Finding into death of Elizabeth Susan Edwina Ferris
Deceased
Elizabeth Susan Edwina Ferris
Demographics
44y, female
Date of death
2022-11-26
Finding date
2026-05-07
Cause of death
Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of presumed drug toxicity
AI-generated summary
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was found unconscious in the street after an apparent overdose involving multiple substances (opioids, benzodiazepines, methamphetamine, and others). She was resuscitated but suffered severe irreversible brain injury and died 16 days later. The coroner found no direct causal link between her death and police responses to family violence incidents, though noted Victoria Police missed opportunities to better protect her from an abusive partner through proper predominant aggressor identification and risk assessment. The case highlights the vulnerability of marginalized individuals with mental health conditions and substance use disorders to both intimate partner violence and fatal overdose, and the importance of nuanced, bias-aware policing responses.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Polysubstance overdose
- Presumed drug toxicity
- Family violence and intimate partner abuse
- Mental health condition (schizoaffective disorder)
- Substance use disorder
- Vulnerability and marginalization
- Police misidentification of predominant aggressor
- Failure of police to conduct risk assessment on 8 October 2022
- Failure of police to pursue civil protections
Coroner's recommendations
- Victoria Police fully implement recommendation 5 of the FVRIM December 2021 report on accurate identification of the predominant aggressor, specifically 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. The review of Family Violence Reports should occur by police and members of the specialist family violence sector together.
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