Finding into death of Ms KSQ
Deceased
Ms KSQ
Demographics
39y, female
Date of death
2023-05-13
Finding date
2023
Cause of death
Plastic bag asphyxia
AI-generated summary
Ms KSQ, aged 39, died by plastic bag asphyxia in May 2023. She had experienced alleged sexual abuse and coercive control from her partner over 12 years. In September 2022, when she attempted to change locks at the family home, police misidentified her as the predominant aggressor despite her disclosures of sexual assault, issuing a family violence order against her instead of providing protection. This misidentification appeared to worsen her mental health. The coroner found police took an incident-based rather than pattern-based approach, disregarding her history of alleged abuse. While the police response was not causally linked to her death, the coroner highlighted systemic issues in identifying predominant aggressors in heterosexual relationships and recommended expanding co-responder programs where family violence specialists work with police to improve victim identification and support.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Alleged sexual abuse and coercive control by intimate partner
- Police misidentification of predominant aggressor in family violence incident
- Incident-based police assessment disregarding historical pattern of abuse
- Deterioration in mental health following adverse police intervention
- Increased suicidality prior to death
- Lack of specialist family violence support engagement
Coroner's recommendations
- That the Department of Families, Fairness and Housing resource an expansion of co-responder programs, such as the Alexis Family Violence Response Model, across Victoria
Full text
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