Finding into death of A S

Contributing factors

• family rejection related to gender identity
• death of mother in July 2020
• lack of contact with mother prior to her death
• social isolation
• longstanding mental health issues
• suicidal ideation from age 13
• lack of engagement with mental health services
• grief on Mother's Day
• exposure to suicide of peer in same community via same method

Coroner's recommendations

1. That the Assistant Minister for Mental Health and Suicide Prevention investigate ways to further restrict online sale and distribution of sodium nitrite in Australia
2. That Victoria Police update data collection systems (LEAP and Form 83) to capture all gender identities for TGD people, in accordance with Pride in our future strategy
3. That the Victorian Department of Health urgently increase resourcing for publicly-funded gender-affirming care services to reduce waitlists and support workforce expansion
4. That the Department of Health devise and implement a statewide framework for culturally-appropriate care to TGD people in public hospitals and health services including rural/regional areas, with additional staff training
5. That the Department of Health consider ongoing funding for culturally-appropriate social/emotional wellbeing supports and suicide prevention/postvention services for TGD people and families
6. That RACGP and RANZCP develop and offer training and support to healthcare professionals under their remits to ensure cultural safety for TGD people accessing services
7. That the State Coroner introduce LGBTIQA+ awareness training with TGD-specific component into induction training for all coronial staff and Coroners