Finding into death of Maryam Hamka

IN THE CORONERS COURT COR 2023 003537 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Judge Liberty Sanger, State Coroner Deceased: Maryam Hamka Date of birth: 19 December 1984 Date of death: 11 April 2021 Cause of death: 1(a) Unascertained Place of death: Unit 8, 1-3 Well Street Brighton Victoria 3186 Keywords: Family violence; homicide; intimate partner homicide; missing person; perpetrator interventions

INTRODUCTION

1. On 11 April 2021, Maryam Hamka was 36 years old when she was killed by her intimate partner, Toby Loughnane. At the time of her death, Maryam lived alone at Brunswick, Victoria.

Background

2. Maryam was the eldest of seven children and previously worked as a cleaner. Her brother described her as having a big heart and worrying about everyone else before herself.

3. As an adolescent, Mr Loughnane commenced using alcohol, cannabis and later, methamphetamine. He previously worked in the construction industry and was previously married, with one daughter from that relationship. At the time of the fatal incident, Mr Loughnane was living at 8/1-3 Well Street, Brighton.

4. At the time of the fatal incident, Maryam and Mr Loughnane were both unemployed and were using illicit substances.

5. Mr Loughnane had an extensive history of alleged family violence and assaults between 2005 and the fatal incident. He was recorded by Victoria Police as a family violence perpetrator on 21 occasions with six previous partners, and 17 of those 21 family violence incidents occurred after February 2017. This history is explored in further detail below.

THE CORONIAL INVESTIGATION

6. Maryam’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

7. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

8. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

9. Victoria Police assigned Detective Leading Senior Constable Jason Stewart to be the Coronial Investigator for the investigation of Maryam’s death. The Coronial Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

10. State Coroner, Judge John Cain (as his Honour then was) originally held carriage of this matter, prior to his retirement in August 2025. I assumed carriage of this investigation on 1 September 2025.

11. This finding draws on the totality of the coronial investigation into the death of Maryam Hamka including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

12. On 16 August 2023, Coroner Kate Despot made a formal determination identifying the deceased as Maryam Hamka, born 19 December 1984, via DNA comparison.

13. Identity is not in dispute and requires no further investigation.

Medical cause of death

14. On 10 August 2023, Forensic Pathologist Dr Brian Beer, Forensic Anthropologist, Dr Samantha Rowbotham, Forensic Pathology Fellow, Dr Michael Duffy and Forensic Pathology Trainee, Dr Kaitian Yeo from the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy. Dr Beer provided a written report of his findings dated 27 November

2023. Dr Rowbotham also provided an undated written report of her findings.

1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

15. The post-mortem examination revealed predominantly skeletonised human remains, with approximately 47% of the skeleton available for analysis. There was evidence of fragmentation, staining and extensive (animal) scavenging of the remains. The cranium exhibited peri-mortem trauma with fractures of the right mastoid process, right orbital floor and nasal bones.

16. Fragmentation of the ribs and fractures of the right scapula and third right rib could not be definitively associated with either blunt trauma, scavenging or both.

17. There was no apparent evidence of skeletal pathologies.

18. Dr Beer was not able to establish a cause of death from examination of the remains.

19. Toxicological analysis of post-mortem samples was not performed.

20. Dr Beer provided an opinion that the medical cause of death was 1(a) Unascertained.

21. I accept Dr Beer’s opinion.

Circumstances in which the death occurred

22. On the evening of 7 April 2021, Maryam spent time with her friend, Dale Wickham, at her Brunswick home. They spent about two hours at Maryam’s home, then walked to the Duke of Edinburgh Hotel in Brunswick. They spent about 30 minutes at the Duke of Edinburgh, before they decided to leave and return to their respective homes.

23. Throughout the evening with Maryam, Mr Wickham observed Mr Loughnane repeatedly calling and sending messages to Maryam, demanding to know who she was with. At one point, Mr Loughnane made a FaceTime video call to Maryam and argued about who she was with, forcing Maryam to turn the camera around and show Mr Wickham on screen.

24. On the evening of 8 April 2021, Maryam visited her friend, Mark Borrelli, at his home.

Mr Borrelli noted that upon her arrival, Maryam was crying, looked “very scared and couldn’t sit still”. Maryam refused to tell Mr Borrelli what had occurred, however stated that she was afraid that Mr Loughnane knew where she was, as he had followed her before. Mr Borrelli offered Maryam to stay the night, however she declined and left a few hours later.

25. In the early hours of 9 April 2021, Maryam was at her Brunswick home, while Mr Loughnane’s phone records indicate that he was in the Brighton area. He sent her

numerous text messages which were harassing and threatening. He claimed he was nearby and threatened to get other people involved because he believed she was cheating on him with her former partner.

26. On the afternoon of 10 April 2021, Maryam walked to the Woolworths supermarket, located at Albert Street, Brunswick. She purchased various grocery items and left on foot, carrying two bags of groceries and her handbag.

27. At 5.30pm, Mr Loughnane left his Brighton home, driving a 2014 Volkswagen Caddy van (‘the Caddy’). The Caddy belonged to the workplace of Mr Loughnane’s associate, Oscar Newman, and Mr Newman and Mr Loughnane both regularly drove it.

28. Later that evening, Maryam’s mother, Susan Iramiyan, observed a light blue van parked near Maryam’s home (believed to be the Caddy). Ms Iramiyan observed Mr Loughnane in the driver’s seat, and her daughter putting bags into the van. Mr Loughnane then drove the Caddy, with Maryam, to his apartment complex on Well Street, Brighton. CCTV captured Mr Loughnane and Maryam entering Mr Loughnane’s Well Street apartment complex with Maryam carrying several bags.

29. Maryam’s friend, Shane Allan, called her twice at 10.17pm and 11.35pm. He recalled that when he spoke to Maryam, she sounded “out of it” and became so concerned that he told her to catch a taxi to his home.

30. At 11.41pm, a text message was sent from Maryam’s phone to Mr Allan which read “Betting;I taxi;\soon [sic]” (believed to mean ‘Getting in a taxi soon’). Mr Allan was unsure if Maryam sent this message or someone else. Police alleged that this message was sent by Mr Loughnane.

31. At 11.45pm, Mr Loughnane recorded a video of Maryam on the floor of his apartment, naked from the waist down. Maryam was distressed and drug-affected in the video, while Mr Loughnane mocked her for consuming “too much juice” and repeatedly asked her to “say hello”. This video was the last known evidence of Maryam alive.

32. At 11.53pm, Mr Loughnane called 131 008 for a taxi from his own mobile phone, however he terminated the call after 17 seconds, prior to the call being answered.

33. Between 1.00am and 3.00am on 11 April 2021, Mr Loughnane’s neighbours heard the sounds of a “female screaming and yelling” from his apartment. They were unable to determine what

the female was yelling about, and initially thought about calling Mr Loughnane’s mother, however later decided against it. The neighbours recalled “significant yelling, banging and screaming” however this subsided at about 3.00am.

