Coronial Findings

RECORD OF INVESTIGATION INTO DEATH

Coroners Act 1995

FOR PUBLICATION

I, Olivia McTaggart, Coroner, having investigated the deaths of

Stephen Montague PUGH and Andrea Lee WRATHALL

WITHOUT HOLDING AN INQUEST

FIND THAT:

Andrea Lee WRATHALL (Ms Wrathall) died on 13 June 2005 at the Royal Hobart Hospital, Hobart.

Ms Wrathall was born in Hobart on 6 August 1979 and was aged 25 years. She was employed as a factory worker.

I find that Ms Wrathall died from gunshot wounds, and that the gunshot wounds were deliberately inflicted by Stephen Montague Pugh.

I find Stephen Montague PUGH (Mr Pugh) died on or about 14 June 2005 at Brighton Army Camp Brighton.

Mr Pugh was born in Ouse, Tasmania on 19 November 1964 and was aged 40 years. Mr Pugh was employed as a timber worker.

I find that Mr Pugh died as a result of a self-inflicted contact range gunshot wound.

Background to the relationship:

During the latter half of 2000, Mr Pugh and Ms Wrathall commenced a relationship that led to them living together as defacto partners in January 2001.

Mr Pugh was a tree feller by occupation and Ms Wrathall was a factory hand employed by Blundstones in Glenorchy.

Ms Wrathall had not been involved in any reported family violence incidents prior to her relationship with Mr Pugh, and only had one traffic conviction recorded with Tasmania Police.

Mr Pugh had a criminal history recorded with Tasmania Police, including assault convictions and breach of restraint order convictions. Mr Pugh had been recorded as being involved in family violence incidents with two other females prior to commencing a relationship with Ms Wrathall.

Mr Pugh was a heavy drinker and some witnesses interviewed considered him alcohol dependant.

Arguments would occur between Ms Wrathall and Mr Pugh when they were both drinking. Prior to January 2005, Tasmania Police had not been notified of any family violence incidents between Ms Wrathall and Mr Pugh.

In mid 2004, Ms Wrathall left Mr Pugh and returned to live with her father. A week later she reconciled with Mr Pugh although some witnesses stated the relationship deteriorated from that point on. Ms Wrathall suspected that Mr Pugh was having an affair. The evidence reveals that Mr Pugh in fact maintained a sexual relationship with another female up until three nights before his death.

There was a fifteen year age difference between the couple, and Mr Pugh could become jealous and possessive of Ms Wrathall, especially if she wanted to socialise without Mr Pugh. There is evidence that physical altercations would take place between them in the form of pushing and shoving.

Despite the reported tensions, the couple became engaged in 2004 and planned to get married. It does not appear a date had been fixed.

An argument between the two occurred in September 2004 that resulted in Ms Wrathall receiving a blackened eye and treatment for an injured right shoulder. Two friends of Ms Wrathall’s also recalled an incident where Ms Wrathall and Mr Pugh had an argument and Ms Wrathall later related that she had been assaulted by Mr Pugh. Neither of these incidents was reported to Tasmania Police.

On 2 January 2005, Tasmania Police attended Ms Wrathall and Mr Pugh’s residence in relation to a family violence incident where Ms Wrathall stated she had been assaulted by Mr Pugh. This was the first of five reported incidents responded to by Tasmania Police. As a result of the first incident Tasmania Police successfully applied for a restraint order against Mr Pugh in order to protect Ms Wrathall. A short time later they recommenced their relationship and continued to reside together at 16 Linda Avenue, in contravention to the conditions of the order.

In March 2005, Mr Pugh was sentenced to four weeks in prison over a drink driving charge.

Mr Pugh loathed the four weeks he spent in Risdon Prison and told associates he would never go back. Whilst he was imprisoned, Ms Wrathall made plans to leave him. However she continued to visit Mr Pugh in prison, visit his friends and pass messages for him. Mr Pugh was not aware that Ms Wrathall was going to leave him and he arranged for flowers to be delivered to her workplace the day he was released.

