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A Victorian coroner has recommended urgent improvements to police systems and increased funding increase for trans and gender-diverse healthcare following an inquest into a series of tragic suicides.
Coroner Ingrid Giles has made the recommendations after an inquest into the deaths of five young transgender women in Melbourne.
One of the women, Bridget Flack (above), was reported missing on December 1, 2020.
Warning: distressing content
However despite her family’s concerns, Victoria Police officers failed to recognise her high risk of suicide, Giles found.
Those delays prevented police using Bridget’s phone signal to find her. Instead, hundreds of members of the LGBTQIA+ community conducted a ground search instead.
Tragically, two of them found Bridget’s body in bushland on December 11, 2020.
Giles said police “failed to consider the safety and wellbeing of the community members searching for Bridget.”
“Police left a vulnerable community to search for one of their own, in the knowledge that Bridget might be found deceased,” the Coroner said.
The inquest confirmed Bridget Flack died by suicide on November 30 and “systemic” police failures had not contributed to her death.
While Giles found no evidence of anti-trans bias, there were nonetheless “concerning gaps” in the police investigation.
The coroner made three recommendations to Victoria Police. They include changes to its missing persons risk assessment and training for officers.
Giles said Victoria Police conducted a thorough internal review into Bridget’s case in 2021. However none of those findings had been implemented, which Giles said must happen “as a priority”.
Bridget Flack’s sister Angela Pucci Love gave evidence at the “tough but worthwhile” inquest. She said the findings were “vindicating” and she and Bridget’s loved ones want “to help the next family”.
“If the next person doesn’t feel they’re not heard or not treated with the respect that they deserve, be it in life or after life, that makes us feel really proud,” she said.
‘You should not feel fear when consulting a doctor’
The inquest also examined the deaths of trans women Natalie Wilson, Matt Byrne, Heather Pierard and another person known under the pseudonym AS.
Coroner Ingrid Giles recommended the federal government restrict the online sale and distribution of a lethal chemical used by three of the women to take their own lives.
Another important recommendation was increasing funding, access and capacity of gender-affirming healthcare in Victoria.
Tragically, the inquest heard that Byrne resorted to gender-affirming surgery from an unlicensed, non-medical “backyard” operator in a Melbourne home.
Giles said the young trans woman’s “confronting” case shows the urgent need to improve accessibility of gender-affirming care which “simply cannot keep up with demand”.
Giles said discrimination, particularly in the health system, has serious and “wholly unacceptable” impacts on trans people.
“You should not feel fear or profound dread when consulting a doctor,” she said.
“There should not be a myriad of horror stories circulating in the community as to what could happen if you walk through the wrong door to get support. There should be no wrong door.”
Coroner’s recommendations ‘long overdue’
Victoria Police and the Victoria Government have both said they will consider the recommendations.
Transgender Victoria chief executive Son Vivienne said the coroner’s findings are detailed and “long overdue”.
Dr Vivienne said it was crucial all frontline staff understood the increased risk trans and gender-diverse people face due to stigma and discrimination.
Anna Bernasochi, from suicide prevention organisation Switchboard Victoria, said the advocacy for systemic change would continue.
“We’re going to be there every step of the way to ensure that government, the police and our institutions are held to account so that we can change this reality for our communities,” she said.
If you need someone to talk to, help is available from QLife on 1800 184 527 or online at QLife.org.au, Lifeline on 13 11 14 or via text on 0477 13 11 14, Kids Helpline on 1800 55 1800, or beyondblue on 1300 22 4636.
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