Finding into death of Thi Minh Phuong Nguyen

Contributing factors

• Chronic intimate partner violence and coercive control
• Removal of child to foster care
• Multiple mental health diagnoses including PTSD, depression, bipolar disorder, borderline personality disorder, and postnatal depression
• Substance misuse (GHB, methylamphetamine)
• Self-discharge from mental health inpatient unit against medical advice
• Lack of integrated family violence risk assessment in mental health settings
• Lack of coordinated care between health services and family violence services
• Child Protection did not complete family violence risk assessment or management plan
• Partner collected patient from hospital despite active family violence intervention order

Coroner's recommendations

1. The Victorian Government urgently increase the total quantum of primary prevention funding and prioritise longer term funding across the primary prevention system, including multi-year funding for organisations leading prevention activities, and stable, ongoing funding for Respect Victoria.
2. The Federal Government commit to long term funding for the development and maintenance of critical infrastructure for the primary prevention of violence against women and family violence, including Our Watch, ANROWS, Australian Bureau of Statistics, and Workplace Gender Equality Agency.
3. The Commonwealth and state and territory governments develop a consistent approach to death review processes and improve knowledge on the relationship between domestic, family and sexual violence and suicide, including establishing death review panels across all jurisdictions and initiating an urgent inquiry into the relationship between DFSV victimisation and suicide.