34. Sometime between 1.00am and 3.00am, Mr Loughnane killed Maryam. He has never revealed what happened during this period of time, however a jury found him guilty at trial. It can be inferred from this guilty verdict and the circumstances that some form of assault occurred, resulting in Maryam’s death. The jury rejected Mr Loughnane’s assertion that she died from a drug overdose. During this time, Maryam lost a significant amount of blood, primarily on the carpet near the front door, at the bottom of the stairs.

35. From 12.01am to 4.41am, Mr Borrelli exchanged numerous messages with Maryam’s phone.

Mr Borrelli noted that some of the latter messages did not appear to have been written by Maryam. Mr Allan tried to call Maryam between 3.00am and 4.00am, however she did not answer. At 4.37am, Mr Allan received a message from Maryam’s phone which read “Hey sorry blew out”. Mr Allan responded and asked her to call him. At 4.41am, Mr Allan received another message which read “just in shower cum [sic] over”. Mr Allan opined that Maryam would not spell ‘come’ in that way and that this message was likely not sent by her.

36. At 4.45am, Mr Loughnane removed the SIM card from Maryam’s phone and placed it in his own phone. Mr Loughnane’s SIM card recorded no usage from 4.45am to 11.04am.

37. At 11.04am, Mr Loughnane removed Maryam’s SIM card from his phone and put his own SIM card back into his phone. At 11.07am, Mr Loughnane called his associate, Mr Newman, however Mr Newman did not answer. Mr Loughnane sent a text message to Mr Newman, asking him to call him. Mr Newman returned his call at 11.09am and they spoke for 44 seconds.

38. Mr Newman arrived at the Well Street address at about 1.15pm. He had a spare set of keys to the apartment and let himself in. When he entered the apartment, he called out but did not hear a response. He observed blood on the carpet downstairs at the bottom of the stairs and observed a syringe and faeces on the floor of the upstairs bedroom. In the ensuite attached to the bedroom, Mr Newman observed Maryam unresponsive, naked and sitting upright on the floor of the shower, however the shower was not switched on. He observed her face was swollen and she did not respond when he called her name. He did not enter the ensuite.

39. Mr Newman checked the other bedroom where he located Mr Loughnane unconscious on the bed, fully clothed. He shook Mr Loughnane; however, he did not wake up. Mr Newman thought his friend likely passed out from using GHB, as this had happened in the past.

Mr Newman left shortly thereafter.

40. On 12 April 2021, Mr Newman did not attend work, despite telling others that he did so. He returned to the Well Street address at 12.47pm and sat with Mr Loughnane out the front of the Gold Moon Restaurant (located next door to Mr Loughnane’s apartment block).

Mr Loughnane told Mr Newman that Maryam overdosed, however due to seeing blood, Mr Newman asked if Mr Loughnane hit her. Mr Loughnane did not respond, and Mr Newman suggested that he call an ambulance. Mr Loughnane refused and reportedly stated, “I can’t, I’ll get done for manslaughter”.

41. At 1.13pm, Mr Loughnane purchased several cleaning products from a nearby Coles supermarket. He also asked Mr Newman to obtain a steam cleaner.

42. That evening, or in the early hours of 13 April 2021, Mr Loughnane moved Maryam’s body from the apartment to Mr Newman’s Mazda 3.

43. On the afternoon or evening of 14 April 2021, Mr Loughnane drove the Mazda 3 to Cape Schanck, with Maryam’s body still inside the vehicle. He dug a shallow grave and disposed of her remains, before returning to his apartment in the early hours of 15 April 2021.

44. On the afternoon of 15 April 2021, Maryam’s sister, Hanna, used Facebook Messenger to contact Mr Borrelli and enquired about Maryam’s whereabouts. Hanna and Mr Borrelli discussed their concerns that Mr Loughnane might be involved in her disappearance and Mr Borrelli suggested contacting police. Maryam’s family contacted police and requested a welfare check.

45. That same day, Mr Loughnane sent several text messages to Maryam’s phone, pretending that she was still alive.

46. Shortly before 5.00pm, police attended Mr Loughnane’s Brighton home to perform a welfare check on Maryam and serve a previously unserved family violence intervention order (FVIO) on him. Mr Loughnane was generally uncooperative and appeared nervous when speaking with police. He claimed that he last saw Maryam four days earlier at his home, and that he last spoke to her via phone about two days prior.

47. That evening, Mr Newman contacted a seller via Gumtree in relation to purchasing a steam cleaner. The seller advised it was still available, and Mr Newman advised that his friend, ‘Heidi’, would attend to collect same. ‘Heidi’ attended the seller’s home at about 7.30pm and collected the steam cleaner as agreed. She claimed that she was helping a friend who was “in a bad place or a bad way”.

48. At 7.20pm on 16 April 2021, police re-attended Mr Loughnane’s home and executed a search warrant. The attending members noted a significant and overpowering smell of cleaning chemicals and located towels and sheets soaking in the bathtub. The carpet at the foot of the stairs, near the front door, was wet and soapy, and police opined that it appeared to be in the process of being deep cleaned.

49. Police interviewed Mr Loughnane on 17 April 2021 in relation to Maryam’s whereabouts.

Mr Loughnane denied knowing Maryam’s whereabouts and alleged that her family were not helping police with their investigations.

50. Police formally charged Mr Loughnane with murder on 25 August 2021.

51. On 15 February 2023, Mr Newman made a statement to police regarding his involvement with Maryam’s death. The statement also implicated Mr Loughnane in her disappearance. On 27 February 2023, Mr Newman pleaded guilty to assisting an offender and gave an undertaking to the court to give evidence against Mr Loughnane.

52. On 5 May 2023, after being implicated by Mr Newman, Mr Loughnane instructed his solicitors on the approximate location of Maryam’s remains. Police undertook several unsuccessful searches, one of which Mr Loughnane attended. Police eventually located Maryam’s shallow grave on 7 August 2023 and recovered her incomplete skeleton (likely incomplete due to animal foraging).

53. Mr Loughnane pleaded not guilty to Maryam’s death and was found guilty by a jury, following a trial in the Supreme Court of Victoria. He alleged that Maryam died of a drug overdose and continued to deny his involvement or guilt. On 14 February 2025, Mr Loughnane was sentenced to 28 years’ imprisonment, with a non-parole period of 20 years’ imprisonment.

FURTHER INVESTIGATIONS AND CPU REVIEW

54. As Maryam’s death occurred in circumstances of family violence and where she was experiencing family violence in the lead-up to his passing, the Coroner’s Prevention Unit

(CPU)2 examined the circumstances of Maryam’s death as part of the Victorian Systemic Review of Family Violence Deaths (VSRFVD).3

55. I make observations concerning service engagement with Maryam and Mr Loughnane as they arise from the coronial investigation into Maryam’s death and are thus connected thereto.

