Coronial
VIChome

Finding into death of Narelle Catherine Simmons

Deceased

Narelle Catherine Simmons

Demographics

42y, female

Date of death

2021-10-19

Finding date

2025-10-09

Cause of death

Haemothorax and pneumonia in the setting of acute and chronic chest injuries and consumption of multiple drugs

AI-generated summary

Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertraline). She was assaulted by her intimate partner Craig Jennion between 10-19 October 2021. Clinical lessons: victims of family violence with substance use disorders are at heightened risk of femicide and may present with injuries initially misattributed to overdose. Police failed to recognise suspicious circumstances despite broken window, open door, unserved FVIO, and witness reports of screaming. Victoria Police investigations identified 22 months of duty failures including failure to investigate FVIO breaches, assaults, and inadequate risk assessment despite escalating threats to kill and suicide risks documented by Corrections Victoria. The case highlights systemic failures in victim support, perpetrator accountability, and potential legislative gaps regarding abandonment of victims in medical need.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

forensic medicinegeneral practiceemergency medicinepsychiatrycorrectional health

Error types

diagnosticcommunicationsystemdelay

Drugs involved

methadonemethamphetaminediazepamsertralineolanzapinecannabisalcohol

Clinical conditions

haemothoraxpneumoniarib fractureshepatic cirrhosischronic alcoholismsubstance use disorderintravenous drug usealcohol withdrawal seizurerenal impairmenthepatorenal syndrome

Contributing factors

  • Rib fractures from assault
  • Hepatic cirrhosis
  • Chronic alcoholism
  • Intravenous drug use
  • Multiple drugs in system (methadone, methylamphetamine, diazepam, sertraline, olanzapine, cannabis)
  • Family violence and assault
  • Possible suffocation or airway obstruction
  • Lack of medical assistance following assault
  • Complacency in police response due to victim's substance use

Coroner's recommendations

  1. That the Attorney-General consider making a referral to the Victorian Law Reform Commission to: (a) consider the creation of a new offence (abandoning a victim in medical need); and/or (b) amend the Family Violence Protect Act 2008 (Vic) to include abandonment of a victim in medical need as an example of family violence; and (c) to consider how family violence perpetrators can be held to account in circumstances where a charge of criminal negligence is not available.
  2. That a copy of this finding be provided to the Department of Families, Fairness & Housing to consider as part of their response to Coroner Giles' recommendation regarding expansion of co-responder programs such as the Alexis Family Violence Response Model across Victoria.
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