Coronial
VIChospital

Finding into death of Ms TP

Deceased

Ms TP

Demographics

37y, female

Date of death

2018-09-21

Finding date

2020-09-07

Cause of death

Hypoxic ischaemic encephalopathy as a direct result of neck compression

AI-generated summary

Ms TP, a 37-year-old woman of Indian origin living in Victoria, died from hypoxic ischaemic encephalopathy resulting from ligature strangulation (neck compression). She was admitted to ICU in cardiac arrest and died nine days later. She had a history of depression and previous suicidality in India but had received no mental health treatment in Australia. While hospital care was appropriate, the coroner highlighted systemic issues affecting South Asian women in the Whittlesea area, including social isolation, language barriers, and inadequate access to culturally appropriate mental health and family violence services. The investigation identified a suicide cluster of South Asian women in 2018. The coroner made recommendations for improved mental health service access and family violence investigations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • history of depression and suicidality
  • social isolation from family in India
  • marital stress and recent argument with husband
  • prolonged financial dependence after immigration
  • previous pregnancy loss (miscarriage at 13 weeks)
  • previous pregnancy termination
  • difficulty finding employment in Australia initially
  • homesickness and separation from extended family
  • lack of access to mental health services in Australia
  • no prior mental health treatment sought or documented in Australia

Coroner's recommendations

  1. The Secretary of the Department of Health and Human Services should review current services supporting the health and wellbeing of South Asian women in the City of Whittlesea, and consult with relevant service providers and stakeholders to identify opportunities to improve South Asian women's access to and engagement with such services.
  2. Victoria Police should allocate Family Violence Investigation Units to investigations into suspected intentional deaths of women in the City of Whittlesea who are from culturally and linguistically diverse communities, in circumstances where there is any indication that previous family violence incidents may have contributed to the death.
  3. Victoria Police should allocate Family Violence Investigation Units to investigations into suspected intentional deaths of women in the City of Whittlesea who are from culturally and linguistically diverse communities, in circumstances where there is any indication that social isolation may have contributed to the death.
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