Two children gunned down by their father. A woman seriously assaulted after officers ignored her request for a protection order. An attack that left a victim with a partially punctured lung recorded as "domestic violence - no offence".
When police fail to follow operating procedures, the consequences can be deadly.
"My mother and I made it clear that our lives were at risk — we were repeatedly ignored, repeatedly failed," domestic violence victim-survivor Ariel Bombara told reporters last week in the aftermath of a double shooting murder at the hands of her father.
"Authorities should have helped us stop him and they failed."
The pair had fled Ariel's father Mark Bombara in March. Seven weeks later, he went to a home in suburban Perth where he thought his ex-wife was hiding, and shot and killed her best friend Jennifer Petelczyc and her 18-year-old daughter Gretl. He then turned the gun on himself.
In a damning statement, Ariel accused the WA Police Force of dismissing multiple pleas for protection, denying requests for a restraining order, ignoring specific warnings about her father's guns and, ultimately, failing to protect the community.
WA Police are investigating the actions of the officers involved.
The inadequacy of police responses to domestic violence is not limited to Western Australia. In 2022, inquiries in Queensland and Victoria uncovered similar problems. Late last year, a series of coronial inquests unearthed critical flaws in Northern Territory police responses to family violence while in South Australia, a royal commission into domestic violence will examine police intervention as part of its inquiry.
The Review of NSW Police Force responses to domestic and family violence incidents, published in June 2023 by the Law Enforcement Conduct Commission (LECC), analysed more than 100 cases where the NSW Police Force (NSWPF) found officers had breached the force's own protocols and failed to properly investigate family violence.
Some breaches are chillingly reminiscent of the accusations levelled at WA Police: failure to seize firearms, failure to record statements, failure to seek protection orders.
In one 2020 case with disturbing parallels to the WA murders, a woman reported a DV incident by her ex-partner, a registered firearms licence holder. The officer — who later faced a criminal charge — didn't create an event report, brief other officers, or complete any firearm checks. As a result, police didn't seize the man's guns.
Several days later, the man went to visit his ex-partner at home. The woman managed to escape but the man shot and killed someone else at the home before turning the gun on himself.
NSWPF made a range of findings against officers including lying, falsifying official records, neglect of duty, and deficient/inadequate investigation. At least one officer faced criminal charges.
All up, the review of 102 upheld complaints identified 171 breaches of the police force's own domestic violence operating procedures.
Odds are, these figures represent a fraction of the true number of inadequate investigations, according to experts.
"It's likely that the problematic number of investigations is much, much higher because, basically, most women won't actually put in a complaint … They're reluctant to pursue any further connection with police after that difficult experience," said Professor Douglas.
"And the worry is, if they have a negative experience with police, they don't go back for support from police in the future."
Breached firearm procedures
In eight of the 171 failures, officers breached legal requirements and internal NSW Police Force operating procedures relating to firearms at domestic violence incidents.
Most of the officers involved were senior constables.
Officers who investigate a family violence incident have a statutory responsibility to inquire about the presence of any firearms in the home. If a police officer establishes that there are firearms in the home, they must inquire after, search for and seize them.
A litany of police errors contributed to the 2018 shooting murders of Jennifer and Jack Edwards by their father John, according to the coronial investigation. Their mother Olga took her own life five months later.
John Edwards was able to lawfully purchase the firearms that he used to gun down his children and himself following numerous failures by police.
Breaches spanned multiple attempts by Olga to report John's violence. They included recording an earlier incident as "no offence" instead of assault, not taking victim statements, not recording the two children as victims, and not recording John Edwards as the "person named" nor Olga as the victim.
According to the coroner, this additional information would have been enough for a protection order — known in NSW as an apprehended domestic violence order (ADVO) — which would have triggered mandatory refusal for a firearms licence.
Under the strengthened gun laws before WA's parliament, a family and domestic violence complaint would automatically strip firearms owners of their guns.
NSW Police agreed "in principle" with LECC recommendations that event reports include more information about the seizure of firearms and operating procedures require officers to record details of firearm checks.
