Hannah Clarke and her children were unlikely to have been saved, even if authorities had done more, a Queensland coroner has found.
WARNING: This story contains content that readers may find distressing.
Deputy state coroner Jane Bentley choked back tears on Wednesday as she closed the inquest into their murder at the hands of Ms Clarke’s estranged husband.
Her findings — more than 150 pages — concluded further action by police, service providers, friends or family had little chance of stopping the perpetrator "executing his murderous plans".
"Rowan Baxter was not mentally ill. He was a master of manipulation," Ms Bentley told the court.
Even so, the deputy state coroner said every agency that dealt with Ms Clarke failed to recognise the "extreme risk" she would be killed.
"That failure probably came about because Baxter had not been violent and had no relevant criminal history."
The findings followed nine days of evidence from late March to early April, in which witnesses recounted the horror of Ms Clarke's car erupting in flames.
The inquest heard her ex-partner forced himself inside the car as she began the school run, doused his family in petrol and set them on fire at Camp Hill in February, 2020.
Aaliyah, 6, Laianah, 4, and Trey, 3, died in the vehicle, their father stabbed himself in the heart, their mother succumbed to her burns in hospital.
Ms Bentley said some of the statements the killer's friends and associates gave police reflected concerning attitudes in the community.
"They stated that Baxter loved his wife and children, he was a great father and that his actions were somehow excused or explained by the fact he was losing everything," she said.
"[The statements said] he was victimised by the process and that Hannah should not have kept the children from him."
'Missed opportunities'
The deputy state coroner found police "missed opportunities" to hold Baxter accountable.
"He was not charged and put on bail for the breach of the domestic violence order and the assault occasioning bodily harm," Ms Bentley said.
Baxter was instead handed a notice to appear in court for the lesser charge of common assault.
Inadequate training
The findings concluded police officers were undertrained when it came to domestic violence.
"There has been inadequate training provided to police officers considering that DV accounts for up to half of all their work," Ms Bentley said.
Lack of perpetrator programs
Counselling, programs, and support for perpetrators is clearly lacking but would not have made a difference in this case, the deputy state coroner found.
"Even if it had been available, Baxter was not interested in engaging unless it furthered his cause," she said.
Children's risk unassessed
Ms Bentley found police and child safety officers failed to undertake a "real assessment" of the risk of harm to the Clarke children.
"The only assessment was that Hannah was able to care for them," she said.
However, Ms Bentley said police officers who dealt with Ms Clarke directly acted appropriately overall.
She praised an officer who helped Ms Clarke realise she was a victim of domestic violence.
"[The officer] did everything she could to help and assist Hannah," Ms Bentley said.
Ms Bentley also spoke highly of the officer who took a statement from Ms Clarke as she was dying.
Agencies failed to recognise 'lethality' risk
Domestic violence services provided to Ms Clarke were "adequate and appropriate" but failed to recognise her "extreme risk of lethality", Ms Bentley said.
She said: "There was a failure to recognise the risk of intimate partner homicide which results from separation in a coercive controlling relationship."
Urgent changes recommended
The deputy state coroner made four recommendations requiring "immediate attention" to prevent similar deaths.
These include a five-day face to face training program for specialist DV police "as a matter of urgency", a mandatory DV module for all officers as part of their annual skills training, and funding for men's behaviour change programs.
Ms Bentley also recommended the Queensland government trial a specialist domestic violence police station for 12 months.
She said it should be in the Logan or Kirwan police districts, which have the highest numbers of DV incidents, and include:
- Specialist domestic violence police officers, including a detective to investigate criminal offences
- A specialist domestic violence support worker
- A child safety officer from the Department of Child Safety to assess the risk of harm to children of families affected by domestic violence
- A Queensland Health worker to assess mental health, drug and alcohol issues and the wellbeing of children
- A lawyer to provide legal advice to police and victims
Ms Bentley said the inquest reinforced the need for 89 recommendations in the Women's Safety and Justice Taskforce report.
The Queensland government has agreed to implement each one and has started an independent inquiry into broader cultural issues in the police service.
'He underestimated how much a mother will fight'
Ms Clarke's parents, Sue and Lloyd Clarke, sat in a packed courtroom in Brisbane as the coroner delivered her findings via a live stream from Southport Court, on the Gold Coast.
The couple said they were happy with the Coroner's findings.
"We believe we need a lot more education and we agree with all [Coroner Bentley's] findings not just for Queensland but that every state in Australia," Ms Clarke said.
"It's not just a Queensland problem," she said.
"With more education people will understand that children are at risk as well," she said.
"We need to keep this conversation going. It's an uncomfortable conversation that we've started and we're having," Mr Clarke said.
Ms Clarke said her daughter's ex-partner failed to realise her strength.
"I think he underestimated how much a mother will fight."
"He didn't love the children like she did."
Additional reporting by Tara Cassidy.
