Executive summary

Family and domestic violence (FDV) has devastating impacts on individuals, families and communities across Western Australia. In the most tragic cases, it results in the loss of life.

Since 2012 we have reviewed 237 FDV fatalities involving 217 offenders. We examine events leading up to a death to strengthen practice and to prevent future harm. Our work has resulted in better risk assessment, improved information sharing, strengthened culturally safe practice, and increased accountability for people who use violence. 

By independently identifying and recommending improvements to service and system gaps, we contribute to a safer, more effective FDV response system for all Western Australians. 

The Western Australian Government has committed to addressing FDV through long-term strategies including Path to Safety: Western Australia’s Strategy to Reduce Family and Domestic Violence 2020-2030 (Path to Safety) and the Strengthening Responses to Family and Domestic Violence System Reform Plan 2024-2029 (System Reform Plan). Together, these frameworks aim to ensure that all parts of the FDV response system work to reduce harm and improve outcomes for victim survivors. 

Despite the hard work of many, and additional government resourcing, FDV remains a serious and growing issue for our community. 

This report captures our FDV fatality review work alongside a thorough point-in-time investigation of the performance of Family and Domestic Violence Response Teams (FDVRT). 

The FDVRT are multi-agency teams that coordinate responses to FDV incidents involving the Western Australia Police Force (WA Police), the Department of Communities (Communities), and the Coordinated Response Service (CRS). After police officers attend an FDV incident, the FDVRT works to share information, identify risks, and plan responses to keep victim survivors safe and hold people who use violence to account. FDVRTs have been operating since 2013. There are currently 18 FDVRTs operating across WA.

We initiated this investigation because our FDV fatality reviews continued to identify familiar patterns, which suggests issues previously raised remain unresolved. These included inconsistent risk assessments, poor data collection, limited support for vulnerable groups, and a lack of follow-up action on agreed recommendations and commitments. 

The FDVRT investigation was designed to test whether FDVRTs meet their operational requirements and if the model is functioning as intended. This was achieved by thoroughly examining a statistically reliable sample of 388 families who engaged with the FDVRT in November 2024. 

The investigation determined that information necessary for victim survivor safety and wrap-around supports to be provided was not reaching support agencies, because it wasn’t being collected as planned. The investigation revealed that 24 per cent of responses to risk and behaviour questions were categorised as unstated or unknown. 

This system failure meant that victim survivor safety was not being optimised. It resulted in some victim survivors not receiving the supports they should have been getting. Our independent application of the mandated risk assessment tool across the sample showed that 61 per cent of cases met the threshold for high risk of serious harm but the Multi-Agency Case Management (MACM) process that should have followed was followed in only 2.5 per cent of these cases.

In addition, the unmeasured effectiveness of FDVRTs means we can’t be certain that victim survivor safety is always being enhanced in the way that is intended. 

The investigation made nine recommendations focused on: 

• strengthening governance and oversight of FDVRT 
• improving risk assessment and data systems 
• removing barriers to escalation of high risk cases 
• improving support for vulnerable groups, including children 
• strengthening accountability for people who use violence 

The lesson for all public administrators is that relied upon procedures should only be varied knowingly and within a formal change control procedure. Calibrating a service response that is reliant on the actions of another becomes impossible where that prior action cannot be relied upon. This was and remains true for FDVRTs. 

Communities and WA Police continue to deploy additional resources to better meet need, and to evolve their practices, including by developing better risk assessment and simpler data collection practices. Resolving differences on how risk and behaviour information should be collected will be an important contributing factor to victim survivor safety and the overall effectiveness of FDVRTs. 

Although preventing harm remains an overriding goal not every incidence of harm can be prevented. Our fatality review work tells us that 72 per cent of offenders were male and 55 per cent of victims were female. 1 in 6 victims were children. Stabbing was the leading manner of death. Distressingly, Aboriginal people account for 35 per cent of victims, despite being only 3.3 per cent of the population. This over-representation should never be normalised and should be understood in its broader historical and systemic context. Solutions will only be found by working authentically with Aboriginal communities. 

In 2024-25, we finalised 14 FDV fatality reviews and made just one recommendation to both WA Police and the Department of Justice. In contrast, we made six recommendations to four separate agencies, arising from just one complex FDV fatality review in 2022-23, involving a young couple, both in their late teens, with children. 

In presenting this report, I would like to acknowledge all victims and their families as well as all the front-line service teams in the community and the public sector who work as best they can to keep our community safe. I also acknowledge the commitment and dedication of the Child and Family Safety Team at Ombudsman WA and all those who advocate and work in this challenging area of public policy. 

Our investigative work recognises the high pressure and dynamic environment and the complex and challenging issues which families and front-line workers navigate. Its purpose is not to assign blame but to identify systemic issues and opportunities to strengthen responses for the betterment of all West Australians. 

Bevan Warner 
OMBUDSMAN