Responding to and preventing family violence: The need for a comprehensive and integrated system

Inquest into the death of Luke Geoffrey Batty [2015] Coroners Court of Victoria
Commonwealth, Royal Commission into Family Violence, Report and Recommendations (2016)


Luke Geoffrey Batty (Luke) was killed by his father, Gregory Anderson (Mr Anderson), on 12 February 2014. An inquest was held into Luke’s death in late 2014. The inquest did not focus on the immediate cause of Luke’s death – this was plain on the facts. The State Coroner, Judge Gray, instead investigated the interactions that Luke and his mother (Ms Batty) had with the family violence system in Victoria in the 18 months prior to Luke’s death. Judge Gray found that no one person or organisation caused or directly contributed to Luke’s death. However, his Honour did recognise some systemic flaws and made a number of recommendations for improvement.


The facts of Luke’s death were highly publicised in the weeks following his death. In the late afternoon-early evening of 12 February 2014, 11 year old Luke and his father were playing cricket in the nets following Luke’s cricket practice. While in the nets Luke’s father deliberately hit Luke in the head with a cricket bat and then proceeded to stab him in the neck with a knife. Ms Batty was present at the cricket grounds, heard Luke and ran to the cricket clubrooms for someone to call an ambulance.  Mr Anderson intentionally prevented ambulance officers from accessing Luke to provide assistance and when they were able to access him he was pronounced deceased. Mr Anderson was shot by police attending the scene, and died in hospital in the early hours of 13 February 2014. 

Evidence and observations

Throughout his life, Luke witnessed his father being physically and psychologically violent towards his mother. Judge Gray wrote:

A number of matters in the 18 months prior to Luke’s death are related to his death… they pointed to the likelihood that Luke would continue to be exposed to family violence from his father and that active risk management of Mr Anderson was necessary”.

From his review of these matters, his Honour identified a number of shortcomings in the family violence system. Brevity prevents us from canvassing the entire history of family violence experienced by Luke and Ms Batty but, for the purposes of this case note, these shortcomings are clearly demonstrated by three incidents addressed at the inquest: 

(A) The first incident

On 16 May 2012, Senior Constable Kate Anderson responded to a violent outburst by Mr Anderson. It was alleged that he had threatened Ms Batty with a vase in front of Luke in Ms Batty’s home. On the same day SC Anderson arrested Mr Anderson. However, charges were not authorised until 1 August 2012 due to workload issues. There were difficulties serving Mr Anderson, and the charges had to be re-issued on 8 January 2013. At the time of Luke’s death, the charges against Mr Anderson had still not been heard by a Court. Judge Gray noted that such delays “can lead to an increasing risk of escalating problematic behaviours on the part of the perpetrator”.

Also in response to the 16 May 2012 incident, SC Anderson issued Mr Anderson with a Family Violence Safety Notice (FVSN) and completed a risk assessment (titled an “L17” form). Both Ms Batty and Luke were identified as “protected persons” on the L17 and the probability of exposure to future harm was assessed as being “likely”. On 17 May 2012, a Family Violence Intervention Order (FVIO) was formally made against Mr Anderson by the Magistrates’ Court naming Ms Batty and Luke as the affected family members. This was the first time that Luke was named as an affected family member on an FVIO. The FVIO also stipulated that, subject to his agreement, Mr Anderson contact a men’s referral service. Judge Gray drew attention to the fact that the court could not require Mr Anderson to attend counselling, or to participate in a family violence program, without his agreement. 

(B) The second incident

On 3 January 2013, Mr Anderson threatened to kill Ms Batty. Luke was not present when the threats were made. Ms Batty reported the threats to police and the following day Mr Anderson was arrested and police bail was refused. The Magistrates’ Court subsequently granted bail on strict conditions, including that Mr Anderson was banned from the suburb of Tyabb (where Luke attended football training). The strong protections afforded by the bail conditions were implemented largely as result of evidence given by policeman, FC Topham. He requested stricter bail conditions than what Ms Batty could achieve by varying her FVIO. FC Topham suggested that this would afford the Batty’s with greater protection and enable police to bring Mr Anderson back before a magistrate in the event of a breach, unlike a breach of a FVIO which would have only given rise to an interview with police and a possible summary offence charge.

(C) The third incident

Ms Batty gave evidence that in April 2013 Luke told her that Mr Anderson had pulled a knife out while they were sitting in his car and told Luke that “It could all end with this”. This incident alarmed Ms Batty and she sought to amend the FVIO issued on 17 May 2012. On 24 April 2013, the Magistrates’ Court ordered “no contact” between Mr Anderson and Luke or Ms Batty. However, this order did not prevent Mr Anderson attending Luke’s football and other sporting events. The Magistrate and Ms Batty discussed this in Court, with Ms Batty concluding that there was less risk in such public forums. 

