Inquest into the Death of Ms L (Name Subject to Suppression Order)
Deceased
Ms L
Demographics
27y, female
Date of death
2021-03-04
Finding date
2022-12-23
Cause of death
multiple injuries sustained from fall from 30-storey building
AI-generated summary
Ms L, a 27-year-old German national, died by suicide on 4 March 2021 after jumping from a 30-storey building in Perth. She had experienced depression since 2016, exacerbated by recent diagnoses of chlamydia and HPV16 in December 2020, followed by gynecological procedures. Police located her at the building, engaged with her for approximately 20 minutes on the terrace area, where she appeared increasingly calm and future-focused. She requested to use the toilet and subsequently accessed the building's roof via an unknown route, stepping off the edge despite Officer Gregoor's desperate attempts to save her. The coroner found police actions were reasonable, appropriate, and compliant with policy. No officer actions caused or contributed to her death. Key clinical lessons include recognising that suicide risk is highly unpredictable and can fluctuate rapidly; depression following medical diagnoses requires careful monitoring; and comprehensive assessment of suicidal ideation may reveal nothing despite high risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
depression exacerbated by chlamydia and HPV16 diagnoses
cervical procedures (colposcopy and LLETZ) with associated psychological distress
relationship stress with partner
suicidal ideation documented in personal journal
social isolation and difficulty accessing mental health support
Coroner's recommendations
Consideration should be given to expanding the hours and days of operation of Mental Health Co-response (MHCR) teams beyond the current six days per week, 1.00 pm to 11.00 pm timeframe
The Mental Health Commission, Police, and Department of Health should work to re-vitalise and re-position the MHCR program given recent changes to its deployment model
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