On the day Mr Pugh was released from prison, Ms Wrathall had moved her belongings from 16 Linda Avenue and was meeting with a solicitor in relation to a property settlement. Ms Wrathall had left a note at Linda Avenue informing Mr Pugh that their relationship was over.

Mr Pugh was initially stunned by Ms Wrathall leaving him. He continued to pursue Ms Wrathall and did not appear to accept the relationship was over. Mr Pugh made numerous attempts to visit and contact her. When Ms Wrathall reiterated that the relationship was over Mr Pugh began to continually phone and harass her.

In April 2005, Ms Wrathall contacted Police and outlined a series of restraint order breaches that had occurred and alleged a course of harassment by Mr Pugh involving damage to property. The allegations comprised phone calls made to Ms Wrathall by Mr Pugh, in person breaches by approach, a minor assault by Mr Pugh grabbing Ms Wrathall’s hand and damage to her car radiator. During April Ms Wrathall also informed Police of other damage to her motor vehicle and damage to the front door. Mr Pugh denied these acts yet on occasions demonstrated a knowledge that indicated involvement. Investigations failed to establish if some of these acts were committed by Mr Pugh or another person with Mr Pugh’s knowledge or consent. A summons file was subsequently submitted for the alleged phone breaches.

In May 2005, Ms Wrathall contacted Police and outlined a series of restraint order breaches that had occurred. The allegations comprised phone calls made to Ms Wrathall, damage to her motor vehicle and apparent entry to her home. Mr Pugh was arrested by Police on 11 May 2005 for breaching the restraint order by phoning Ms Wrathall. Mr Pugh was granted bail, despite Police opposition, on 12 May 2005. At that time he was also charged with the series of telephone breaches that had occurred in April 2005. These breaches were taken into account by the Court in granting Mr Pugh bail upon conditions including a surety.

The laying of the charges would have clearly signalled to Mr Pugh that Ms Wrathall would not reconcile, and that he may be facing a term of imprisonment in relation to the breaches upon which he was bailed. Mr Pugh was also aware that Ms Wrathall was at that stage in a relationship with another male. It appears that the resentment Mr Pugh held against Ms Wrathall for leaving him and seeking a property settlement significantly increased. Mr Pugh’s thought processes and judgement would undoubtedly have been affected by his heavy drinking.

The phone calls and harassment of Ms Wrathall stopped after 12 May 2005, until Ms Wrathall received a phone call from Mr Pugh’s house on 5 June 2005. Text messages sent between Ms Wrathall and a friend on the weekend before 13 June indicated Ms Wrathall was still interested in the movements of Mr Pugh. However at no time did Ms Wrathall wish to reconcile with him. During this time there is conflicting evidence as to the degree of concern Ms Wrathall held for her own safety.

Sometime around the end of May 2005, Mr Pugh borrowed a .22 calibre bolt action Bruno rifle from Mr Hall who was licensed to hold this firearm. He had lent it to Mr Pugh on two other occasions in the preceding seven months and on both occasions Mr Pugh returned it in good condition. Mr Pugh, on this occasion, told Mr Hall he wanted to shoot some crows that were interfering with the eggs from his hens.

Both Ms Wrathall and Mr Pugh continued to work and socialise with their friends during the first two weeks of June 2005.

On Saturday 11 June 2005, Ms Wrathall discovered the sump plug had been removed from her vehicle. She reported this to Police, who commenced investigations that day by attending Mr Pugh’s address on two occasions and receiving no reply when knocking on the door. Mr Pugh later informed two friends that Police had attended his address on that day but he had pretended he was not at home. Police continued investigations the following day.

Mr Pugh spent Sunday 12 June 2005 drinking with friends and arrived home at approximately 8.00pm that evening before eating dinner and going to bed. Ms Wrathall spent Sunday evening at the house of her boyfriend, Ricky Clark.

Ms Wrathall returned home at about 10.30am on Monday 13 June 2005. Her sister Kylie was also home at that address.

Events of 13 and 14 June 2005:

On Monday 13 June 2005, Mr Pugh left his residence and walked to Bedford Street to confirm that Ms Wrathall was home. This conclusion is drawn due to the direction Mr Pugh was heading, the time, his demeanour, and the fact that he was not carrying anything; as witnessed by Kerry Faulkner the caretaker for the army barracks and Jeffrey and Barbara Lewis.

Mr Pugh then armed himself with the .22 Bruno rifle covering it in green material before walking to 14 Bedford Street Brighton. At 12.15pm, Mr Pugh gained entry via the front door and confronted both Ms Wrathall and Kylie Wrathall. Mr Pugh attempted to shoot Ms Wrathall in the kitchen, but failed due to a .22 cartridge not being chambered correctly.

Ms Wrathall fled the house via her bedroom window and Mr Pugh followed her, shooting her, Mr Pugh then left the address and walked up to the porch of the next door neighbour, The neighbour was tending to Ms Wrathall. The neighbour retreated inside under threats from Mr Pugh. Mr Pugh then shot Ms Wrathall in the head. He then moved quickly along Bedford Street, crossing Seymour Street and disappearing from sight in the vicinity of the Brighton Race Track adjacent to the army barracks. A possible sighting of Mr Pugh was recorded near the access lane to 7 and 7A Linda Avenue between 12.30pm and 1.00pm.

Police attended the scene and Ms Wrathall was conveyed to the Royal Hobart Hospital where she died as a result of the gun shot injuries at approximately 3.15pm on 13 June 2005.

Police conducted searches and other investigations in an effort to locate Mr Pugh. Investigations revealed Mr Pugh had left two notes at his residence and spoken to a number of persons that afternoon to whom he admitted shooting Ms Wrathall. Mr Pugh was spoken to by a police officer by telephone at 5.16pm on 13 June 2005. Advice from Telstra indicated that Mr Pugh attempted to mislead police as to his location but remained in the Brighton or Pontville area.

It is probable that Mr Pugh stayed in the vicinity of the army barracks and racecourse where there were numerous areas to remain concealed. Whilst a search of the army grounds was conducted on Monday afternoon, there is no evidence the rubbish pile was searched on that day.

Investigations and searches were continued over the evening of Monday 13 June 2005, in an effort to locate Mr Pugh.

The army barracks at Brighton was subsequently searched by police on Tuesday 14 June 2005 at 9.23am. This was a result of speaking to Mr Pugh by telephone earlier that morning at 6.40am, and a text message sent by Mr Pugh to Mr Coleman at 7.02am, stating “Old Army camp Se ya”. Telstra also provided advice as to Mr Pugh’s possible location as still being in the Brighton or Pontville area.

At about 10.20am on 14 June 2005 Mr Pugh was located deceased and concealed amongst plastic bags in a rubbish pile on the army grounds. Mr Pugh had died as a result of a single self-inflicted wound, to the head. This wound had been inflicted by a .22 bolt action rifle.

Family Violence Response:

As part of the Coronial investigation the reported family violence incidents involving Ms Wrathall and Mr Pugh were comprehensively reviewed against established protocols under the Safe at Home Family Violence Strategy.

As a result of the review, it was established that in some instances officers had not followed established procedures in dealing with each of the reported incidents. Procedural departures included:

The above list of points summarises the conclusions from a comprehensive investigation into the response by police and associated persons to reported family violence incidents between Ms Wrathall and Mr Pugh since the first incident reported by Ms Wrathall on 2 January 2005.

These unintended departures from procedure are not to be condoned, particularly as victim safety is often dependent upon compliance by police with policies that are designed to enhance communication and provide an effective and coordinated response to the risk of harm to victims of family violence. The procedures are particularly aimed at ensuring that various relevant incidents, known to individual police officers, can be collectively considered. Had this occurred in the case of Ms Wrathall and Mr Pugh in a consistent way police may have had a more complete understanding of the history of the relationship and the possible risk of harm to Ms Wrathall.

