Finding into death of EDH
Deceased
EDH
Demographics
32y, female
Date of death
2021-01-10
Finding date
2025-04-11
Cause of death
mixed drug toxicity including phenobarbitone
AI-generated summary
A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in a coercive relationship, including sexual assault, physical violence, and ongoing harassment despite family violence intervention orders. Critical failures included police misidentifying her as the predominant aggressor after she reacted violently to her abuser's persistent contact (November 2019), inadequate workplace security allowing unsecured access to the lethal drug for nearly 5 hours, and insufficient escalation when the drug breach was discovered. Mental health treatment in December 2020 and early January 2021 appeared appropriate. The death highlights systemic failures in police identification of family violence perpetrators, inadequate drug security protocols in veterinary practices, and the profound impact of police misidentification on victim wellbeing and help-seeking behaviour.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- family violence and coercive control by intimate partner
- police misidentification of victim as predominant aggressor
- inadequate workplace security protocols for pentobarbitone
- failure to escalate discovery of unsecured drug
- ongoing harassment and FVIO breaches by perpetrator
- victim's perception that police response was dismissive
- allocation of family violence worker who was a family friend, reducing engagement
- victim's chronic mental health conditions and suicidal ideation
- recent sexual assault by housemate's friend
Coroner's recommendations
- That Safe and Equal update Code of Practice: Principles and Standards for Specialist Family Violence Services for Victim-Survivors to include: (1) clear instructions not to allocate workers to clients who they know personally, including family friends and acquaintances; (2) clear guidance on what workers should do if they identify that they know a client personally after a referral has been made to them; (3) clear guidance on how services should manage referrals where the client has a personal association with all available workers.
- Support for State Coroner's recommendation that Victoria Police fully implement FVRIM recommendation 5 to trial a review process involving the specialist family violence sector for any Family Violence Report where a woman is identified as a respondent before it is committed to Victoria Police's LEAP database
Full text
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