Finding into death of Natalie Wilson

Contributing factors

• chronic suicidality from age 17
• severe social anxiety and agoraphobia
• fear of discrimination as transgender person
• recent relationship breakdown
• social isolation and loneliness
• borderline personality disorder
• depression and anxiety
• post-traumatic stress from 2004 psychiatric admission
• gender dysphoria
• mistrust of psychiatric hospitals

Coroner's recommendations

1. Victoria Police update LEAP systems and Form 83 to capture all gender identities in line with Australian Bureau of Statistics Standard and consistent with Pride in our future: Victoria's LGBTIQA+ strategy 2022-32
2. Victorian Department of Health urgently increase resourcing to meet growing demand for publicly-funded gender-affirming care to reduce waitlists and support existing workforce; consider revision of existing framework for delivery of gender-affirming healthcare
3. Victorian Department of Health devise and implement statewide framework for culturally-appropriate care to TGD people in public hospitals and health services including rural/regional Victoria, with training for staff
4. Victorian Department of Health with Department of Families, Fairness and Housing consider ongoing funding for culturally-appropriate social and emotional wellbeing supports, and suicide prevention, postvention and bereavement supports for TGD people and families
5. RACGP and RANZCP under guidance of TGD experts develop and offer training to healthcare professionals to ensure cultural safety for TGD people accessing services, including training on suicide risk factors
6. State Coroner of Coroners Court of Victoria introduce LGBTIQA+ awareness training module with TGD-specific component into induction training for staff and Coroners, addressing factors contributing to suicide risk