I am however satisfied that by 12 May 2005, when Mr Pugh appeared before the court on the charges and applied for bail, the Police Prosecutor opposing bail put sufficient of the relevant circumstances and breaches collectively to the court to enable the court to come to an informed decision regarding the admission of Mr Pugh to bail. I also note that the Prosecutor objected to both of the sureties nominated by Mr Pugh on the grounds that they would be unable to exercise control over his actions.

At that time neither the police nor the Court could have predicted on all available information the extent of the risk to Ms Wrathall, or the state of mind and ultimate intentions of Mr Pugh. The restraint order breaches that were presented to the court all related to phone calls and/or voice messages. With the exception of the incident reported on 11 May, where it appeared entry had been gained, the breaches were of a threatening and harassing nature. Whilst the breaches collectively could be interpreted as somewhat sinister and persistent conduct, Mr Pugh’s more recent behaviour had not escalated to violence. In addition, Ms Wrathall indicated that for the most part she did not fear for her safety.

Ms Wrathall’s Response to the Restraint Order and Police Intervention:

The foregoing comments and analysis of the circumstances of the relationship and the risk to Ms Wrathall must be examined in light of Ms Wrathall’s own conduct towards Mr Pugh, her reporting to police and her attitude to the restraint order. The following matters are relevant in this regard:

• The integrity of the restraint order granted on 3 January 2005 was immediately undermined when Ms Wrathall reconciled with Mr Pugh a short time later, and they recommenced cohabitating. The deterrent effect of the order was thus reduced dramatically by Ms Wrathall allowing Mr Pugh to move back into the house, and making no steps to alter or have the order rescinded. Ms Wrathall effectively allowed Mr Pugh to disregard the provisions of the order whilst they lived together, however expected him to abide by them when she ended the relationship at the end of March 2005;
• By her own admission to police officers, and further corroborated by an undated letter written by Mr Pugh, Ms Wrathall herself continued to contact Mr Pugh by telephone, thus aiding breaches of the order by Mr Pugh;
• The majority of Ms Wrathall’s complaints and frustrations stemmed from the phone calls she was receiving from Mr Pugh. Ms Wrathall was given appropriate advice to change her phone numbers to immediately stop this form of harassment yet indicated she was not prepared to;
• Ms Wrathall did not want to proceed with charges in respect to the matters reported to police on 17 April. These comprised persistent telephone and “in person” breaches occurring from 1 April to 16 April;
• Some incidents, potentially amounting to stalking, were not reported to police at all, even though a friend was a witness to some of the breaches;
• In general Ms Wrathall would not report breaches to police as they occurred and would wait until a more significant event occurred, such as damage, to report a series of breaches. Ms Wrathall’s report to police on 11 June 2005, of a possible phone breach that had occurred on 5 June, is evidence of her not reporting breaches as they occurred. In this instance, Ms Wrathall only reported the phone breach after the sump plug was removed from her vehicle on 10 or 11 June 2005.

Upon analysis of the large volume of evidence from many witnesses, I am of the view that the tragic events of the 13 and 14 June 2005 could not have realistically been foreseen or prevented. After Mr Pugh was admitted to bail on 12 May 2005 his conduct to Ms Wrathall substantially ceased. Whilst a number of issues regarding police response have been identified, I am satisfied for the reasons given above that those shortcomings did not contribute to the death of Ms Wrathall.

All of the evidence from Mr Pugh’s friends and associates indicates that his actions in taking Ms Wrathall’s life were unexpected. Mr Pugh communicated to friends in the two weeks before his death that he was very upset at the prospect of a property settlement in favour of Ms Wrathall, and a possible return to prison. He also expressed to one friend in this period that if he did not have his son to take care of he “would end it”. He also spoke to his regular taxi driver in terms that suggested he would not be seeing him again. However he gave no indication of any wish to do violence to Ms Wrathall. In general Mr Pugh’s associates state that he was in good spirits in the weeks before his death and occupying himself with his usual work and social activities.

