Finding into death of Bridget Flack

28y · Female·compression of the neck and hanging

28-year-old Bridget Flack, a transgender woman experiencing complex mental health issues including depression, anxiety, borderline personality disorder and PTSD, died by suicide in December 2020 after becoming increasingly isolated during COVID-19 lockdowns and experiencing relationship breakdown. She was actively help-seeking via private mental health admission but was unable to access preferred private care due to lack of insurance, and was reluctant to use public mental health services due to prior negative experiences. The coroner identified systemic failures in Victoria Police's missing persons investigation including inadequate risk assessment on the initial report (recorded as 'medium' risk when should have been 'high'), failure to triangulate her phone on first request, and lack of engagement with the LGBTQ+ community undertaking search efforts. The inquest examined broad systemic issues affecting trans and gender diverse (TGD) communities including high rates of mental ill health and suicidality driven by discrimination and social exclusion; significant barriers to accessing gender-affirming care due to long waitlists and cost; inadequate mental health and suicide prevention services; and discrimination in mainstream health services. Clinical lessons include the need for culturally-safe mental health services responsive to TGD populations, better risk assessment in vulnerable populations, timely access to gender-affirming care as protective factor against suicidality, and comprehensive postvention support following TGD suicides.