Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of presumed drug toxicity

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.