Failed to protect child at risk
In eight instances, officers failed to follow legal requirements that make it mandatory for them to report children at risk of significant harm to the Department of Communities and Justice.
Further, police that believe children are at risk of immediate harm have the power to remove them from the home.
In one 2019 incident, a woman reported to police that her husband had assaulted her while she was holding their young child in her arms. The officer made no notebook record. The event report stated the woman had reported a verbal argument and did not disclose any DV offences. In the Child At Risk section, the officer wrote that the child appeared "healthy and happy", despite never checking the child's welfare.
The officer was investigated for falsifying official records, served with a warning and placed on a six-month conduct management plan.
In another example, a woman reported that her ex-partner had breached his ADVO orders, assaulted her and taken one of their children away. The officer failed to create an event report, including any record of the child's welfare.
The LECC did not make specific recommendations about this section, noting police operating procedures already require officers to report children at risk.
Failure to follow ADVO requirements
In 22 of the complaints upheld by the NSWPF, officers failed to comply with operating procedures for Apprehended Domestic Violence Orders.
NSW Police officers are legally obliged to apply for an ADVO if they suspect or believe that a domestic violence offence is likely to be committed.
In one case, police attended an incident involving a man, his ex-partner and her one-year-old. They had information about a history of domestic violence between the couple but after interviewing the pair, declined the woman's request for an ADVO.
Several weeks later, the ex-partner seriously assaulted the woman.
An internal investigation found the two senior officers involved "did not pick up on the victim's fears and failed to investigate the victim's allegations". One officer had already been sanctioned for inadequate investigation of another DV incident. The second was put on a conduct management plan.
"Every breach of an intervention order is a red flag that the victim-survivor is at risk of violence escalation and even death," said Monash University professor Kate Fitz-Gibbon.
Women's Community Shelters CEO Annabelle Daniel told the ABC that there's no such thing as a "low-level ADVO breach".
"Perpetrators will continually test the limits. That is a feature of coercive control."
She said one of the most striking contradictions in the WA case was the police response to Ariel Bombara's warnings that her father had 13 firearms: the officers donned bulletproof vests, yet refused her plea for a temporary protection order.
"If the police believed they could be shot, why did this case not meet the threshold for protection for [Ariel and her mother]?"
WA Police Commissioner Col Blanch has since told reporters the measure was not warranted based on the information the police had at that time.
The NSW report did not make specific any specific recommendations about ADVO procedures, noting existing obligations.
Failure to collect evidence, including statements
In 44 of the 171 failures reviewed, officers failed to properly collect critical parts of the brief of evidence.
These include 17 instances of failing to obtain witness statements or to even canvas the area to identify possible witnesses, 14 cases of failing to obtain victim statements, and 9 investigations in which officers didn't take photographs or obtain relevant CCTV footage at the scene.
In one case outlined in the LECC report, a woman with visible injuries to her face went to a police station to report that her ex-partner had assaulted her. The officer took no photos of the woman's injuries and told her that police would not investigate.
Daniel says victims statements are paramount to judging the risk of further harm.
"Victim-survivors' assessments of their own risk are extraordinarily accurate … [They're] probably the best indicator of the risk that the violence will escalate," she said.
"Quite often [the victim-survivors] have lived with or been close to the abuser for years. They know the patterns of behaviour that they're demonstrating, so it's incredibly important that victim-survivors' fears about escalation are listened to."
Witness statements are equally vital, according to the LECC report, especially where there are no obvious physical injuries and the courts have to decide between the accuser's and defendant's versions of the incident.
The report doesn't make specific recommendations for this area. It points out that police materials already emphasise the importance of collecting evidence, that statements are among "the most basic and commonly used methods" for police to record events.
Missing, incomplete or falsified records
Police officers responding to a domestic violence incident in NSW must complete two key documents: a police notebook and event report in the Computerised Offender Policing System known as COPS.
Fifty-three of the 171 failures upheld after investigation by NSW Police involved problems with missing, incomplete or misleading notebook entries and event reports.