However, the available evidence does not support a finding that there is any direct causal connection between the circumstances highlighted in the observations made below and Maryam’s death.

56. I further note that a coronial inquiry is by its very nature a wholly retrospective endeavour and this carries with it an implicit danger in prospectively evaluating events through the “the potentially distorting prism of hindsight”.4 I make observations about services that had contact with Maryam and Mr Loughnane to assist in identifying any areas of practice improvement and to ensure that any future prevention opportunities are appropriately identified and addressed.

Family violence history between Mr Loughnane and Maryam 2020

57. Maryam commenced a relationship with Mr Loughnane in January 2020. The first known incident of family violence occurred in July 2020, when Mr Loughnane allegedly assaulted Maryam, resulting in bruising, two black eyes, swelling to her face and a burst blood vessel in one eye. The alleged assault also involved Mr Loughnane hitting Maryam with his fist and a glass bottle, gagging her with a sock, refusing to let her leave and taking her phone off her.

Maryam fled to a nearby supermarket where staff called her brother and an ambulance attended.

58. Maryam was conveyed to the Alfred Hospital where she disclosed Mr Loughnane’s violence to staff. Police attended the hospital and photographed Maryam’s injuries, however she did not provide any details of Mr Loughnane and indicated that she did not know his real name.

2 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.

3 The VSRFVD provides assistance to Victorian Coroners to examine the circumstances in which family violence deaths occur. In addition the VSRFVD collects and analyses information on family violence-related deaths. Together this information assists with the identification of systemic prevention-focused recommendations aimed at reducing the incidence of family violence in the Victorian Community.

4 Adamczak v Alsco Pty Ltd (No 4) [2019] FCCA 7, [80].

Maryam left the hospital prior to speaking to the hospital’s social worker or Victoria Police’s Family Violence Investigation Unit (FVIU), who were due to attend.

59. In December 2020, Maryam disclosed to her family that the bruising they observed in July 2020 was caused by Mr Loughnane assaulting her. Maryam did not want to report the assault to police as she was fearful of the repercussions from Mr Loughnane.

January 2021

60. On 21 January 2021, Mr Loughnane and Maryam attended the home of one of Maryam’s friends for dinner. During the dinner, Mr Loughnane and Maryam engaged in a verbal argument and Mr Loughnane alleged physically assaulted Maryam. Maryam left her friend’s house, and Mr Loughnane pursued her in his car. A witness from a nearby home called Triple Zero and reported that a woman was being chased by a man in a car. Police spoke to Maryam, and she did not disclose the violence, dismissed the allegations and provided police with a false name (her sister’s name).

61. From January to April 2021, three of Maryam’s friends received threatening text messages from Mr Loughnane. The messages included threats to the friends and/or towards Maryam, however these messages were not reported to police. From February to April 2021, Mr Loughnane also sent violent, threatening and graphic messages to Maryan. Maryam did not report these messages to police.

62. Mr Loughnane reportedly tasered Maryam on several occasions, however the timing of these assaults is unknown.

February 2021

63. On 21 February 2021, Maryam was at Mr Loughnane’s Brighton home with his friend, Kylie Zammit. Maryam disclosed Mr Loughnane’s violence to Ms Zammit, who later observed Mr Loughnane assault Maryam. Ms Zammit reportedly said, “you could have killed her” and Mr Loughnane responded, “she is lucky I didn’t”.

64. A neighbour called police to report the incident, however when police attended Mr Loughnane’s home, no one answered the door and no further action was taken.

65. The next day, Mr Loughnane sent a series of graphic text messages to Maryam, including: a) “I’ll funking murder u cunt !!!! Show em that rat”

b) “I’m going to slice ur face u funking dog just wait !!! I. Going to reallyw dare u yell that out ur fucked cunt make sure ur in pain u DOg ho” c) “Jail don’t scare me …not teaching u manners does” d) “I’m going to fuxk u up 4 last night can’t wait to c ur face n scream like a bitch” March 2021

66. On 6 March 2021, Maryam tried to escape from an assault by Mr Loughnane by fleeing to her mother’s home. Mr Loughnane chased her into the home, then into the toilet with a knife and locked the door. Maryam’s sister’s partner broke down the door with a baseball bat after hearing Maryam screaming for help. When police attended, Maryam was already gone and when police called her, she denied being at the property at all. While police were present at the scene, they observed Mr Loughnane fleeing in a car.

67. Mr Loughnane sent the following messages to Maryam during March 2021 (that were not reported to police): a) “Ur dead cunt” sent on 5 March 2021.

b) “I will beat u beyond recognition 2 inch of ur life” sent 9 March 2021.

c) “Ok my mum knows neighbours called ur dead” sent 10 March 2021.

d) “I’m going to jump on ur ficking head dog” sent 24 March 2021.

e) “Ho e alone which blokes with u in going to cut urfuxki g head off u better hope the cops come for ir sake in going g to literally kill u” also sent 24 March 2021.

68. On 17 March 2021, police applied for an application and warrant in relation to 6 March 2021 incident, with bail conditions prohibiting all contact and communication with Maryam. The application returned to court on 1 April 2021; however, Mr Loughnane did not attend. The court granted an interim FVIO, however it remained unserved at the time of the fatal incident.

April 2021

69. Mr Loughnane sent further threatening messages to Maryam in April 2021, including: a) “I’m going to jump on ur yead” sent 3 April 2021.

b) “Waiting g 4 u dog cunt ur fu led I’m awake and waiting 4 u u pie e of shit” sent 4 April 2021.

c) “Maryam u meth mutt wake up doggy I’m here…im going to break ur jaw dog” also sent 4 April 2021.

d) “When I get u dog ur going to wish u never born dog” sent 5 April 2021.

e) “Broken jaw and ribs” also sent 5 April 2021.

f) “Call me now ormkllmstab u in the face with a pencil when c u” sent on 7 April 2021.

g) “Keep playing games I will tie u up gag u n beat u all night with a blunt object” also sent 7 April 2021.

h) “U wont get away this time I got handcuffs” also sent 7 April 2021.

70. On 6 April 2021, police authorised charges of assault with a weapon and unlawful assault in relation to the 6 March 2021 incident. The Court later confirmed that these charges were filed via mail.

Risk and contributory factors

71. The Family Violence Multi-Agency Risk Assessment and Management (MARAM) Framework details several evidence-based risk factors associated with greater likelihood and/or severity of family violence, and factors which may indicate an increased risk of the victim being killed or almost killed.5

72. These risk factors are divided into three categories: a) Those which are specific to adult victim-survivors; b) Those which are caused by perpetrators’ behaviour towards an adult or child victimsurvivors; and c) Those which are caused by perpetrators which are specific to child.6 5 Family Safety Victoria, Family Violence Multi-Agency Risk Assessment and Management Framework (2018), 26.