Safe at Home Initiative:

The deaths occurred within a relatively short time after the implementation the Tasmanian Government’s Safe at Home Initiative. Key elements of the policy commenced on October 2004.

The objective of the Initiative, involving Tasmania Police and other agencies, is to effectively respond to, and manage family violence situations with the priority being the safety and well being of victims.

The attachment marked “A” describes and summarises the development of the Safe at Home Initiative.

It is to be particularly noted that the Family Violence Act was proclaimed on 30 March 2005 and that the Family Violence Management System only became operational on 30 May 2005. I was informed by Acting Deputy Commissioner of Police S A Tilyard that since these dates Tasmania Police and other key stakeholder agencies have continued to refine and integrate operational response policies and procedures.

I was also informed by Acting Deputy Commissioner Tilyard that appropriate remedial action in respect of the issues arising in this investigation has been undertaken as required. I accept this is the case.

A review of the provisions of the Family Violence Act, including an investigation of the effectiveness of its mechanisms will be conducted by the Minister and tabled in Parliament before 30 March 2008.

Death in Custody Investigation:

Mr Pugh’s body was discovered at 10.20am on 14 June 2005. The area surrounding Mr Pugh, had, since 9.23am been the subject of a police search and establishment of a perimeter. The Forensic Pathologist was not able to exclude the possibility that Mr Pugh died between these two time points. Therefore, at my direction, a thorough investigation was conducted by Police Internal Investigations to determine whether Mr Pugh’s death occurred whilst he was in the custody or control of police officers.

I have considered the detailed report provided to me concerning this aspect of the investigation.

I am satisfied that until Mr Pugh’s body was discovered police did not, despite the formation of the perimeter, know his exact location or that they were in actual fact surrounding him.

I am satisfied that police had no contact with Mr Pugh whilst conducting the search and had no intentional influence over his behaviour.

I am satisfied that at all times police acted properly in the search.

I am satisfied on the evidence that, on 13 June 2005 after shooting Ms Wrathall, Mr Pugh formed the intention to end his life.

For these reasons Mr Pugh was not a person in the custody or control of police at the time of his death.

Mr Pugh’s access to the firearm:

Mr Pugh was able to gain access to a firearm when he was not the holder of a licence.

Mr Pugh would not have been eligible to hold such a licence at that time, having been convicted of assault less than 5 years previously (s29 Firearms Act 1996).

Mr Hall had known Mr Pugh for about 20 years. Mr Pugh told Mr Hall that he had a licence and owned a shotgun that he could not use due to the noise it would make.

At no stage did Mr Hall make any independent enquiries to verify Mr Pugh’s licence status.

When he lent the gun to Mr Pugh he either accepted Mr Pugh’s assertion that he had a licence or was prepared to lend the rifle to him regardless of whether or not he had a licence. Either way, Mr Hall was in breach of his licence conditions that required him not to allow any other person to possess or use the firearm if that person is not authorised to do so.

The prime consideration underpinning the statutory regulation of firearms and the firearms licensing system in Australia is that of public safety. It is intended, by the legislation, that only fit and proper licensed persons should have access to firearms.

Licensed persons who allow use of their firearms to unauthorised persons seriously undermine public safety. Whilst Mr Hall could not have expected Mr Pugh to take the actions he did, he allowed Mr Pugh to arm himself with little difficulty, providing both the firearm and the ammunition.

The fact that Mr Pugh had the use of a firearm and ammunition is likely to have contributed in a material way to his decision to kill Ms Wrathall, and then himself.

I can only urge all holders of firearms licences to take the utmost care and responsibility to understand and comply with their duties under the Firearms Act 1996 and abide by their licence conditions.

It must be reinforced to licensed persons that time and again tragic incidents have occurred that illustrate the devastating consequences of firearms in the hands of those who should not possess them.

Conclusion:

Ms Wrathall ended her relationship with Mr Pugh at the end of March 2005. Ms Wrathall then suffered varying degrees of harassment by Mr Pugh who attempted to maintain control over her, still wanting the relationship to continue.