Nine instances related to officers incorrectly recording an event report as 'domestic violence – no offence' even though the victims had reported an assault. This included one case where the victim provided medical evidence of serious injuries, including fractured ribs and a partially punctured lung.
Five investigations related to officers falsifying information, including one in which the officer stated police had attempted to locate and arrest an offender. "This information was fabricated," according to the LECC report.
In another example from 2018, police lied to a complainant who had witnessed an assault on a young child. The officer told the complainant there was no use providing a statement because the play centre had told the officer that the CCTV footage was unclear. It turned out that the officer had never contacted the play centre.
The internal investigation described the incident as "an inexcusable failure" on the part of the officer.
Most breaches involved officers failing to "record all relevant information … accurately and truthfully," according to the LECC report.
University of Melbourne law professor Heather Douglas told the ABC police sometimes downgrade domestic violence incidents at the request of the victim.
"This is often as a result of her fear of the ongoing threats and harm from her partner, and pressure from him to [downgrade the offence]," she said.
"It can also be because … she doesn't want him to go to jail because she's relying on income and maybe support from [him]."
However, downgrading or not recording an offence can have serious ramifications, she added. "The behaviour of the violent perpetrator or the abusive partner goes unchecked and if there's future violence, it's more difficult to establish a pattern of abuse."
The LECC report recommended the force "ensure that a COPS event report is created for every domestic and family violence incident attended by police."
The NSWPF agreed in principle, advising that officers are already required to record every DV incident attended.
Other issues
The LECC report also identified 15 cases of inadequate supervision, 12 instances of failing to support the victim and 9 cases where prosecutions failed because "officers did not follow basic investigative requirements, such as subpoenaing witnesses to attend court or officers themselves failing to attend court".
Most of the failures involved senior officers, including chief inspectors, sergeants and leading senior constables.
Professor Douglas said this was not surprising.
"Police cadets have the most recent and up-to-date training about domestic violence. They're usually not very cynical at this point and they're taking on board what they've learned.
"Whereas with senior officers, they perhaps haven't had training on domestic and family violence for some years. They're more jaded and frustrated with the work in the field."
Poor conduct spreads when senior officers don't model appropriate police behaviour to junior officers that accompany them on a job, she added.
NSWPF agreed with the LECC's recommendation that officers be retrained at regular intervals throughout their careers.
Daniel told the ABC that police face onerous administrative workloads and streamlining internal processes would minimise inaccuracies.
"It takes about 150 pages of reporting in the police operating system to properly and fully record a domestic and family violence incident," she said.
"And if there are children attached to the incident or if there are children who witnessed it, who were there, then there's additional dozens of pages that need to be completed."
Professor Fitz-Gibbon said the recent spate of domestic violence tragedies across Australia had "called into question current frontline police ability to provide effective responses". She stressed the need to examine the justice system as a whole.
"The scale of the crisis and the range of documented failures within the justice system means that tinkering at any one point will not deliver transformative outcomes for victims."
Experts who spoke to the ABC emphasised that many victim-survivors report positive experiences with police. "They feel like some police have really saved their lives," Douglas says.
But whether the officer you speak to truly understands the complexities and dynamics of domestic and family violence is "still a bit of a lottery", according to Daniel.
"What we always need to remember, particularly in light of domestic and family violence matters, is that the ones that come to police attention are just the tip of the iceberg," she said.
"Women generally come to police as a last resort … so when they do, they desperately want to be taken seriously. They want to be heard."
In a statement, a NSWPF spokesperson told the ABC that the team is "continuing to work through the reform outlined" in the LECC and other relevant reports published recently.
The statement outlined some of the changes launched since the report's release a year ago. These include a suite of technological advances designed to streamline the police response to DV, a Domestic and Family Violence registry of experts to advise and respond to DV incidents, and the implementation of recommendations from the 2021 parliamentary inquiry into coercive control.
The latter "constitutes the largest rollout of training for frontline officers" in about 20 years, according to the statement.