6 Ibid.

73. The MARAM also identifies a number of people who can experience “particular risks, forms of family violence and barriers to accessing support” which can impact on the options and outcomes available to them.7 The risk factors documented in the evidence available to the Court in relation to Mr Loughnane and Maryam includes: a) Controlling behaviours b) Physical harm c) Unemployment d) Drug misuse e) Stalking and harassment f) Obsessive jealousy g) Increasing severity of violence h) Threats to kill i) Use of a weapon j) History of family violence k) Previous breach of FVIO l) History of violence towards others m) Self-assessment/fear of harm.

74. As referenced above, Mr Loughnane had an extensive history of reported family violence and assaults between 2005 and the fatal incident. Including Maryam, Mr Loughnane had at least five FVIOs against him (at various times) protecting his current/former partners. He had three FVIOs against him (at various times) protecting relatives of his former partners and on 13 January 2021, a FVIO was implemented against Mr Loughnane to protect his mother. There were various other intervention orders in place against Mr Loughnane to protect him from six other unknown victims.

7 Ibid, 33-36.

75. Mr Loughnane’s recorded charges between 2005 and 2019 included breaching FVIOs, intentionally threatening serious injury, recklessly causing injury, aggravated assault, threats to kill, persistently contravening FVIOs, and unlawful assault. He also received several terms of imprisonment: a) 213 days in 2007 for multiple charges including intentionally threaten serious injury and breach FVIO, primarily against a former partner.

b) 2008 for drug trafficking charges.

c) One month in 2017 for making a threat to kill and contravening an FVIO, primarily against a former partner and her mother.

d) Four months in 2017 for persistent contravention of a FVIO and committing an indictable offence while on bail, against a former partner (same partner referenced in c).

e) Eight months in 2018 for multiple charges including use or procure intimidation of a person, contravention of a conduct condition of bail, unlawful assault, persistently contravening a FVIO, recklessly cause injury, and aggravated assault of a female, against a former partner (same partner referenced in c and d).

76. Mr Loughnane received a Community Corrections Order (CCO) in June 2018 in response to his offending against a former partner. He was fined for breaching his CCO in July 2019 and the CCO was only confirmed.

Alfred Hospital

77. As noted above, Maryam was admitted to the Alfred Hospital on 9 July 2020 following an alleged assault by Mr Loughnane. The Alfred Hospital records include: a) Maryam alleged an assault at her boyfriend’s home one day prior, including being hit in the head with a glass bottle/phone/fists, stated she had a sock pushed into her mouth and she was not permitted to leave the home.

b) That Maryam was “possibly strangled”.

c) Maryam’s injuries included bilateral peri-orbital bruising on her head, abrasions on her neck and midline C-spine tenderness, and a minimally displaced fracture of the nasal bone.

78. Maryam left the hospital once her spine was cleared of injury. She left prior to the social worker attending and staff documented a plan in case she decided to return (which she did not).

79. I have not identified any deficiencies with respect to the Alfred Hospital contact with Maryam on this occasion.

Victoria Police

80. I note that Victoria Police’s involvements with Mr Loughnane and Maryam were relatively limited. However, I note that Victoria Police had extensive information about Mr Loughnane’s perpetration of family violence (and violence generally) against former partners, family members and other victims. Of note: a) In 2017, Victoria Police implemented a Priority Target Management Plan (PTMP) for Mr Loughnane, in relation to the risk he posed to his former wife.

b) In October 2019, Victoria Police implemented a High Risk Management Response (MRT) for Mr Loughnane in relation to the risk he posed to his mother.

July 2020

81. As noted above, Victoria Police members attended the Alfred Hospital and spoke to Maryam while she was in hospital following an assault by Mr Loughnane. She disclosed limited details and denied knowing Mr Loughnane’s real name, address or other details. She told police that Mr Loughnane kept her phone, so she was unable to provide his phone number or contact details. The LEAP records of this incident indicate that police checked CCTV to determine if they could identify where Maryam came from, prior to the ambulance being called, however this was unsuccessful.

82. Maryam’s brother spoke to police about the incident on 9 July 2020. At the time, her brother told police that he believed it was her boyfriend who assaulted her, however, did not know his name or details. He reported that this person had Maryam’s phone and possibly lived in Elwood. Maryam’s brother later gave evidence that Maryam had begged him not to make a statement in relation to the incident, so he did not do so.

83. The LEAP narrative noted that “enquiries with family indicate possibly associate Toby Loughnane but unable to link beyond reasonable doubt”. Police attempted to obtain statements from Maryam’s family without success.

84. The Victoria Police member who attended the hospital advised that a FVIU member would be coming to speak with Maryam, however she left before this occurred. It does not appear that a Family Violence Report (FVR L17) was lodged on LEAP, and consequently, referrals were not made.

85. After Maryam was reported missing, police charged Mr Loughnane with intentionally cause serious injury, recklessly cause serious injury and commit indictable offence while on bail in relation to this incident. These charges were made based on the statement that Maryam made at the time, and further statements made by her family members after she disappeared.

21 January 2021

86. As noted above, a woman called Triple Zero to advise that she could see a woman being chased by a car from her apartment. She later called back to advise that police had pulled over the correct vehicle (when they pulled over Mr Loughnane).

87. When police spoke to Maryam, she stated there was no assault and was dismissive of the information provided by the Triple Zero caller. At the time police spoke to Maryam, she was not in the vehicle, however she was standing near it when they approached.

88. When police spoke to Mr Loughnane, he appeared “irritated”, queried why police pulled him over and advised that he had been “talking to his girlfriend”.

89. Police followed up with the Triple Zero caller, however she was unable to provide any further details due to the distance between her apartment and the location of the incident. In the LEAP records provided to the Court, there was no reference to this incident, however I note that Maryam provided her sister’s name and therefore the incident might have been recorded under her name. Police were also unaware that Maryam’s friend witnessed the incident at the time.

90. I note that while Maryam was uncooperative, given that the description of the vehicle and the female (Maryam) matched the description given by the Triple Zero caller, in my view, a quick review of Mr Loughnane’s significant history of violence could (and should) have raised further concerns for the members. This may not have resulted in charges; however, it might have resulted in family violence referrals being made.

21 February 2021

91. As noted above, an anonymous caller contacted Triple Zero and advised: a) There is a drug dealer at the address (Mr Loughnane’s home) b) There is “lots of commotion” c) There is a girl who “obviously” wants drugs d) The male “has beaten her up and she is screaming” e) The male has assaulted her, and it has been “going on” for about an hour f) The female is hurt g) This is not the first time as people attend this address to buy drugs and things “get nasty” h) The male’s name is Toby, and he recently got out of gaol. The caller also provided a physical description.

92. Police attended Mr Loughnane’s home however they were unable to locate him or Maryam.

Ms Zammit later told police that Mr Loughnane forced her to hide when police attended and advised her that the last time police attended, they “shot him” and she was fearful. Maryam left the area before police arrived.

93. In the LEAP records provided to the Court, there was no reference to this incident, and no reference to any further follow-up or investigation.

