Critical Domestic Violence Death Reviews Halted in Queensland
A crucial Queensland government body established to prevent domestic violence deaths has quietly stopped routinely analysing recent cases, raising serious concerns among experts about the state's ability to protect vulnerable women.
The Domestic and Family Violence Death Review and Advisory Board, considered a fundamental part of Queensland's response to domestic violence, has shifted its focus from comprehensive reviews of all new deaths to examining mostly historical cases that fit predetermined themes.
Board's Change in Focus Sparks Resignation and Concern
Professor Molly Dragiewicz, a respected domestic violence researcher, resigned from the board earlier this year citing profound concerns about this change in direction. In her resignation letter, she stated she was leaving due to the board's "change in focus away from comprehensive timely review of domestic and family violence deaths" and its failure to continue publishing substantial annual data reports.
Dragiewicz emphasised that death reviews serve as "the single most comprehensive and accurate data source on domestic and family violence cases" and play an essential role in violence prevention. Her letter also highlighted that the board lacked representation from domestic and sexual violence services and First Nations experts, presenting challenges for meaningful case analysis.
Betty Taylor, founder of the Red Rose Foundation and former board member, expressed similar concerns, stating: "We've got to hear survivors' voices... we've got to listen to dead women. They'll tell us more about what's gone wrong than anyone. We can only do that by doing the most thorough reviews."
Systemic Failures and Under-Resourced Unit
The board's operations are supported by a specialised unit of coronial staffers and a Queensland police service representative who review cases and provide reports. However, Guardian Australia's investigation reveals this unit has been plagued by significant problems.
A 2020 review obtained by Guardian Australia found the unit was ineffective due to resource changes, staff shortages, and susceptibility to psychological injury among workers. For extended periods, more than half of the unit's positions remained vacant, severely hampering its ability to function.
Perhaps most alarmingly, the review discovered the unit had no fit-for-purpose database, instead relying on an Excel spreadsheet to manage critical data about domestic violence deaths that "used to support national decisions." This practice reportedly continued long after the review identified it as a major concern.
Kate Pausina, a former senior detective who worked periodically as police liaison to the unit, revealed that the liaison position was frequently vacant, including during the high-profile murders of Hannah Clarke, Doreen Langham and Kelly Wilkinson - cases where documented police failings have since emerged.
"There was nobody there to go through the system of looking at reportable deaths every day to find out how many others should have fallen within the scope," Pausina stated. On one occasion after returning from a four-week holiday, she discovered 18 deaths with domestic violence histories that hadn't been reviewed at all.
Staff Trauma and Whistleblower Allegations
The working conditions within the unit have taken a severe toll on staff, according to whistleblower testimony. A staff member identified as Elsie reported to the Crime and Corruption Commission in 2024 that colleagues were "so traumatised and distressed one started to lose their hair in clumps. Another expressed suicidal thoughts. I was really scared someone would take their own life."
Elsie's disclosure also alleged significant leadership issues in the coroner's court, including ineffective communication, lack of accountability, and failures to address staff concerns.
A spokesperson for the coroner's court confirmed the board had decided to focus on themed cases rather than all recent deaths over the past two years, but noted that some recent cases fitting the chosen themes had been included. The spokesperson stated that support for vicarious trauma was available to board members and staff.
This development comes amid Guardian Australia's broader Broken Trust investigation, which has uncovered evidence raising concerns about how Queensland's coronial system investigates women's deaths and the accuracy of the state's domestic violence statistics.
