A coroner has chastised police at a murder-suicide inquest saying their submissions can be "read as victim-blaming" the infant victim's mother.
South Australian Deputy Coroner Ian White is inquiring into the deaths of nine-month-old Kobi Anastasia Isobel Shepherdson and Henry David Shepherdson, 38, at a dam northeast of Adelaide on April 21, 2021.
They died hours after a magistrates court granted a variation to a no-contact order to allow Shepherdson to care for Kobi while her mother was at an appointment.
The inquest has previously been told Shepherdson had called the baby's mother 149 times from prison, in breach of an intervention order, and coerced her into dropping charges against him.
During closing submissions on Thursday, Mr White had a tense exchange with Lauren Gavranich, representing government agencies including South Australia Police and the Department of Correctional Services.
"The (written) submissions, particularly on behalf of the commissioner of police ... commenting on Kobi's mother, caused me to have a very bad reaction," Mr White said.
"They seem to not acknowledge the coercive pressure she was under at all.
"You and everyone else here heard 15 gruelling calls played in open court."
The coroner said he was troubled by a paragraph of the police submission, which read: "Kobi's mother did not need to pick up any of the calls or speak with him, particularly in circumstances where she was safe and he was in custody".
"I believe these submissions on behalf of the commissioner are capable of being read as victim-blaming," he said.
"Your Honour, I completely disagree with you and that is not the commissioner's position in any way, shape or form," Ms Gavranich said.
"That's how it's going to be publicly recorded," Mr White replied.
"It's a wrong submission to say she had no choice to pick up those calls."
He said it was "not being melodramatic" to say Shepherdson was an unusual and dangerous man.
Counsel assisting Martin Kirby said Kobi's mother was "completely blindsided" when she received the first phone call from Shepherdson, from prison on January 31, 2021.
"She's quiet, she's initially unresponsive and she sounds fearful ... this would have been a very frightening and shocking moment," he said.
Shepherdson had been prevented from contacting her, and for six weeks she'd been safe and supported with her family in Victoria, he said.
"Not long after returning to Adelaide, where she was without family support, she answers the phone to have Mr Shepherdson telling her 'it's me, I'm back'," he said.
Shepherdson called her 13 times that day, immediately pressuring her to drop the charges against him and let him back into her life.
"He gaslit her, he dominated her, and he manipulated her," Mr Kirby said.
Questions why Kobi's mother answered the phone and didn't tell police Shepherdson was contacting her "discount and minimise the emotional and psychological issues that face domestic violence victims".
Shepherdson, he noted, was a large man.
"She was a woman alone with a child. It is not speculative to consider the additional level of physical threat that his presence would have been," Mr Kirby said.
Shepherdson had significant mental health and drug issues and a history that included threats of suicide.
And while his early life "might inspire some sympathy" he was also a domestic violence perpetrator and convicted armed robber, Mr Kirby said.
SA Police's initial response to the case was appropriate, with Shepherdson being arrested and Kobi's mother being offered support, he told the court.
"Your Honour can find that the domestic abuse risk forms were completed inaccurately on each occasion and the processes in place by which those scores could be reviewed failed to detect the errors," he said.
Mr Kirby said he was not seeking findings against any individuals because the issues were systemic.
He made a series of recommendations involving policies and procedures at various government agencies.
Mr White will deliver his findings at a later date.
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