Finding into death of CWQ
Demographics
74y, male
Date of death
2022
Finding date
2025
Cause of death
Unascertained
AI-generated summary
A 74-year-old man with a long-standing history of delusional disorder and social phobia died at his Melbourne home between August and December 2022; the cause of death was unascertained. He lived with his sister, who also had unmet support needs and mental health difficulties of her own. Multiple services—mental health, housing, estate management, and police—attempted engagement through welfare checks and home visits over many years, but he largely declined support and services struggled to gain access to his property. The case illustrates critical gaps in Victoria's fragmented adult safeguarding framework. The coroner found that a coordinated safeguarding mechanism might have enabled proactive assessment of his self-neglect risk and implementation of multi-disciplinary risk management strategies. The coroner recommends the Victorian Government implement comprehensive adult safeguarding legislation, consistent with recommendations from the Australian Law Reform Commission, Office of the Public Advocate, and the Disability Royal Commission.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Mental illness (delusional disorder, social phobia)
- Self-neglect
- Paranoia and distrust of services
- Dependence on sister while sister had own unmet care and support needs
- Fragmented and uncoordinated adult safeguarding system
- Services unable to gain access to property
- Lack of regular medical engagement or general practitioner
Coroner's recommendations
- The Victorian Government implement adult safeguarding legislation to establish adult safeguarding functions including assessment, investigation, and coordination of responses to allegations of abuse, neglect, and exploitation of at-risk adults
- The Victorian Government review the circumstances of CWQ's passing and similar cases together with the safeguarding recommendations of the ALRC, OPA and DRC
- Ensure any new adult safeguarding agencies are adequately funded by the Victorian Government
- New safeguarding agencies should work cooperatively with other service providers to facilitate timely provision of support services to at-risk adults
- Introduce legislation to permit adult safeguarding agencies to receive and share information in a timely manner, including information about neglect, with police, healthcare entities, government departments, OPA and other agencies
- Implement recommendations of the Office of the Public Advocate to build capacity of mainstream service providers to identify and respond to abuse of at-risk adults
- Make funding available for regular community awareness, media engagement and education campaigns about new adult safeguarding functions
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