94. In a statement to the Court, Acting Executive Director, Claire Waterman, of the Family Violence Command (FVC) noted that at the time of this incident, police were unable to make inferences about a family violence risk to Maryam because: a) Police were unable to establish that an assault occurred; b) Police had no reason to believe that Maryam was present or was the victim; c) Police had no reason to believe the incident involved family violence; and

d) Unconfirmed reports of assault against an unknown person in a potentially drugrelated dispute is not an evidence-based risk factor in standardised family violence risk assessment.

95. I accept Ms Waterman’s submission as it was unclear from the limited information provided whether the incident was indeed a family violence related incident.

6 March 2021

96. The LEAP record for this incident states that the parties had no previous family violence reports and no FVIOs between them. I note this is incorrect as Mr Loughnane had an extensive history of family violence with other people. Furthermore, I note that Maryam was recorded as a perpetrator of family violence against her mother, and there was a FVIO in place to prevent her from attending her mother’s home.

97. When police attended the scene, they called Maryam’s phone. She claimed she was in Sunbury and denied that any incident occurred.

98. Upon reviewing the body worn camera (BWC) footage of the incident: a) Mr Loughnane is observed driving past police. He refused to stop when police shouted at him to stop.

b) Maryam’s sister disclosed that “he bashed her really bad previously, he chased her inside and locked in the toilet [sic]”.

c) The attending members stated, “If she won’t play ball, all we can do is complaint and warrant, reckless driving and possess weapon – we can do her for breach and if she does a statement, we can drop it”.

99. The LEAP record of this incident referenced “completion of breaching the IVO for the AFM”.

100. On 7 March 2021, the FVIU reviewed the incident and triaged it as medium risk and “in line with the FVIU Risk Assessment and Management Guidelines, investigation primacy will remain with the investigating member”. Despite not taking primacy of the investigation, the FVIU offered to assist the investigating member. Due to the passage of time, it is unclear what assistance (if any) the FVIU provided to the investigating member.

101. On 10 March 2021, police attended Mr Loughnane’s home, however, were unable to locate him. Police arrested Mr Loughnane on 16 March 2021 in relation to an application and warrant for a FVIO (to protect Maryam). Mr Loughnane signed a bail undertaking in relation to the FVIO on 17 March 2021 and the conditions of the bail prevented him from having contact with Maryam. He was bailed to return to court on 1 April 2021; however, it does not appear this occurred.

102. Police charged Mr Loughnane with assault with a weapon on 6 April 2021 and as noted above, this occurred via mail.

Analysis

103. I note that interviewing Mr Loughnane, applying for a FVIO and filing charges against him were all appropriate steps. However, I am concerned about the risk assessment that was performed and the risk management strategies implemented to mitigate the risk he posed following this incident.

104. I am also concerned about the attending members considering charging Maryam with breaching the FVIO against her (to protect her mother). It is correct that Maryam was at her mother’s house in breach of the FVIO, however it is unclear what weight (if any) police gave to the fact that Mr Loughnane chased Maryam into the house with a knife, or that Maryam’s sister alleged a serious prior assault. I note that police ultimately did not charge her.

105. In Ms Waterman’s statement to the Court, she noted that the risk assessment (medium risk) was appropriate. Although there was limited information available to Victoria Police at the time about Mr Loughnane’s perpetration of family violence against Maryam specifically, there was extensive evidence of the risk he posed to multiple intimate (former) partners, their family members, his mother and others via LEAP. Mr Loughnane was listed as the respondent in 17 incidents after 2017 and he was a respondent in 13 intervention orders prior to this incident.

Mr Loughnane was subject to a PTMP with his former wife in 2017 and an MRT with his mother in 2019. Mr Loughnane’s criminal history clearly demonstrated his disregard for court orders and in my view, a FVIO or bail conditions were unlikely to ameliorate this risk.

106. Ms Waterman explained that it appeared that the attending members considered these risk factors as they ticked ‘yes’ in relation to the following questions on the L17:

a) Does the current respondent have any prior family violence incidents as the Respondent or the Affected Family Member (AFM) (with the current AFM or any other person)?

b) Has the respondent ever been charged with contravention of an intervention order?

c) Has the respondent ever been charged with breaching a court order?

d) Has the respondent previously been charged with a violent offence? (E.g., homicide, rape, sex (non-rape) offences including physical contact with the victim, robbery, abduction/kidnap, arson, aggravated burglary, assault)?

107. I note that a binary answer (yes/no) to each of these questions, when compared with Mr Loughnane’s extensive and violent history (considered in totality) may not be well enunciated or emphasised. He had been charged with breaching (and persistently breaching) FVIOs in relation to multiple victim-survivors, had assaulted multiple victim-survivors and had a significant history of family violence incidents. Simply answering ‘yes’ to the question of does the person have a history of family violence incidents cannot sufficiently distinguish a perpetrator who has a long history of family violence incidents from a perpetrator who has one prior incident.

108. In my view, the incident itself was relatively serious (chasing Maryam with a knife), and when considered in a context of Mr Loughnane’s ongoing pattern of violent behaviours, this incident should have been classified as high risk.

109. Ms Waterman submitted that after this incident, police implemented the following measures to support Maryam, specifically: a) Implementation of a FVIO; b) Formal referrals were submitted for both Mr Loughnane and Maryam.

c) Police made several attempts to follow up and engage with Maryam. Ms Waterman noted that AFM engagement with police is a key component in ongoing risk management. With the exception of the first call (21 January 2021), police made several attempts to speak to Maryam, however she did not answer or reply to any calls.

Police did not have her address and therefore this further hindered their ability to engage with her.

d) Police served the FVIO on Mr Loughnane on 15 April 2021. I note that this was after Maryam was reported missing.

110. As a result of the incident being classified as medium risk, there was no FVIU oversight, no proactive monitoring and no involvement by the FVIU’s intelligence analyst. Ms Waterman noted that it was not possible to determine what role, if any, the intelligence analyst played in this case (given the passage of time), however noted that generally speaking, the analysts do not have input into risk management strategies for family violence perpetrators unless the incident is deemed high risk and the FVIU has primacy of the incident.

111. I note that risk ratings can be manually overridden up or down by members, to escalate a family violence incident to the FVIU if it is deemed necessary. As noted above, Mr Loughnane was previously subject to a PTMP and MRT with other victims (his former wife and mother, respectively).

112. Ms Waterman noted that the reason why a PTMP had been established for Mr Loughnane in relation to his former wife “would have been due to the risk identified between those two parties. That same level of risk had not been identified between Mr Loughnane and Ms Hamka.

Perpetrators are not automatically subject to a PTMP due to the fact that they have previously been subject to a PTMP in relation to a different AFM”.

