The brutal murder of a vibrant and outgoing water polo coach was indicative of a horrific pattern of violence against women that demands urgent change, a tearful coroner has found.

Lilie James was killed when Paul Thijssen struck her in the head with a hammer at least 25 times inside St Andrew’s Cathedral School in Sydney on October 25, 2023.

The 21-year-old had ended her casual relationship with her 24-year-old colleague five days earlier, prompting him to stalk her and then to plan her murder, an inquest was told.

Chilling footage captured Thijssen practising the murder by alternating the hammer between his hands as he lunged forward and pushed open the bathroom door hours before he enacted his deadly plan.

James’ “senseless and violent” death inside her workplace was indicative of the alarming and persistent scourge of gendered and domestic violence in Australia, State Coroner Teresa O’Sullivan found.

“Lilie’s death is not an isolated tragedy,” the state’s most senior coroner said in her inquest findings on Tuesday.

“It is part of a devastating pattern of violence against women that demands urgent and sustained action.”

Lilie’s parents Peta and Jamie James have pleaded for cultural change to prevent more women being killed.

In handing down her findings after an inquest into James’ and Thijssen’s deaths, O’Sullivan highlighted the need for reform.

She recommended bolstering education and awareness programs, particularly around the identification of coercive control and the role technology can play in coercion.

Information and advice services should be developed, particularly for young men aged between 19 and 24, around respectful relationship behaviours, the coroner found.

“I am of the view that there are lessons to learn from these tragic circumstances,” she said.

“I urge that more be done through education and cultural change to challenge attitudes that drive this violence and to protect women’s lives.’

When James had previously tried to break up with Thijssen, the inquest was told he lashed out with degrading, derogatory, and manipulative language in a bid to control her.

He obsessively checked her location on social media platform Snapchat and shared a private image of James in a move experts say was calculated at asserting dominance.

At the conclusion of the inquest, James’ parents Peta and Jamie called for better education and awareness around identification and prevention of gender-based violence.

“As parents, if we are not teaching our sons how to respect a woman’s opinions and choices and accept rejection, we could be setting our daughters up for failure,” Peta James said through tears.

“In our case, a moment in time we will never recover from.”

O’Sullivan became emotional as she said Peta James’ message continued to resonate deeply.

“It is my hope that Peta’s message and the lessons learned from this tragedy echo beyond this court room and contribute to meaningful change,” she said.

Thijssen stalked Lilie James seven times before their last fatal interaction, but mental health experts testified the fatal assault would have been hard to predict because he had no history of aggression or indicators of violence.

“The first incidence of violence was the final incidence of violence,” forensic psychiatrist Danny Sullivan told the inquest.

After the inquest findings were handed down, James’ father  stressed the importance of awareness, education, and speaking out.

“Please, if it’s been a while since you talked about violence or abuse against women, whether that’s at home, at work or with friends or in the community, please start that conversation,” Jamie James said.

Domestic violence experts during the inquest criticised “unhelpful” descriptions of the attack as “out of character” for Thijssen, highlighting his previous pattern of coercive control.

Days after Lilie James was killed, Thijssen was remembered as “an absolute delight” by his former principal during a lengthy address to the parents and students of elite all-boys school Shore.

“He was not a monster; rather, in the last five hours of his life, he committed a monstrous act,” John Collier wrote in 2023.

Jamie James echoed the coroner’s recommendation that media do their part to not reinforce unhelpful community stereotypes.

“Please don’t report on positive comments saying people are good blokes and delightful,” he said.

“It’s disheartening and it’s cruel.”

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-AAP