A coroner has recommended sweeping changes to domestic violence training and support in the wake of the deaths of Hannah Clarke and her children at the hands of her murderous ex-husband.
Deputy State Coroner Jane Bentley became emotional as she delivered her long-awaited findings into the deaths of the young family, detailing how their lives were snuffed out in her ex's "final act of cowardice" following the arson attack.
Clarke and her children Aaliyah, 6, Laianah, 4, and Trey, 3, were killed after her New Zealand-born ex-husband Rowan Baxter ambushed the young family on their way to school on February 19, 2020.
Baxter doused the family car in petrol and set it alight as horrified neighbours watched on.
The shocking crime shone a spotlight on Australia's domestic violence crisis and prompted an outpouring of grief across the nation.
In her findings, published on Wednesday, Bentley found that Clarke died from multi-organ failure from the fire inflicted by Baxter.
She said Clarke's children died at 8.25am on February 19 from the effects of the fire Baxter started, while Baxter died from a self-inflicted stab wound.
Hannah Clarke's children Aaliyah, Laianah and Trey.
"The children died almost immediately from the inhalation of fumes and burns," Bentley said.
"Hannah had received full-thickness, non-survivable burns."
Bentley said despite the injuries, Clarke showed "astounding bravery" and was able to describe to witnesses what Baxter had done.
The findings come three months after a long-awaited coronial inquest into the deaths of Clarke, her children and Baxter.
Throughout the inquest, the court was told Baxter constantly displayed controlling and abusive behaviours towards Clarke.
Some of these included controlling what Clarke wore and who she could see, demanding sex every night and berating her body image.
The court was told Baxter abducted Laianah from Clarke on Boxing Day 2019, fleeing to northern NSW before returning the child days later.
On another occasion, he assaulted the young mum after she confronted him over why he had explicit pictures of her in his car – something Baxter hoped to use in court.
Bentley said she found it unlikely any further actions from police, service providers and family could have stopped Baxter from carrying out his "murderous" plans.
She described the estranged ex-husband as a "master of manipulation".
"After Hannah left him and he realised he could no longer control her, he began to rally support from friends he had not seen for years and professionals he considered could advance his cause."
Bentley said Baxter killed himself in a "final act of cowardice", unable to live with the public denunciation and punishment he would receive.
The court was told the majority of statements provided to the inquest gave an insight into Baxter's controlling and abusive behaviour.
Rowan Baxter was served an application for a domestic violence and police protection order as his behaviour towards his ex-wife became worse.
"The truth is Hannah, who knew him best, was initially in favour of him having contact with the children … but she perceived he was becoming more dangerous," Bentley said.
"Her fears were genuine and realistic and ultimately confirmed in the worst way."
Bentley said there were missed opportunities by police to keep Baxter accountable, citing their response to his breach of the domestic violence order.
The court was told there was inadequate training for police officers around domestic violence, especially for frontline officers.
Bentley said there was also a "significant lack of counselling programmes and support" for perpetrators of domestic violence in Queensland.
"However, in this case, I am satisfied that even had it been available, Baxter was not interested in engaging in such programmes unless it furthered his cause … [of] Hannah agreeing to his wishes," she said.
Bentley recommended immediate comprehensive training was required to bring police up to speed on legislation.
She said there was a failure by support agencies to recognise the "extreme lethality" of Clarke's domestic violence plight.
This was attributed to the lack of physical violence inflicted by Baxter.
Bentley made four recommendations, including the Queensland government fund the QPS to provide a "five-day face-to-face domestic violence training programme for all specialist domestic violence police officers".
She also recommended QPS include mandatory face-to-face training for all police officers and trial a specialist domestic violence police station for 12 months with specialist staff, including detectives and child safety and housing support workers.
"My final recommendation is that the Queensland government provide funding for men's behaviour change programmes both in prisons and in the community as a matter of urgency," Bentley said.
"I offer my most sincere condolences to Mr and Mrs Clarke, other family members and friends and family of their children."
Outside court, Hannah's parents Sue and Lloyd Clarke said they were very pleased with the findings.
"We expected most of the results," Clarke told reporters.
"We need to see everything that's been recommended implemented in every state."
How to get help
If you're in danger now:
• Phone the police on 111 or ask neighbours or friends to ring for you. • Run outside and head for where there are other people. Scream for help so your neighbours can hear you. • Take the children with you. Don't stop to get anything else. • If you are being abused, remember it's not your fault. Violence is never okay.
Where to go for help or more information:
• Women's Refuge: Crisis line - 0800 REFUGE or 0800 733 843 (available 24/7) • Shine: Helpline - 0508 744 633 (available 24/7) • It's Not Ok: Family violence information line - 0800 456 450 • Shakti: Specialist services for African, Asian and Middle Eastern women and children. Crisis line - 0800 742 584 (available 24/7) • Ministry of Justice: For information on family violence • Te Kupenga Whakaoti Mahi Patunga: National Network of Family Violence Services • White Ribbon: Aiming to eliminate men's violence towards women
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