Former champion skateboarder Ben Pappas killed his ex-girlfriend and took his own life after her body was found, a Victorian coroner has found.
Pappas's body was found floating in the Yarra River, near Victoria Harbour at Melbourne's Docklands, eight days after the body of his ex-girlfriend Lynette Phillips was found on March 2, 2007.
Ms Phillips had been strangled, her body wrapped in a quilt and weighed down at Dights Falls in Abbotsford.
Coroner Jennifer Coate said that on the balance of probabilities, 28-year-old Pappas had caused Ms Phillips' death and then placed her body in the Yarra River.
She said her conclusion was based on a number of factors, including that Ms Phillips was last seen alive in his company, her body was wrapped in a doona cover and weights that were previously in Pappas's possession, and his history of violence against her.
Police evidence at the inquest suggested Pappas killed himself after learning her body had been discovered.
Judge Coate said the former couple's relationship was marred by violence and drug abuse, and Ms Phillips had made a number of attempts to leave the relationship.
The coroner recommended a study be done on establishing an on-call service to advise general practitioners about how to deal with family violence.
She said Ms Phillips and Pappas had continued to see the same doctor, posing difficulties in managing their problems.
Judge Coate said Dr Michael Kozminsky seemed in awe of Pappas's sporting prowess, which may have clouded his judgment "possibly to the detriment of the duty he also owed Lynette".
She said while her care was not compromised to the extent it contributed to her death, the doctor may have overestimated his ability to safely control the complex situation.
In Dr Kozminsky's medical notes on Pappas, he wrote, "psychotic; depressive; ?suicide risk; ?? murder risk".
Judge Coate said Ms Phillips was undoubtedly a significant risk when Dr Kozminsky documented those concerns.
The coroner also found Pappas required a far more comprehensive crisis plan for his mental health issues, temperament and drug history.
While there are guidelines for doctors on treating a couple where family violence is apparent, Dr Kozminsky did not appear to be aware of them at the time.
Ms Phillips' family called for health professionals to be obligated to report cases where a family violence victim is in danger.
Her mother, Cheryl Dyson, said the doctor had acknowledged Pappas was capable of murder.
"My question was, if you really believe that, and he did, tell somebody," she told reporters.
"Why couldn't he just tell us?"
Pappas was a former world No.2 skateboarder who as a teenager was earning $15,000 a month on the professional circuit.
But his career spiralled downhill after he was found trying to import cocaine into Australia in 1999, when he was 21, and lost his passport and his international career.
- Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Suicide Call Back Service on 1300 659 467.