Coronial
VICcommunity

Finding into death of Andrea Dorothy Milner

Deceased

Andrea Dorothy Milner

Demographics

55y, female

Date of death

2022-09-23

Finding date

2025-03-04

Cause of death

Multiple injuries sustained in a train incident

AI-generated summary

Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 September 2022. The coroner concluded she intentionally took her own life. While Andrea had chronic suicidal ideation, her treating clinicians found no obvious warning signs of imminent risk; she consistently denied intent to act on suicidal thoughts. Her GP had recently commenced escitalopram and reduced mirtazapine on 13 September. The coroner found her treatment was appropriate and reasonable. The investigation revealed no clinical failures. The death highlights the complexity of assessing suicide risk in patients with chronic mental health conditions and communication difficulties.

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

Contributing factors

  • suicidal ideation
  • depression and anxiety
  • recent medication changes
  • difficulty with bowel care management
  • social stress and embarrassment

Coroner's recommendations

  1. Metro Trains Melbourne review and update its CCTV viewing infrastructure to include appropriate labelling of all camera angles and/or a geographical representation
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