Finding into death of Helen
Deceased
Helen
Demographics
68y, female
Date of death
2015-04-14
Finding date
2016-08-22
Cause of death
Multiple injuries sustained in a fall
AI-generated summary
68-year-old woman with bipolar affective disorder and history of suicide attempts died by jumping from a car park rooftop on 14 April 2015. She had been discharged from psychiatric inpatient care to aged care on 2 March 2015 after a protracted admission. On 2 April 2015, she presented with suicidal ideation following her mother's death and was re-admitted to psychiatric care under a Temporary Treatment Order. Her mental state improved and the order was revoked on 9 April 2015. She was granted day leave on 10 April but did not return, presenting to St Vincent's Hospital after a collapse. On 14 April, she absconded from the voluntary psychiatric admission and jumped from Car Park A. The coroner found care reasonable but criticised the car park operator for failing to implement suicide prevention measures despite multiple deaths at the location and repeated complaints from neighbouring occupants.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Suicide at a publicly accessible location with known suicide deaths
- Lack of suicide prevention barriers at car park
- Recent maternal bereavement
- Ongoing psychosocial stressors
- Dissatisfaction with accommodation
- History of bipolar affective disorder and previous suicide attempts
- Absconding from voluntary psychiatric admission
Coroner's recommendations
- Victorian Department of Environment Land, Water & Planning implement amendments to the Building Act 1993 and Building Regulations 2006 to provide Municipal Building Surveyors with powers to require modification to publicly accessible buildings which have been used as a suicide location
- Australian Building Codes Board consider implementation of a requirement for increased jumping suicide prevention measures on commercial, industrial and public buildings under the National Construction Code, with particular attention to car park facilities
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —