The article discusses suicide. It contains content that some readers may find disturbing.

Victorian State Coroner Ingrid Giles last week released the findings of an inquest into the suicide of young transgender woman Bridget Flack and four other suicides by transgender and gender diverse (TGD) people in 2020 and 2021. The report criticised both Victoria’s public health system and Victoria Police.

On December 1, 2020, Flack was registered as a missing person after a friend last saw her on Lygon St in Carlton, Melbourne. Her disappearance sparked a large, largely community-coordinated search amidst dense bushland along Yarra Bend in Melbourne’s north-east.

Flack’s body was found in Willsmere-Chandler Park in Kew on December 11 by two members of the public. Her death was later ruled a suicide by police.

Victoria Police have faced a backlash from the community for their slow search efforts. In releasing her findings, Giles justified those concerns, highlighting “serious shortcomings” in the Victoria Police response.

“I consider that the problems in the Victoria Police investigation into Bridget’s disappearance, identified with hindsight, were at an organisational level rather than an individual level,” Giles said, adding that “the police underestimated the real risk of suicide that Bridget posed”.

Flack’s sister, Angela Pucci Love, says that “it’s a sense of fulfillment in knowing that what we asked for and should have received was not unreasonable.”

“While the coroner said she did not believe Bridget was discriminated against by Victoria Police because of her gender identity, they did not undertake a thorough risk assessment,” Pucci Love said. Crickets.

In December 2021, Victoria Police conducted an internal review, generating a list of findings and recommendations regarding the search for Flack. It was revealed that it took more than six hours to upload a missing person report to the police system, and that search efforts were further hampered by an initial request to access Flack’s phone triangulation data, which was denied.

Giles wrote in her conclusions: “I believe the decision not to triangulate Bridget’s phone until it was too late to obtain any data from it was a significant missed opportunity to accurately and timely locate Bridget.”

Victoria Police have placed some of the blame on outdated IT systems. Giles noted that despite an internal review, none of its recommendations have been implemented so far. Giles continued, saying it is “concerning that none of the recommendations have been implemented for several years due to what is allegedly an IT issue.”

Giles also claimed that Victoria Police “failed to consider the safety and well-being of community members searching for Bridget, many of whom were LGBTIQA+” and that “police left the community vulnerable in the search for one of their own, knowing that Bridget could be found dead”.

“During the coroner’s inquest, there was a concept that Bridget’s disappearance may have sparked suicidal thoughts in the LGBTQIA+ community,” Pucci Love said in reference to the four other suicides.

“It has been determined that the search for Bridget has become so public and I only went to the media because of the shortcomings of the Victoria Police,” Pucci Love said.

“If they had taken the necessary steps to find Bridget, there would not have been need to involve so many people and create a potential risk of suicide contagion.”

Giles also called on the federal government to restrict the sale of a dangerous chemical that has been linked to three of the five suicides investigated as part of the inquiry.

Public health services in Victoria have also come under fire. Flack was on a waiting list for inpatient services at the time of her disappearance, but she also reported negative experiences after being admitted to a public mental health hospital in 2013.

As Pucci Love explained, “the reason Bridget did not want to use public mental health services was that she had previously used public mental health services and felt ridiculed and physically insecure because she presented as a transgender woman.”

Giles called for wide-ranging changes to the delivery of health services to transgender and gender nonconforming patients, stating that “the inquiry found a clear need to develop and implement a statewide framework to ensure culturally appropriate care for transgender and gender nonconforming people in public hospitals and health services.”

“This is crucial to ensuring mainstream services are truly accessible to people with TGD, including those in crisis.”

Giles also recommended changes to the way older relatives are identified.

“There’s a lot to take in,” Pucci Love concluded. “How do we hold people accountable and make them listen? A lot of time, emotion and money has been put into this investigation for a reason, because this is a public health issue and it’s an urgent and crucial issue that needs to be addressed.”

For all those seeking help, Lifeline It’s 13 11 14 and Beyond the blue is 1300 22 4636. To speak to a First Nations Crisis Supporter, call 13 YARN (13 9276). In an emergency, call 000.