Ms Wrathall had largely moved on from the flawed relationship and was getting on with her life; maintaining employment and enjoying the company of another boyfriend, friends and family.

As a result of not being able to control Ms Wrathall, the distinct possibility of a term of imprisonment and the developing property dispute, Mr Pugh gained access to a firearm and took the life of Ms Wrathall before subsequently taking his own.

I formally extend my appreciation to Detective Sergeant David Gill for his exhaustive investigation into all aspects of the deaths of Ms Wrathall and Mr Pugh. His brief for my consideration comprised 6 volumes of evidence, a chronology of all relevant events in the form of a lengthy time line, and a concluding 114 page report. I sincerely thank him for his many months of dedication in producing a brief to the Coroner of the highest quality and which provided such great assistance with this finding.

In conclusion, I convey my sincere condolences to the families of Ms Wrathall and Mr Pugh in respect of their tragic deaths.

DATED:Friday, 2^nd November 2007 at Hobart in the State of Tasmania

Olivia McTaggart

CORONER

“A”

Safe At Home Initiative

The Safe at Home family violence initiative was formally launched on 24 May 2004. It is a whole of government response to family violence in Tasmania and the three key agencies involved are the Department of Justice (lead agency), Department of Health and Human Services and Department of Police and Emergency Management.

The primary objectives of Safe at Home include a reduction in the incidence of family violence in the medium to long term and enhanced safety outcomes for victims (both adult and children).

Tasmania Police has had a key role in the implementation of the strategy, including an expanded responsibility in managing risk and safety issues for persons affected by family violence.

The strategy is founded upon the principle of ‘primacy of the safety of the victim’ and this is supported by the objects of the Family Violence Act 2004 which state : “in the administration of this Act the safety, psychological wellbeing and interests of people affected by family violence are the paramount considerations”.

From the time of the formal launch of the initiative in May 2004, Tasmania Police, and the other key agencies, undertook a continuous development of revised processes, procedures and implementation of new services.

From 1 September 2004, new services developed by Tasmania Police were progressively implemented and some were operational to coincide with the proclamation of the Family Violence Act 2004 on 30 March 2005. These included the Victim Safety Response Teams, the Family Violence Response and Referral Line and the employment of Safe at Home Prosecutors.

In this transitional period, many of the operational protocols, both at inter and intra agency level were not finalised and continued to be developed and refined. As at the end of March 2005, some protocols and processes had still not been finalised.

Victim Safety Response Teams:

For Police, District based Victim Safety Response Teams (VSRTs) had a very limited capability of 1 Sergeant and 1 Constable from 1 September 2004 until 1 March 2005. During this transitional period, the two VSRT members had an important role in respect to the development, implementation and evaluation of trial protocols and procedures, as well as involvement in the evaluation and rollout of further training.

It was understood the capacity of the VSRTs to provide specialist services would not reach full capacity until March 2005. In March 2005, an additional 3 Constables were transferred to each District VSRT. As a result of these additional personnel, enhanced assistance could be provided to victims of family violence.

The VSRTs provide the focus for District coordination, administration, oversight and monitoring of District based programmes and strategies. This Section coordinates the exchange of information with other agencies concerning victim safety and offender rehabilitation.

There is a requirement for VSRT members to liaise closely with key external stakeholders including the Department of Justice (Court Support & Liaison Service and Family Violence Offender Intervention Program) and the Department of Health and Human Services (Child and Family Services and Family Violence Counselling and Support Service). This was occurring on a limited basis prior to September 2005.

Integrated Case Coordination Meetings:

On December 2004, an inaugural meeting was held and attended by key stakeholders from Justice, Police and Health regarding the development of case management model and process. Work progressed on this issue and culminated with a draft Integrated Case Management Manual being tabled to stakeholders by the Department of Justice in January 2005. A fourth draft Manual was released in January 2006 following a statewide review of the district Integrated Case Coordination Meetings (ICCMs).

Prior to September 2005, meetings were held between key stakeholders to assist with the integration of activities and provide services to clients. These were a precursor to the more structured, ICC Meetings. The ICCM process enabled a collaborative management approach in addressing risk and safety considerations for people affected by family violence.

