monitoring of risk assessments and referrals; however formal auditing processes are still being 191 Transcript, page 872 (Iversen) 192 Transcript, pages 755, 756
determined. The Office for Women co-chair Multi-Agency Responses Governance Group Meetings to discuss implementation of both MAPS and the FSF and enable escalation of matters where required. Outside of formal auditing procedures, the FSF Practice Manual details clear processes referrers can follow if they are not satisfied with the outcome of their referral. Office for Women provides guidance regarding this procedure as needed.
13.30. Given those recent developments, I now see no need to make a recommendation about information sharing for the purposes of FSF meetings. This Court may examine the effectiveness of that newly introduced Portal if the situation arises in the future.
13.31. I was also advised by Ms Vas Dev on behalf of the Office for Women that Women’s Safety Services SA received funding through Victims of Crime to provide a round of specialised risk assessment and safety management training for FSF referrers and FSM representatives. These trainings are being provided across all 17 regions. The FSM representative training includes information regarding positive action planning. These training sessions reference previous coronial findings and recommendations made in the matters of Hayward and Durance193 and Wyatt and Wyatt.194 This training is being provided across 2023-24, however, there is no ongoing funding for state-wide training.
In my view, it would be appropriate for that training to be conducted on an ongoing basis.
Key Words: Domestic Violence; Homicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 29th day of August, 2024.
State Coroner Inquest Number 01/2020 (0884/2015) 193 Inquest 14/2011 into the deaths of Robyn Eileen Hayward and Edwin Raymond Durance, Deputy State Coroner Schapel, 23 January 2011 194 Inquest 19/2011 into the deaths of David James Wyatt and Jakob James Wyatt, State Coroner Johns, 20 February 2012
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