Finding into death of Ms HRZ

48y · Female·Neck compression secondary to hanging

Ms HRZ, a 48-year-old Turkish-born woman, died by suicide on Christmas Day 2020 after experiencing years of family violence. She first endured abuse from her ex-husband, then sexual coercion, assault, stalking and threats from an older man (Mr IPK). A critical failure occurred when police misidentified her as the perpetrator rather than victim after Mr IPK's false blackmail complaint, leading to her arrest and traumatic police interview. This systems abuse—compounded by cultural shame fears within her Turkish community—precipitated rapid mental health deterioration despite psychological support. She feared community exposure of intimate recordings Mr IPK had made. The coroner identified multiple systemic failures: premature police database entry before full investigation, lack of specialist sexual assault crisis support referral, and her isolation despite brief contact attempts by family violence services. While the immediate cause was her decision to end her life, the coroner found family violence—including systems abuse—was the key driver. Key lessons include: identify the true perpetrator using patterns of coercive control not incident-based assessment; provide trauma-informed specialist sexual assault support proactively; and strengthen systems against weaponisation by abusers.