This article mentions suicide and contains material some readers may find upsetting.
Victorian Coroner Ingrid Giles last week handed down her findings in the inquest into the suicide of young transgender woman Bridget Flack and four other suicides by members of the trans and gender-diverse (TGD) communities between 2020 and 2021. The report was damning of both Victoria’s public health system and Victoria Police.
On December 1, 2020, Flack was registered as a missing person after she was last seen by a friend on Lygon St in Carlton, Melbourne. Her disappearance sparked extensive searches coordinated predominantly by community amid dense bushland along the Yarra Bend in Melbourne’s northeast.
Flack’s body was found on December 11 in Willsmere-Chandler Park in Kew by two community members. Her death was later ruled as a suicide by police.
Victoria Police found itself facing fierce community backlash for its sluggish search efforts. In handing down her findings, Giles substantiated these concerns, highlighting “serious deficiencies” in Victoria Police’s response.
“I find that the issues in the Victoria Police missing persons investigation for Bridget, that have been identified in hindsight, prevailed at an organisational rather than at an individual level,” Giles ruled, adding that “police failed to appreciate the actual risk of suicide that Bridget presented”.
Flack’s sister Angela Pucci Love says that “there is vindication in knowing that what we were asking for and what we should have been provided was not unreasonable”.
“Even though the coroner said she didn’t believe Bridget was discriminated against by Victoria Police because of her gender identity — they did not accurately assess the risk,” Pucci Love told Crikey.
In December 2021 Victoria Police undertook an internal review, generating a list of findings and recommendations specific to the search for Flack. It was revealed it took more than six hours for the missing person’s report to be uploaded into the police system, while search efforts were further hindered by an initial request to access Flack’s phone triangulation data being denied.
Giles wrote in her findings, “I consider the decision not to approve triangulation of Bridget’s phone until it was too late to obtain any data from it, to be a significant lost opportunity to locate Bridget with precision and in a timely manner.”
Victoria Police has placed some of the blame on outdated IT systems. Giles noted that despite the internal review, so far not one of its recommendations has been implemented. Giles went on to say it was “troubling that no recommendations have been implemented several years on due to what is ostensibly an IT issue”.
Giles also found Victoria Police “failed to consider the safety and well-being of the community members searching for Bridget, many of whom were LGBTIQA+” and that “police left a vulnerable community to search for one of their own, in the knowledge that Bridget might be found deceased”.
“The concept of Bridget’s disappearance bringing up suicidal contagion within the LGBTQIA+ community was brought up [by the coroner’s inquiry],” Pucci Love said in relation to the four other suicides.
“What has been established is that the search for Bridget became so public and that I only went to the media because of the deficiencies of Victoria Police,” Pucci Love said.
“Had they taken the necessary steps to find Bridget, there wouldn’t have been the necessity to get so many people involved and create potential risk of suicidal contagion.”
Giles also called on the federal government to restrict the sale of a dangerous chemical that was linked to three of the five suicides investigated as part of the inquest.
Victorian public health services also came under fire. Flack was on a waiting list to access in-patient services at the time she went missing, but had also reported a negative experience after being admitted to a public hospital mental health service in 2013.
As Pucci Love explained, “the reason why Bridget wouldn’t access public mental health support is because she had been in the public mental health system before and had felt ridiculed and physically unsafe presenting as a transgender woman”.
Giles called for widespread change within the delivery of health services for trans and gender-diverse patients, stating that “[the] inquest has established a clear need to devise and implement a statewide framework for the provision of culturally appropriate care to TGD people in public hospitals and health services”.
“This is critical to ensuring that mainstream services are genuinely accessible for TGD people, including those presenting in crisis.”
Giles also recommended changes regarding how senior next of kin are identified.
“There’s a lot to digest,” Pucci Love concluded. “How do we hold people accountable and make people listen? A lot of time, emotion and money has been put into this inquest for a reason because it’s a matter of public health and it is an urgent and crucial matter that needs to be addressed.”
For anyone seeking help, Lifeline is on 13 11 14 and Beyond Blue is on 1300 22 4636. To speak to a First Nations crisis supporter, call 13 YARN (13 9276). In an emergency, call 000.