113. I agree that the mere presence of one PTMP does not automatically give rise to the creation of another PTMP. However, in my view, the fact that Mr Loughnane was previously subject to a PTMP should have raised the suspicions of the investigating members in relation to the 6 March 2021 incident. This is particularly pertinent given Mr Loughnane’s extensive history of family violence perpetration and disregard for FVIOs. When taking into account Mr Loughnane’s pattern of behaviour and risk (i.e., perpetrating significant family violence against his intimate partners) despite this matter technically being triaged as ‘medium risk’, I am of the view that it should have been re-classified or manually overridden to allow for FVIU oversight.

114. I raise the issue of the risk rating in circumstances where Victoria Police is currently working to implement version 3 of the Case Prioritisation and Response Model (CPRM) case management tool. In April 2025, phase two of the implementation of version 3 (prior to full statewide implementation) commenced and further work is planned, including: a) Evaluating the performance to ensure it continues to perform as expected.

b) Development of a full suite of practical guidelines.

c) Development and delivery of risk management training for FVIUs, and a full review of policy to better streamline management processes and better support workload.

115. An evaluation of the CPRM was canvassed in Judge Cain’s finding into the passing of Noeline Dalzell. His Honour recommended: Victoria Police engage an external independent suitably qualified person to conduct an evaluation of the effectiveness and skillset of the FVIUs. The review ideally should be conducted prior to the rollout of the CPRM to provide valuable benchmarking information to assist in the evaluation of the CPRM program which has been foreshadowed by the Chief Commissioner of Police in his submissions.

116. In response, Victoria Police advised: This recommendation is accepted in principle but is subject to timing and funding issues. This recommendation requires an evaluation of the effectiveness and capabilities of the FVIUs prior to the implementation of the Case Prioritisation and Response Model (CPRM). However, version 3 of the CPRM is already being rolled out, and pausing or halting this process is neither practical nor beneficial. In addition, as highlighted in Victoria Police's closing submissions, significant new training for FVIUs has been delivered over the past 12 months. This training now requires time to be effectively integrated into practice. The timing of any external evaluation is therefore critical and must be carefully planned to ensure optimal outcomes.

Moreover, engaging external evaluators will depend on available funding and resources, as well as the inevitable need to prioritise competing demands across Victoria Police.

117. The Court advised Victoria Police of my intention to restate Judge Cain’s recommendation above. Victoria Police advised that it is supportive of the recommendation in principle, save for two issues, namely: a) Roll out of Version 3 of the CPRM is already underway; and b) Engaging external evaluators will depend on available funding and resources.

118. I therefore intend to recommend that the Victorian Government adequately fund and resource an evaluation of Version 3 of the CRPM and the FVIUs.

Procedural fairness response

119. As a matter of procedural fairness, the Court wrote to Victoria Police and advised of my preliminary views and intention to finalise this matter by way of written findings in chambers.

Victoria Police were also provided with an opportunity to respond to proposed adverse comments.

120. The correspondence noted: The Coroner's preliminary view is that the fact that Mr Loughnane was previously subject to a PTMP should have raised the suspicions of the investigating members in relation to the 6 March 2021 incident. This is particularly pertinent given Mr Loughnane's extensive history of family violence perpetration. When taking into account his pattern of behaviour and risk, despite this matter technically being triaged as 'medium risk', the Coroner is of the view that it should have been re-classified or manually overridden to allow for FVIU oversight/involvement

121. Solicitors on behalf of Victoria Police submitted that there was insufficient evidence to make such a finding and that such a finding could only be made with the benefit of hindsight.

Victoria Police further submitted that the risk assessment undertaken by the attending members and the subsequent assessment and prioritisation by the FVIU was in accordance with policy and evidence-based practice at the time. As noted above, the incident was triaged as ‘medium risk’.

122. Victoria Police further noted that the relationship between family violence history and risk of future severe harm is complex. It is exceedingly difficult to predict future severe family violence, including family violence leading to fatal outcomes.

123. Victoria Police submitted that: Respectfully, the State Coroner’s view that the incident “should have been classified as high-risk” reflects the clarity that hindsight provides. It is respectfully submitted that the appropriate standard is whether the risk assessment was reasonable and in accordance with evidence-based policy at the time it was made, based on the information then available. The standard is not whether, with the benefit of hindsight, members should have foreseen a tragic outcome,

124. I do not disagree that the assessments and prioritisation were conducted in accordance with relevant Victoria Police policies at the time. I also do not disagree that the relationship between family violence history and risk of future severe harm is complex. However, at the time of police assessing the incident as ‘medium rusk’, Mr Loughnane was: a) The respondent in at least 12 intervention orders, and a total of 32 times in intervention orders.

b) Recorded as a family violence perpetrator on 21 previous occasions with six previous partners. 17 of those 21 incidents occurred between February 2017 and Maryam’s death.

c) Charged with multiple relevant offences between 2005 and 2019, and served periods of imprisonment for numerous violent charges, including FVIO breaches.

d) Had been subject to both an MRT and PTMP for different AFMs; and e) The ‘medium risk’ incident in question involved Mr Loughnane chasing Maryam into a house where she was legally excluded (by way of FVIO) with a knife and she screamed to an extent that her brother-in-law broke down the door.

125. This information suggests that his violence was persistent and potentially escalating, he had an ongoing disregard for the law and Maryam’s refusal to even acknowledge her presence at the incident (despite multiple witnesses putting her there) could have been assessed as indicative of her level of fear.

126. Even if the risk assessment tool did not assess this as high risk, in my view, this does not obviate the need for members to use professional judgment.

127. The 2019 Code of Practice for the Investigation of Family Violence (‘the Code of Practice’) notes that police “will respond to and take action on any family violence incident reported to them, regardless of who made the report and how it was made. In meeting this policy of compulsory action, police will: …

• Using professional judgment, assess the likelihood of future risk to determine the most appropriate risk management strategy (Options Model).8

128. Furthermore, the Code of Practice provides the following guidance in relation to the assessment of future risk as ‘likely’ or ‘unlikely’: The following steps are intended to guide police professional judgment:

• Consider each piece of information obtained including all abuse, not just the most serious incident and anything else known.

• Examine the risk and vulnerability factors combined with the AFM’s own assessment of their level of fear in conjunction with your understanding about the continuum of family violence.

• Use professional judgment as to whether there is a likelihood of future family violence.9

129. I am not suggesting that by manually reclassifying the incident as ‘high risk’ that Maryam’s death would have been prevented. Nor that members should or could have anticipated that Mr Loughnane would murder her. However, it is my view that if his serious history of violence had been accorded appropriate weight, it is likely that the incident would have been manually classified as high-risk, which would have attracted FVIU oversight. gvfIt is therefore critical that members use the tools they have (e.g., the L17 risk assessment) in combination with the perpetrators’ known history and their own professional judgement.

Recent improvements and reform

130. Victoria Police further noted that it is committed to continuous improvement and addressing the ongoing harm caused by repeat perpetrators. Victoria Police advised that it continues to actively explore opportunities to enhance risk assessment management processes.

