Coroners Court


Domestic Violence Death Review Team

Role and function

The Domestic Violence Death Review Team (DVDRT) was established in 2010 under the Coroners Act 2009 (NSW) to review deaths occurring in the context of domestic violence in New South Wales. The review has both a qualitative (individual case) and quantitative review function. The review looks into cases of domestic violence and uses these as a window, or a lens, into systems, services and communities, identifying opportunities for intervention, prevention or where the story may be been changed.

The DVDRT is a multi-agency committee that undertakes comprehensive analyses of deaths occurring in a context of domestic violence to identify issues arising in individual, or across, cases, identify trends and patterns in quantitative data, highlight limitations or weaknesses in service delivery from its qualitative analysis and make recommendations. The DVDRT is staffed permanently by an Executive constituting a Manager and a Research Analyst.

The DVDRT aims to develop and promote domestic violence intervention and prevention strategies so as to reduce the likelihood of deaths occurring in similar circumstances in the future, and to improve the response to domestic violence more generally.

The DVDRT reviews individual closed cases of domestic violence deaths occurring in New South Wales and identifies systemic issues; meaning issues in the ways in which systems operate or where systems do not reach. The DVDRT understands domestic and family violence as a complex, intergenerational and 'wicked' problem that requires complex responses that reach across government, non-government and community. The DVDRT also collects data, including broad prevalence and disaggregated domestic violence context data in relation to homicides and suicides.

The DVDRT is a member of the Australian Domestic and Family Violence Death Review Network and through this, and other bodies, undertakes research that aims to improve responses to domestic and family violence. 

The DVDRT reports to the NSW Parliament biennially, setting out findings from the qualitative case analysis and the recommendations which are derived from this analysis. This report also profiles the Team's quantitative data and any recommendations that may derive from this. The DVDRT undertakes public monitoring of its recommendations and responses to these in its tabled reports and on its website.

The DVDRT Executive also works with Coroners on open cases of domestic violence related deaths.

The philosophy of the DVDRT like death reviews nationally and internationally, is to enhance our collective understanding of the scourge of domestic violence in our communities by learning from these tragic, radiating and serious cases. 

DVDRT Membership

The DVDRT is convened by the His Honour Magistrate Leslie Mabbutt, State Coroner and brings together representatives from key government agencies as well as non-government service providers and sector experts.

Government members

The DVDRT's Government representatives comprise:

  • Rosemary Caruana (Corrective Services NSW) 
  • Carolyn Thompson (Department of Justice)
  • Melinda Norton (Women NSW, NSW Health)
  • Conjoint Associate Professor Adrian Dunlop (Centre for Population Health, NSW Health)
  • Commissioner Michael Fuller APM (NSW Police Force)
  • Inspector Sean McDermott (NSW Police Force)
  • Sharon Gudu (Statewide Housing Services, FACS)
  • Melanie Hawyes (Juvenile Justice)
  • Mahashini Krishna (Victims Services)
  • Trisha Ladogna (Department of Education and Communities) 
  • Lorna McNamara (NSW Health)
  • Grace Romeo (Community Services, FACS)
  • Anthony Seiver (Aboriginal Affairs NSW, DEC)  
  • Natasha Luschwitz (Department of Premier and Cabinet)


​Non-government members

The DVDRT's non-Government service provider representatives comprise:

  • Christine Robinson (Wirringa Baiya Aboriginal Women's Legal Service)
  • Susan Smith (Sydney Women's Domestic Violence Court Advocacy Service)

The DVDRT's non-Government sector experts comprise:

  • Dr Lesley Laing (School of Social Work and Policy Studies, University of Sydney)
  • Dr Jane Wangmann (Faculty of Law, University of Technology Sydney)


The Team reports to Parliament on domestic violence deaths reviewed in the previous year.

Government responses to Reports


The Australian Domestic and Family Violence Death Review Network 

The Australian Domestic and Family Violence Death Review Network was established in 2011 as an initiative of state and territory death review processes, and is endorsed by all state and territory Coroners and the Western Australian Ombudsman. The Network’s goals include producing national data concerning domestic and family violence related homicides in accordance with the National Plan to Reduce Violence Against Women and their Children 2009-2021. With this work the Network seeks to contribute to the formation of evidence-based policy and decision making in relation to domestic and family violence, enhancing opportunities for prevention and intervention and contributing to the enhanced safety of women and their children across Australia.

The Network published its first data report in May 2018 which provides national data with respect to all intimate partner homicides that occurred between 2010 and 2014.  Network reports are not tabled in Parliament in any jurisdiction.

Network reports