Family Violence Management System:

Fundamental to the Safe at Home initiative is the exchange of core data and information between the key agencies. Tasmania Police developed the Family Violence Management System (FVMS) to capture operational data arising from family violence incidents reported to, and attended by, police.

The FVMS replaced the DVIR System on 31 May 2005. The DVIR was utilised to record information relating to family violence incidents, family disputes and non-intimate partner matters. There was limited read-only access to members of the Domestic Violence Crisis Services (which became the Family Violence Counselling and Support Service in March 2005).

The FVMS provides Police with:

o the capacity to record information regarding family violence incidents;

o a method to record the outcomes of Risk Assessment Screening Tool (RAST);

o a facility to record information regarding issues of risk and safety;

o a capacity to electronically complete Police Family Violence Orders;

o a capacity to electronically complete an application for a Family Violence Order;

o a capacity to electronically complete an application for a Restraint Order (for matters of non-family violence requiring more immediate police intervention: and

o the capacity for both Police and other key stakeholders with authorised access with the ability to record notes subsequent to the incident.

Once validated by a Supervisor, FVMS information reports are made available for access by selected DOJ and DHHS personnel to assist with the integrated approach to Safe at Home activities and services.

FVMS reports are reviewed on a daily basis by District VSRT Sergeants. This allows for a more ‘case’ focussed rather than ‘incident’ focussed response to address issues of risk and safety for persons affected by family violence.

Following the FVMS going ‘live’, a number of faults resulted in system instability for both Police and external users. Consistent monitoring, review and repair have now resulted in a more stable platform for all users.

Prior to September 2004, when Tasmania Police began its enhanced response to family violence matters utilising the Justices Act 1959, there appeared to be an ad hoc manner in the response to and recording of these incidents on the DVIR system.

Training and the implementation of the FVMS system enabled members to record both matters of family violence and family disputes (where no family violence offence is disclosed and there are no obvious risk and safety issues) for appropriate intervention and response by both Police and other Safe at Home service providers.

Training:

During the transitional period from September 2004 to March 2005, regular basic training was held to inform members of Tasmania Police of Safe at Home. Some 800 members received this training.

The inaugural 5-day VSRT Course was held in August 2004. This Course has been held regularly since this time and some 142 DPEM employees have completed it. The Course is held on an annual basis.

Frequent training is now held at district level regarding family violence within the formal district training frameworks.

In 2004 and 2005, VSRT Courses were coordinated and run by an interstate service provider. Following a review of curriculum, from 2006 Tasmania Police assumed responsibility for this.

The Course and its curriculum are re-assessed on annual basis to ensure all currency of training.

Where issues associated with the response to family violence arise, appropriate instructions are issued to all members.

A Handbook for Operational Members is currently being drafted. Upon finalisation, it will be provided to all members and freely available electronically in addition to intensive statewide training.

Risk Assessment Screening Tool:

Attending police are required to complete a Risk Assessment Screening Tool (RAST) at all instance of family violence. They are only to be undertaken by officers who have received the training.

During the transitional period from September 2004 to March 2005, a limited number of members received this training. RAST training is now undertaken at District level and at the Academy for recruits.

Prior to a review by the Tasmanian Institute of Law Enforcement Studies (TILES) in May 2005 a number of issues emerged regarding the RAST for operational police. This included the rating of low, medium, high and extreme categories of risk for offenders repeating or escalating their violent behaviour towards victims. This appeared to regularly result in offenders being screened as ‘high’ risk, and may not have been accurately reflective of their actual risk level.

As a result of a review of RASTs completed during the transitional period by trained personnel, input from VSRT members and consideration of TILES information, the RAST had some small redesign configuration, which resulted, potentially, in a more accurate and predictive reflection of risk.

A copy of this finding has been forwarded to:

• Attorney-General
• Minister for Police
• Commissioner of Police
• Secretary,Department of Justice
• Australian Institute of Criminology