131. Victoria Police noted that while the FVR is functioning as intended, an evaluation identified opportunities to enhance other aspects of the CPRM, namely: a) The Case Prioritisation Tool (CPT) is a method of classifying cases that are identified as requiring further assessment by the FVIU; and 8 Victoria Police, Code of Practice for the Investigation of Family Violence, 2019, 15.

9 Ibid, 25.

b) The Case Prioritisation Review (CPR) which is a process for reviewing cases that are not initially prioritised using the CPT are reviewed using the CPR. This provides an additional layer of FVIU review.

132. In mid-2025, Version 3 of the CPRM introduced an enhanced CPR, providing clearer guidance on: a) Using structured professional judgment and dynamic risk factors; b) Considering past family violence history alongside dynamic risk factors; and c) Better assessing adequacy of current risk management.

133. Victoria Police advised that in mid-2027, Version 3 of the CPRM will introduce a new CPT algorithm, supported by policy and risk management practice guidelines for FVIUs that include consideration of what the FVIU’s role means in the context of the uniform and FVIU interface on moderate/medium risk cases. This will include investigative guidance on risk management strategies.

134. The roll-out of version 3 of the CPRM will also include a re-evaluation of the CPRM by Swinburne University, prior to the completion of state-wide implementation to ensure it is performing as intended.

135. These changes appear positive and will hopefully allow members to combine their professional judgment with structured risk assessment tools to appropriately assess and manage family violence perpetrators and victim-survivors.

Systemic issues - bystanders

136. There were multiple people in Maryam’s life who were aware of the violence that Mr Loughnane was perpetrating against her. There were also instances where police were not called, sometimes at Maryam’s request, and others called police on two occasions.

137. On the night of the fatal incident, Maryam’s neighbours heard screaming and did not contact police. It is unclear if they were the same neighbours who previously contacted police.

138. The Royal Commission into Family Violence (RCFV) examined how ‘informal supporters’ and ‘third party witnesses’ might be better equipped to respond to family violence, given research indicating that victims of family violence are more likely to talk to family and friends

about their experience of violence than to contact a family violence service or police.10 The RCFV recommended creating a website to provide information to the public about family violence, how to recognise it and where to seek help.11 It also recommended that the Support and Safety Hubs (now called The Orange Door) be a referral entry point for family and friends of those affected by family violence.12

139. The Court has subsequently endorsed these recommendations in several family violencerelated deaths, and The Orange Door has a section on its website outlining how they can be contacted to seek help for someone else.13 Safe and Equal also has an annual campaign and website called Are you safe at home? that provides resources to assist others in multiple languages.14

140. In former State Coroner, Judge Cain’s finding into the death of Monique Leszak,15 his Honour recommended: That the Department of Families, Fairness and Housing and Family Safety Victoria work with and resource bodies such as Respect Victoria and Safe and Equal to deliver a public campaign to resource the broader community, beyond service providers, to better understand the risks that perpetrators of family violence pose, including in the absence of physical violence. This campaign should consider how to reach the broadest possible audience including through education, health, local community, sports and faith groups. The campaign should enhance awareness of fatality risks posed by those who use coercive and controlling behaviour, factors that may increase risk (such as in the context of separation) - and should include clear information to victims, friends, family and bystanders as to services available to help keep them safe.

10 Glennys Parker and Christina Lee, ‘Violence and abuse: An assessment of mid-aged Australian women’s experiences’ (2002) 37(2) Australian Psychologist 142-148; Jenny Mouzos and Toni Makkai, ‘Women’s Experiences of Male Violence: Findings from the Australian Component of the International Violence Against Women Survey (IVAWS)’ (Research and Policy Series No 56, Australian Institute of Criminology, 2004) 101; Janet Fanslow and Elizabeth Robinson, ‘Help-seeking behaviors and reasons for help seeking reported by a representative sample of women victims of intimate partner violence in New Zealand.’ (2010) 25(5) J Interpers Violence 929-951 11 Royal Commission into Family Violence (Final Report, March 2016) vol 2, 27.

12 Ibid, 285.

13 Family Safety Victoria, Support for someone you know, < https://www.orangedoor.vic.gov.au/support-someone-youknow>.

14 Safe and Equal, Are you worried about someone?, https://areyousafeathome.org.au/someone-you-know/.

15 Finding into death without inquest – Monique Leszak.

141. In response, the Department of Families, Fairness and Housing (DFFH) stated that it supports the intent of this recommendation and advised that it consulted with Respect Victoria and Safe and Equal during consideration.

142. DFFH explained that educating the wider community about coercive control is a priority under the “whole of community” focus area identified in Victoria’s “Until every Victorian is safe: Third Rolling Action Plan to end family and sexual violence 2025-27” (‘the Third RAP’).

The Victim Survivor’s Advisory Council (VSAC) has strongly advocated for greater community awareness about coercive control. DFFH committed to partnering with VSAV to increase community awareness and understanding about what coercive control is and what to do once it is identified. This is an action in the Third RAP.

143. DFFH noted that Respect Victoria has produced a series on its website and social media channels in various forms targeting coercive control and non-physical violence. Engagement with this content has been high, particularly for the topics of ‘love bombing’ and ‘gaslighting’.

144. DFFH also noted various other initiatives, including: a) Implementation of the Ballarat Community Saturation Model.

b) The ‘What Kind of Man do you want to be’ campaign produced by Respect Victoria.

c) The ‘Are you Safe at Home’ campaign produced by Safe and Equal.

d) The ‘Are you Safe at Home’ day, held on 10 May every year, with proactive marketing and communications initiatives.

145. Sadly, as demonstrated by this case, community awareness and understanding of coercive control is still lacking. I therefore intend to direct a copy of this finding be provided to Safe and Equal and Respect Victoria, to inform their ongoing work in this area.

Systemic issues – perpetrator interventions (high-risk offenders)

146. The perpetrator interventions in Victoria consist of two key intervention types – behaviour change interventions (largely Men’s Behaviour Change Programs – MBCPs) and legal and policing interventions.

147. Tragically, Mr Loughnane is yet another case before the Court in which a man with a lengthy history of violent behaviour interacts multiple times with various family violence systems

(including legal and policing) and then went on to kill an intimate partner.16 Mr Loughnane had numerous intervention orders taken out against him, had a significant history of breaching court orders, had been convicted of various violent offences, served several short terms of imprisonment, and was subject to CCOs. Despite these numerous interventions, Mr Loughnane continued to exhibit a disregard for the law and continued to perpetrate significant violence.

