Coroner Finds 'Preventable' Baby Death Due to 'Significant Errors' in Risk Assessment

A coroner has determined that the death of nine-month-old Kobi Shepherdson, who died in a murder-suicide at South Australia's Whispering Wall, could have been prevented. Judge Ian White, acting deputy state coroner, cited a "series of fundamental errors" by authorities, stating that a police risk assessment failed to capture the true danger Kobi and her mother faced from her father, Henry Shepherdson.

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I was extremely disappointed by the submissions on behalf of the Commissioner of Police, both in writing and orally, that Kobi's mother could have simply refused to answer calls from him.

The inquest revealed Shepherdson, 38, had a history of abusive and manipulative behavior towards Kobi's mother. He was arrested for domestic violence offenses in December 2020. While in custody, he engaged in persistent, coercive phone calls with the mother, which Judge White described as "relentless" and "pivotal" in his ability to have criminal charges, including threats to kill, dropped.

Judge White expressed strong disappointment with submissions suggesting the mother could have simply refused Shepherdson's calls. He emphasized Shepherdson's dangerous nature, his poor criminal record, and his constant focus on exploiting the mother for his own benefit, noting the "almost unbearable" pressure she endured. The judge stated that Shepherdson's manipulative behavior continued "unchecked for months."

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It should not be forgotten that he was a dangerous man with a bad criminal record who had a constant focus on Kobi's mother doing everything for his own selfish benefit.

The coroner identified "significant errors" made by SA Police and the Department for Correctional Services. He concluded that if Kobi and her mother had been classified as "high risk," numerous protective measures and inter-agency protocols would have been enacted, potentially preventing the tragedy. The findings underscore critical failures in risk assessment and inter-agency communication that contributed to the preventable death.

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The significant errors" made by SA Police and the Department for Correctional Services "cannot be ignored.