At the same Court appearance, the Magistrate issued two bench warrants for Mr Anderson’s arrest (one relating to a family violence charge and the other relating to a criminal charge), with the intention that he be served with the warrants and the amended FVIO when he reported to police under his bail conditions. However, by issuing the warrants, the Magistrate cancelled Mr Anderson’s bail conditions. Mr Anderson did not report for bail and the warrants were not executed. Judge Gray noted:

It is obviously an unintended consequence of the issue of warrants following a non-appearance on bail. It can be exploited, and was by Mr Anderson.”

Indeed, Mr Anderson attended one of Luke’s football training sessions in the suburb of Tyabb in the days after the warrants were issued. When Ms Batty contacted the police to report the breach of his bail conditions, the police informed her that the conditions were no longer in effect.

Judge Gray’s comments and recommendations

After a full review of the family violence perpetrated by Mr Anderson in the 18 months prior to Luke’s death, Judge Gray noted a number of systemic problems seen in the responses to Mr Anderson’s violence and made 29 recommendations to address these issues. Below is a broad summary of some of the key points made by Judge Gray:

  1. Failure to engage Mr Anderson in the family violence system and make him accountable for his actions 

Judge Gray noted that “This case has dramatically highlighted the need for an emphasis on perpetrator accountability”. His Honour found that delays and disjoints in the system made it difficult to hold Mr Anderson accountable for crimes he allegedly committed or to require him to engage with support services and counselling. Further, Mr Anderson was never the subject of a comprehensive mental health assessment, such that he never received a formal diagnosis nor any targeted medical care.

His Honour recommended that perpetrator engagement will be strengthened by reducing delays in serving family violence charges and FVIOs, and in executing warrants. He also recommended that consideration should be given to amending the Bail Act 1977 (Vic) to ensure that a warrant for arrest does not have the effect of cancelling bail and that bail should be refused where the accused cannot demonstrate that the failure to appear was not due to causes beyond their control. In addition, his Honour suggested that there should be a judicial power to mandate that a perpetrator can be assessed by a forensic psychiatrist where there are safety concerns, particularly in relation to children.

  1. Risk assessments

On the evidence, Judge Gray found that no single agency held or assessed all of the information for the purposes of conducting risk assessments, and managing the risks posed by Mr Anderson. The risk assessments done by various agencies were performed in “silos” and were not shared or updated. His Honour recommended that the State of Victoria undertake empirical validation of the Common Risk Assessment Framework and that all agencies operating within the integrated family violence system should use that framework once validated. Judge Gray emphasised the importance of greater uniformity between agencies who perform assessments and an improved process of sharing previous assessments between agencies.

  1. FVIOs and the intersection of the family violence and family law systems

Judge Gray agreed with evidence and submissions made that FVIOs can be unclear and that they should be written in plain English to ensure their effect can be easily understood. His Honour also noted that the interaction between family law, and in particular parenting orders under the Family Law Act 1975 (Cth), and FVIOs is complex and should be made plain by the terms of the relevant FVIO. 

  1. Magistrates’ Court – Family violence cases

Judge Gray commended the pilot of the Family Violence Division of the Magistrates’ Court of Victoria which ensured integration of relevant jurisdictions and enabled the listing of charges arising out of family violence incidents to be expedited. His Honour recommended that access to the Family Violence Court Division be expanded across Victoria.

  1. Agencies operating within the integrated family violence system

Judge Gray recommended that steps be taken to facilitate the sharing of information between all agencies operating within the integrated family violence system, and that the roles of all agencies working in the family violence system should be clearly delineated and contained in legislation and/or documented in publicly available policies. 


The findings of the inquest highlighted a number of problems with Victoria’s family violence system. While Judge Gray concluded that none of these caused Luke’s death, his Honour did recommend improvements that would hold perpetrators of family violence more accountable and afford families greater protection. The central messages of the inquest’s findings are the need for more cooperation between family violence agencies and for a coordinated approach to updating information systems. This will enable first responders, Magistrates and the relevant agencies to understand the family violence history and make a comprehensive assessment of the risk to families.

A thorough review of the Victorian family violence system has since been conducted by the Royal Commission into Family Violence which tabled its report in Parliament on 30 March 2016, and largely addressed the issues raised by the Coroner in this inquest.

A copy of the inquest findings is available here.

A copy of the Royal Commission’s findings is available here.

Kate Boyd, Solicitor at King & Wood Mallesons.