148. The Australian Law Reform Commission (ALRC) canvassed issues with short prison terms in their report Pathways to Justice – An Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples.17 The ALRC found that while short prison sentences can provide a brief period of safety for victims of family violence,18 they do not deter offenders, and may increase the likelihood of recidivism. The ALRC commented that prisoners serving short sentences are less likely to be able to access programs which might assist them to desist from offending and are generally released into the community without supervision or supports.19

149. The ALRC did not recommend the abolition of short sentences given the dearth of community-based sentencing options, supports and programs available to replace them. It did, however, recommend expansion of community programs aimed at addressing the underlying causes of crime, and therefore of community-based sentencing options.20

150. In former State Coroner, Judge Cain’s finding into the passing of Noeline Dalzell, his Honour commented that although the homicide offender in that case was successfully prosecuted and served several short sentences for his family violence offending, these criminal sanctions had no impact upon his recidivism. His Honour suggested that alternative means to manage the risk created by recidivism should be explored.21

151. I note the recent finding by Coroner Simon McGregor into the death of HCG,22 in which the perpetrator engaged with MBCPs several times, yet this failed to impact on his family violence recidivism or the gendered attitudes that underpinned same.

16 See, for example, Finding into death without inquest – PLM; Finding into death without inquest – ZSQ; Finding into death without inquest – HCG.

17 ALRC, Pathways to Justice—An Inquiry into the Incarceration Rate of Aboriginal and Torres Strait Islander Peoples (Final Report No 133, 2017).

18 Ibid, 271-272.

19 Ibid, 268.

20 Ibid, 271-272.

21 Finding into passing with inquest - Noelene Dalzell, 68.

22 Finding into death without inquest – HCG.

152. According to Australia’s National Research Organisation for Women’s Safety (ANROWS), Australia is yet to adequately invest in behaviour change work with perpetrators of family violence.23 Effective intervention with high-risk perpetrators of family violence is a particular challenge for the service sector,24 and the Expert Advisory Committee on Perpetrator Interventions (‘the Committee’) found that there is “an urgent need for a more intensive intervention in the community to respond to higher risk perpetrators”, particularly those found unsuitable for a MBCP, and those recently released from prison whose sentence was too short to allow for participation in perpetrator intervention.25 The RCFV made a similar finding.26 The Committee therefore recommended the development of “a family violence intervention in the community for high risk perpetrators who are unsuitable for participation in an

MBCP.”27

153. ANROWS further note that although fiscal pressure creates pressure to fund cheap interventions,28 short-term perpetrator interventions “do not seem effective and should be replaced or augmented with programs that include wraparound and holistic supports”.29

154. In March 2024, Family Safety Victoria finalised the program requirements for a pilot program entitled ‘Changing Ways: Intensive interventions for serious-risk adults using family violence’ (‘Changing Ways’). The pilot will run for two years and target serious-risk adults using family violence with an intensive, coordinated response based on their level of risk. The service model includes leading and coordinating multi-agency risk assessment and management, advocacy for victim-survivors,30 and where appropriate, responsive, individual readiness for change and behaviour change work.31 It aims to increase safety for victim23 Helps, N., Bell, C., Schulze, C., Vlais, R., Clark, O., Seamer, J., & Buys, R. The role of men’s behaviour change programs in addressing men’s use of domestic, family and sexual violence: An evidence brief (February 2025).

ANROWS, 23 24 State of Victoria, Expert Advisory Committee on Perpetrator Interventions, Final Report (2018), 67.

25 Ibid, 70.

26 Family Safety Victoria, Changing Ways: Intensive interventions for serious-risk adults using family violence – Program requirements (March 2024), 6.

27 State of Victoria, Expert Advisory Committee on Perpetrator Interventions, Final Report (2018), 7.

28 Helps, N., Bell, C., Schulze, C., Vlais, R., Clark, O., Seamer, J., & Buys, R. The role of men’s behaviour change programs in addressing men’s use of domestic, family and sexual violence: An evidence brief (February 2025).

ANROWS, 26.

29 Bell, C., & Coates, D., ANROWS, The effectiveness of interventions for perpetrators of domestic and family violence: An overview of findings from reviews (2022) 3.

30 Family Safety Victoria, Changing Ways: Intensive interventions for serious-risk adults using family violence – Program requirements (March 2024), 16.

31 Ibid, 28.

survivors, reduce or stop the substantial harm caused by serious-high adults using family violence, and build evidence of what works.32 The pilot will be independently evaluated.33

155. The evidence suggests that individualised, tailored programs such as Changing Ways contribute to more positive outcomes for people who use violence rather than ‘one-size-fitsall’ approaches.34 A tailored approach may have benefited Mr Loughnane, who had a specific background of problematic substance use which may have impacted the nature and intensity of his use of violence.

156. An intensive perpetrator intervention such as Changing Ways may have also promoted Maryam’s safety, for example, by keeping Mr Loughnane in view of police, even if he chose not to engage. However, I note that this program is yet to be evaluated as to its effectiveness in responding to high-risk perpetrators. Involvement with an intensive perpetrator intervention program such as Changing Ways, may have also prompted other agencies (e.g., Victoria Police) to implement more proactive risk management strategies, however, would have required Mr Loughnane to have been identified as a high-risk perpetrator in the first instance (which he was not, in relation to Maryam).

157. I therefore intend to recommend that the Victorian Government commit to funding for longterm perpetrator interventions that provide holistic, wrap around supports, such as the Changing Ways pilot. I also intend to direct a copy of this finding be provide to Family Safety Victoria, so that they can incorporate learnings from her death into their work on the Changing Ways pilot, particularly how they work with Victoria Police in circumstances of high-risk family violence perpetrators.

FINDINGS AND CONCLUSION

158. Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Maryam Hamka, born 19 December 1984; 32 Ibid, 6.

33 Ibid, 40.

34 Helps, N., Bell, C., Schulze, C., Vlais, R., Clark, O., Seamer, J., & Buys, R. The role of men’s behaviour change programs in addressing men’s use of domestic, family and sexual violence: An evidence brief (February 2025).

ANROWS 14; Fitz-Gibbon, K., McGowan, J., Helps, N. & Ralph, B. (2024) Engaging in Change: A Victorian study of perpetrator program attrition and participant engagement in men’s behaviour change programs. Monash University, Victoria, Australia, 7, 82

b) the death occurred on 11 April 2021 at Unit 8, 1-3 Well Street, Brighton Victoria 3186, from unascertained causes; and c) the death occurred in the circumstances described above.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:

(i) As recommended by Judge Cain in his Honour’s finding into the passing of Noeline Dalzell, I recommend that Victoria Police engage an external independent suitably qualified person to conduct an evaluation of both the CPRM Version 3, and of the effectiveness and skillset of the FVIUs and that the Victorian Government adequately fund and resource this evaluation.

(ii) That the Department of Families, Fairness and Housing provide ongoing funding for long-term perpetrator interventions that provide holistic, wrap around supports, such as the Changing ways pilot.

I convey my sincere condolences to Maryam’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Susan Iramiyan, Senior Next of Kin Department of Families, Fairness and Housing Family Safety Victoria Respect Victoria Safe and Equal Victoria Police (C/- Lander & Rogers) Victorian Government Detective Leading Senior Constable Jason Stewart, Coronial Investigator Signature: ___________________________________ Judge Liberty Sanger, State Coroner Date: 27 February 2026 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.