Deceased
PFS
Demographics
50y, female
Date of death
2017-12-17
Finding date
2022-03-10
Cause of death
Hanging
AI-generated summary
A 50-year-old woman died by hanging in December 2017 after a relationship characterised by family violence and her own depression. She had been in an intimate partner violence situation for years, had presented to ED with suicidal ideation in July 2017, and was receiving counselling. Critical clinical and service failures included: (1) her Employee Assistance Program counsellor inappropriately recommending couple's counselling despite disclosed physical violence and controlling behaviours—contrary to family violence best practice; (2) the counsellor failing to appropriately address or escalate the family violence disclosures; (3) Victoria Police failing to complete required family violence risk assessment forms (VP Form L17) at two critical incidents in April and December 2017, missing opportunities for formal referrals to support services; and (4) the mental health assessment in July 2017 failing to document any family violence history despite PFS's known FVIO. These systemic gaps prevented coordinated protection and appropriate therapeutic intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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