‘We’ve got to listen to dead women’: critical part of Queensland’s DV response stops reviewing all recent deaths | Queensland politics

Queensland’s advisory panel tasked with reviewing domestic violence and domestic violence deaths has quietly stopped routinely analyzing new cases and has not reviewed many of the most recent deaths for more than two years.

Guardian Australia’s Broken Trust investigation has uncovered evidence and allegations raising concerns about the way the judicial system investigates women’s deaths and the accuracy of Queensland’s DFV statistics.

Coroners have repeatedly ruled that nothing more could have been done to prevent the killings, in the face of women’s deaths and evidence of serious policing and system failures that contributed to rising deaths.

The Queensland Domestic and Family Violence Fatality Review and Advisory Board is considered a “critical” part of the state’s response to domestic and family violence. Its goal is to “prevent preventable deaths in the future.”

The Board has historically analyzed comprehensive reports on all DFV-related deaths, identified systemic problems raised by these cases, made recommendations for reform, and published detailed anonymised case studies in its annual report. Some of these revealed significant police failures that would not normally be made public.

But Guardian Australia can reveal the board has stopped routinely investigating deaths. Its last two annual reports do not include detailed case studies and instead look mostly at historical cases that fit selected “focus areas.”

_{Sign up: AÜ Breaking News email}

DFV researcher Prof Molly Dragiewicz resigned from the board this year, citing concerns about a “change of focus”.

“I am resigning because the board has moved away from comprehensive and timely examination of deaths resulting from domestic and family violence, publishing important annual data reports on these cases, making current case-based recommendations to strengthen system responses to prevent future deaths, and publicly communicating these findings to educate the public and professionals about domestic and family violence,” Dragiewicz wrote in his resignation letter.

The board lacked representation from domestic and sexual violence services and First Nations experts, the letter said. He said this “presents a challenge for meaningful case analysis and the formulation of pragmatic recommendations to improve practice, policy and procedure to prevent future deaths”.

“Death investigations play an important role in preventing violence by being the single most comprehensive and accurate source of data on domestic and family violence incidents and responses to them,” he wrote. “I hope that the board of directors will return to its exemplary work by fulfilling its basic functions in the near future,” he said.

Betty Taylor, founder of DFV charity Red Rose Foundation and former death review board member, said she was concerned the board had stopped “centring women’s experiences”.

“We must hear the voices of the survivors… We must listen to the dead women. They, more than anyone else, will tell us what went wrong. We can only do this by carrying out the most comprehensive investigations.”

The board is supported by a “unit” of coroners and a representative of the Queensland police force, who review cases and report back to coroners and the board.

Guardian Australia has obtained a 2020 review of the unit which found significant concerns about staff welfare, processes and a lack of expertise. Several people familiar with the unit’s work say its functioning has “significantly deteriorated” since the review and have raised concerns that problems with the cases are not being resolved.

The review found that the unit was ineffective due to resource changes, staff shortages, and staff were prone to psychological injury. For a long time, more than half of the unit’s roles were vacant.

“The unit has a critical role in the province’s DFV response and it is therefore imperative to ensure it is set up to operate at a high-performance capacity within the intended organizational design,” the review stated.

It was also found that the unit did not have a “fit for purpose” database. Data and other information “used to support national decisions” about DFV deaths were kept in an Excel spreadsheet. This practice continued long after the review.

The Queensland Coroner’s Court did not respond directly when asked whether the data was held in a spreadsheet. In the statement, it was stated that “investment in leadership data capacity” was made in the coroner’s court record.

Kate Pausina, a former senior detective, worked periodically as the unit’s police liaison. Hannah Clarke says the liaison position was frequently vacant, including during the murders of Doreen Langham and Kelly Wilkinson; Police misconduct in these cases has been documented.

“And they [just the] “High-profile deaths that we are aware of even when no one is around,” he says.

“There was no one there to review the system that looks at reportable deaths each day to find out how many other people should be covered.”

Pausina said he once returned from a four-week vacation to find 18 deaths during that period, where there was a history of domestic and family violence but “had never been investigated or reported.”

Elsie*, a coroner whistleblower, reported her concerns as part of a statement to the Crime and Corruption Commission in 2024.

“Queensland’s judicial system was under-resourced and did not adequately support coroners and bereaved people,” Elsie told the CCC.

“There were significant leadership issues at the coroner’s court, including ineffective communication, limited approachability, a lack of accountability or transparency in decision-making, failures to address staff concerns and the urgent need to upskill most leadership staff.”

Elsie said staff in the unit were “so traumatized and distressed that one started losing her hair in clumps. Another expressed suicidal thoughts. I was really afraid someone would take their own life.”

A spokesperson for the coroner said support was offered to board members and staff regarding vicarious trauma.

The spokesperson confirmed that the board had decided to look at themed cases rather than the most recent ones from the last two years, and that these included some new cases that fit the chosen theme.

“The board’s work plan and approach for the case investigation function is determined at the beginning of each financial year,” the spokesperson said.

Do you know more? Contact ben.smee@theguardian.com