Coroner's Finding: De-identified HJ
Demographics
71y, female
Date of death
2022-01-08
Finding date
2023-04-03
Cause of death
starvation
AI-generated summary
A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check and found her severely malnourished, mentally unwell, and unable to care for herself. Despite her obvious grave illness, police did not call an ambulance or arrange mental health assessment. Instead, they submitted an internal report believing it would trigger referral to mental health services—a critical misunderstanding. No external agency was notified. Her brother's subsequent welfare concerns on 7 January 2022 were not acted upon. She was found dead on 8 January 2022, weighing 35 kg with evidence of starvation ketosis. The coroner identified failure to call emergency services, lack of mental health referral mechanisms, and organisational breakdown in communication as key failures. Tasmania Police subsequently updated procedures to mandate direct contact with mental health services in such situations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- severe mental illness with paranoia
- social isolation and estrangement from family
- failure of police to call ambulance despite obvious grave illness
- failure to arrange mental health assessment
- police misunderstanding that internal report would trigger mental health referral
- lack of automatic notification mechanism between police and mental health services
- failure of landlord to follow up after door damage
- inability to self-care with no follow-up support
- inadequate response to brother's welfare concerns on 7 January 2022
Coroner's recommendations
- Tasmania Police to update its Manual to include specific instructions requiring direct contact with Mental Health Services for advice and referral whenever there are concerns about the mental health of a person with whom police have had contact
- Tasmania Police to communicate to all police commands the need to call Mental Health Services when necessary and to clarify that the police information system does not have automatic notification capability to mental health agencies
Full text
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