- In short: A 71-year-old Tasmanian woman, who was living alone in community housing, starved to death shortly after a police welfare check in which no action was taken
- What's next? Tasmania Police say they will update procedures and send correspondence to all commands, reinforcing the need to call Mental Health Services when necessary
A woman with mental health issues, who was living in community housing, died from starvation within weeks of a police welfare check, a coroner has found.
In his report, Coroner Simon Cooper wrote the woman's "lonely death, of starvation, in the suburbs of an Australian capital city, raises several issues", including with Tasmania Police's inaction.
The woman, who Mr Cooper shielded from identification, had a "lengthy and well documented history of mental illness".
"HJ's existence was 'that of a hermit' — she was estranged from family and had no friends," he wrote.
"Her brother, KN, was probably the person closest to her and said it was 10 years since HJ had let him into her unit. He also said she rarely, if ever, answered her phone."
The 71-year-old woman rented a unit in Bridgewater, north of Hobart, from community housing provider Centacare Evolve.
"It was surrounded by chest-high grass. The unit's garden was full of rubbish. The blinds were permanently down," Mr Cooper wrote.
In December 2021, one of the woman's neighbours contacted police because he was concerned that he had not seen her for about two weeks.
Three officers from the Bridgewater Station were sent to do a welfare check on December 9.
The entire interaction was caught on body-worn camera.
After knocking on the door with no response, the officers eventually forced their way in.
There they found HJ.
"She was obviously malnourished and frail," the coroner wrote.
"Her hair, grey in colour was matted into large clumps. Her eyes were glazed."
Mr Cooper also wrote that she "made no sense".
"She spoke rapidly of various conspiracies involving the police, people from China, Isis and Jesus," he wrote.
"It is abundantly plain viewing the footage — which frankly is uncomfortable to watch — that HJ was gravely ill, both mentally and physically."
The officers left without contacting an ambulance, although they did advise Centacare that the door needed to be repaired.
When the officers returned to the police station, they filed a report, apparently understanding that by submitting the report "the appropriate services such as CAT [Crisis Assessment and Treatment] and Centacare Evolve would be contacted and HJ would receive the appropriate attention".
Nothing else was done.
No food in the house
On January 7, 2022, the woman's brother, who was "gravely concerned for her welfare", went to her unit.
The report said there were no sounds or signs of life, and when she did not answer his knocks, he went to police.
He finally got hold of them the next morning, they forced their way into her unit and found her dead.
Paramedics who attended noted that the "house [was] completely empty of any food and contains very few items".
"Fridge completely empty except for [a] dirty empty cup," the report said.
"[Patient] does not appear to be eating food. Laundry had 4 x garbage bags, visible chocolate biscuit packet – bags not opened.
"[Patient] appears to have been living in situation not suitable for mental health state — unable to self care with no follow-up."
At the time of her death, she weighed just 35 kilograms, with Mr Cooper writing the cause of death was "obviously starvation".
'It's very concerning'
In his report the coroner said her "lonely death" raised several issues.
"First, the decision by attending police on 9 December 2021, not to call an ambulance to at least enable a mental state assessment to be carried out was, in my view, wrong," he wrote.
"Second, the apparent inaction by HJ’s landlord [Centacare Evolve Housing], when called by police to repair the door damaged when entry was forced is difficult to understand.
"Third, the fact that the submission of an internal report by police actually achieved nothing to assist an obviously gravely ill person is very concerning."
In response to the coroner, Tasmania Police said the "belief of the attending officer that a street check would generate a notification to mental health services was a misunderstanding by an individual, not a belief embedded across the organisation".
Tasmania Police also informed the coroner that it was updating the Tasmania Police manual, "with correspondence sent to all police commands reinforcing the need to call Mental Health Services when necessary and highlighting that the police information system does not have the capability to send notifications".
Mr Cooper said that given Tasmania Police's response, he did not need to make any further comment or recommendation.
He noted: "But for the response from Tasmania Police, I would have been minded to make a formal recommendation that Tasmania Police urgently review its procedures to ensure that upon submission of any internal report detailing concerns in relation to the mental health and wellbeing of a member of the public the appropriate external agencies are notified".
