AN investigation into the July 2018 death of Phillip Island mother of three, Samantha Fraser, by the State Coroner, Judge John Cain, has found that the system let her down.

The response by Victoria Police, since that time significantly reformed, he said, was inconsistent, lacked the necessary investigative experience and failed to give sufficient weight to impending court proceedings, involving criminal charges brought by the victim against her estranged husband, the man convicted of her murder, Adrian Basham.

He said Ms Fraser faced barriers when applying for a Family Violence Intervention Order, including being exposed to her husband in court, a person of whom she was “terrified”, dealing with different police prosecutors and legal representation at each hearing, different magistrates and the use of out-of-court negotiations motivated more by minimising court time than protecting the victim.

He also identified that the response by general practitioners wasn’t in line with best practice including seeing both Ms Fraser and her husband at the same time, even after the GP became aware that Mr Basham was a family violence risk to Samantha and referring them to the same psychologist for counselling.

Judge Cain also noted serious shortcomings in the response by the psychologist which he said may relate to the absence of mandatory family violence training for private psychologists and the fact that they aren’t prescribed under the Multi-Agency Risk Assessment and Management (MARAM) Framework which sets out the responsibilities for identifying, assessing and managing family violence risk.

In handing down his report last Wednesday, November 6, Judge Cain noted that the dual role of the coroner was to independently investigate reportable deaths and to make recommendations that might help prevent deaths in the future.

In discharging those responsibilities, he provided a comprehensive report on the circumstances surrounding Ms Fraser’s murder, accepting the assessment by Forensic Pathologist Dr Sarah Parsons that the cause of death was hanging in the setting of multiple blunt force injuries.

Adrian, he said, was convicted by a jury of Samantha’s murder on April 21 2022. In Her Honour’s sentencing remarks, Justice Taylor found that the offending fell into the worst category of murder and was premeditated.

He also provided commentary on system failure, made mention of subsequent reform and summarised his recommendations as follows:

1. I endorse the recommendation by Coroner Giles in BCJ (COR 2020 3368): With the aim of promoting public health and safety and the administration of justice, I recommend that the Victorian Government ensure that all Specialist Family Violence Courts in Victoria have adequately-funded and resourced specialist legal and nonlegal specialist family violence services on site to engage with both affected family members and respondents in an intervention order hearing to provide both legal and non-legal advice and support, including where Victoria Police is the applicant for an intervention order.
2. That Family Safety Victoria consider the available evidence and consider including re-partnering and pending criminal date for criminal charges brought by the victim as risk factors to be considered in the MARAM.
3. That measures be taken by the APS and RANZCP to introduce family violence mandatory CPD for registered psychologists and psychiatrists to provide for an occupation-specific level of family violence understanding and referrals for further support where a patient/client is identified as experiencing or suspected to be experiencing family violence.
4. That FSV consider how the pilot program currently underway in Bayside, Peninsula and Barwon areas may respond to fixated threat perpetrators.

Judge Cain also conveyed his sincere condolences to Samantha’s family for their loss.

The full report from the coroner can be accessed HERE.

Turning tragedy into action

DETERMINED to “transform the deep impact of Sam's loss into tangible and positive change”, friends of Samantha Fraser and their supporters started the ‘Change for Sam’ initiative in pursuit of a community free from gendered violence.

The initiative identified two primary goals; to implement a comprehensive plan to prevent family violence against women and children, and to create an integrated service system to respond to incidents of family violence when they do occur.

Among their projects to date is the development of a 24/7 monitored personal alarm system and also a simple personal safety alarm designed to help deter attacks by emitting a 130 decibel signal and flashing light, enough to attract attention and to help you feel safe and secure.

Recently, with the help of Bass MP Jordan Crugnale, representatives of Change for Sam, including organiser of the project, Sam’s best friend Lija Matthews, met with ministerial representatives and state MPs about attracting funding for the initiative.

You can find out more by going to the Change for Sam website at https://www.changeforsam.com.au/

You can also make a contribution to the ‘Change for Sam’ personal safety devices project on the group’s Go Fund Me page HERE

The cost of a personal safety alarm, which also has a handy torch, is $20 at: https://www.changeforsam.com.au/store