Finding into death of Bridget Flack
Deceased
Bridget Erin Flack
Demographics
28y, female
Date of death
2020-11-30
Finding date
2024-08-29
Cause of death
compression of the neck and hanging
AI-generated summary
28-year-old Bridget Flack, a transgender woman experiencing complex mental health issues including depression, anxiety, borderline personality disorder and PTSD, died by suicide in December 2020 after becoming increasingly isolated during COVID-19 lockdowns and experiencing relationship breakdown. She was actively help-seeking via private mental health admission but was unable to access preferred private care due to lack of insurance, and was reluctant to use public mental health services due to prior negative experiences. The coroner identified systemic failures in Victoria Police's missing persons investigation including inadequate risk assessment on the initial report (recorded as 'medium' risk when should have been 'high'), failure to triangulate her phone on first request, and lack of engagement with the LGBTQ+ community undertaking search efforts. The inquest examined broad systemic issues affecting trans and gender diverse (TGD) communities including high rates of mental ill health and suicidality driven by discrimination and social exclusion; significant barriers to accessing gender-affirming care due to long waitlists and cost; inadequate mental health and suicide prevention services; and discrimination in mainstream health services. Clinical lessons include the need for culturally-safe mental health services responsive to TGD populations, better risk assessment in vulnerable populations, timely access to gender-affirming care as protective factor against suicidality, and comprehensive postvention support following TGD suicides.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- untreated/inadequately managed mental health conditions
- depression and anxiety
- borderline personality disorder
- post-traumatic stress disorder
- relationship breakdown
- social isolation during COVID-19 lockdown
- difficulty accessing mental health services
- barriers to accessing gender-affirming care
- increased alcohol use
- failure to access planned private mental health admission
- lack of timely mental health support
Coroner's recommendations
- Victoria Police implement all five OSCIR recommendations as priority: develop prompt sheet for missing person reports including guidance on vulnerable/priority communities; review missing person risk assessment to identify risks specific to LGBTQ+ and TGD communities; achieve consistency between electronic and hard copy risk assessment forms; review Crime Investigative Guidelines for urban missing persons procedures; develop risk assessment matrix for phone triangulation decisions
- Victoria Police make LGBTQ+ awareness training mandatory for all police members and staff with TGD-specific component addressing suicide risk factors in these communities
- Victoria Police progress amendment of LEAP and Form 83 to capture all gender identities as matter of priority, in accordance with Pride in our Future strategy Priority Area 3
- Attorney-General consider reform of 'senior next of kin' definition in section 3 Coroners Act 2008 to reduce distress for LGBTQ+ people estranged from biological family
- Department of Health urgently increase resourcing to meet growing demand for publicly-funded gender-affirming care to reduce waitlists and expand workforce
- Department of Health devise and implement statewide framework for culturally-appropriate TGD care in public hospitals and health services including rural/regional areas, with staff training
- Department of Health consider ongoing funding options for social/emotional wellbeing supports and suicide prevention/postvention services for TGD people and families
- RACGP and RANZCP develop and offer training on TGD health and cultural safety to all healthcare professionals under their remits, including suicide risk factors
- State Coroner introduce LGBTQ+ awareness training module with TGD-specific component in induction for all staff and coroners
Full text
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