The death of Darcey Iris Freeman shocked the country.

The death of Darcey Iris Freeman shocked the country.

During consultations at her local clinic in 2007 and 2008,Ms Barnes disclosed she was worried about her children's welfare,telling at least one doctor she was fearful Mr Freeman would harm them.

Mr Freeman went on to throw their four-year-old daughter to her death,on the morning of January 29,2009 in a crime that shocked the nation.

Peta Barnes leaves the Coroners Court of Victoria in July after hearings on her daughter's death.

Peta Barnes leaves the Coroners Court of Victoria in July after hearings on her daughter's death.Credit:Joe Armao

In the inquest findings,released on Friday,Victorian Coroner Ian Gray agreed with expert opinion that while one of the disclosures warranted a risk assessment,the law did not require a report to have been made by any of the doctors.

"I make no adverse finding against any of the treating GPs or other professionals in this matter as the weight of the available evidence does not support a finding that they departed from the prevailing standards of their respective professions,"Mr Gray wrote.

In Victoria GPs are required to contact police if they have a reasonable belief that a child is at significant risk of physical harm or sexual abuse.

The doctors treating Ms Barnes told the inquest they did not believe the children were in danger and were under the impression the situation was being handled by police and Ms Barnes'lawyer.

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However,Judge Gray found there was scope for improvement in the training and education of GPs and other professionals who worked with family violence and child abuse victims.

This included on mandatory reporting obligations and the functions of child protection services.

It also included ensuring doctors understood they were able to report family violence and child abuse that did not meet the mandatory threshold to child protection and referral service CHILD First.

The inquest into the death of the girl was to examine whether it could have been prevented or if there could be recommendations to prevent future deaths.

Judge Gray made clear that the investigation did not reduce the importance of placing the responsibility of Darcey's death solely with Mr Freeman.

He said,as he found in his investigation into Luke Batty's death - another child who died at the hands of his father - there was no way to predict such a murder.

"The evidence before me leads to conclude that Mr Freeman's actions and Darcey's death were unable to have been predicted with any great certainty,"he said.

"As I recently found in my investigation into the death of Luke Batty,there is no validated risk assessment tool that can accurately predict whether a parent is likely to commit filicide."

Freeman was driving his three children back from his parents'home in Aireys Inlet when he stopped on the bridge about 9.15am,took his daughter from the car and threw her off the bridge.

Darcey,who was to have started prep that day,fell 58 metres. She died in hospital that day.

Freeman was in 2011 found guilty of her murder and was jailed for life,to serve a minimum 32 years in jail.

Ms Barnes last year won a confidential settlement from VicRoads over the lack of safety barriers on the West Gate Bridge,which,she argued,would have saved her daughter's life.

Barriers were erected on the bridge soon after her death.

At the request of Judge Gray,the coroners prevention unit found the number of suicides at the bridge had dropped from 11.8 per year,from January 2000 to April 2009 when there were no barriers,to zero since permanent barriers were erected in 2014.

There was an average of 1.9 deaths per year while temporary barriers were in place in the interim.

Judge Gray received submissions from the Family Court of Australia,the Victorian Bar Association,the Law Institute of Victoria,the Royal College of General Practitioners,the Department of Human Services and the Emergency Services Telecommunications Authority,which operates Victoria's Triple 0 service.

For help or information call Lifeline on 131 114 or Kids Helpline on 1800 551 800

With Adam Cooper

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