Finding into death of VNP

41y · Female·Injuries sustained in a fall from a height

VNP was a 41-year-old woman with longstanding bipolar disorder type 1, chronic pain from endometriosis, and substance misuse history who died by suicide on 10 July 2023. She had experienced homelessness, family estrangement, and loss of custody of her son. While staying in temporary motel accommodation, she attended Dandenong Shopping Centre carpark intoxicated with alcohol and methylamphetamine. Despite timely police response and 67 minutes of professional negotiation, she fell from the rooftop 11.12 metres to pavement below. The coroner commended emergency responders for professionalism and compassion. Comprehensive mental health assessments in the days prior, including ED review and ENGAGE program follow-up on 6 July, revealed no acute suicide risk. The coroner found no preventable factors or opportunities for intervention; acute intoxication significantly contributed to impaired judgment on the day.