Coroner urges missing persons overhaul after probe into deaths of young trans women

Warning: this article contains distressing content

A Victorian coroner has called for an overhaul of the way police deal with missing person cases after finding the force failed in its search for a transgender woman who was later found dead in a park by members of the LGBTQ community.

Coroner Ingrid Giles called for more robust risk-assessment systems for people who disappear, and also urged governments to crack down on the easy availability of a chemical substance linked to a Melbourne cluster of suicide deaths of trans women.

Bridget Flack in 2020.Credit: Facebook

The findings were handed down on Thursday following a three-day inquest last year that examined the deaths of five trans women aged between 18 and 33 who were undergoing a gender-affirmation process before taking their own lives during the pandemic.

Bridget Flack, Natalie Wilson, Matt Byrne, Heather Pierard and “AS” – whose identity has been suppressed – died in Melbourne in 2020 and 2021. Some of the women knew each other and all had a history of mental health issues.

The lead case was Flack, whose body was found in bushland in Kew two weeks after she was reported missing.

Giles found while there was no evidence the investigation had not been taken seriously because she was transgender, the search was plagued by deficiencies, including delayed efforts by police to triangulate her phone and a lack of ground searches where her phone was last detected.

“Police failed to appreciate the actual risk of suicide that Bridget presented ... this infected the time-critical steps in the investigation,” Giles found.

Flack was last seen by her friend on the morning of November 30, 2020, in Lygon Street, Carlton. The 28-year-old had said she was going to take a walk in a park in Fairfield, but despite contacting people via phone later in the day, she never returned home.

Her disappearance made national headlines and more than 120 people helped her family search for her.

Flack’s body was eventually found by two members of the LGBTQI community at Willsmere-Chandler Park.

Giles did not make any adverse findings against the police officers involved in Flack’s case and found she most likely died the day she went missing.

But the coroner said it was “deeply concerning” none of the recommendations Victoria Police had made following its own extensive internal review into its search for Flack in 2021 had been enforced.

Victoria Police said the challenges in Flack’s case were partly due to challenges with a dated IT system, and it would strive to take into account LGBTQI status when assessing risk for future missing person cases.

But Giles said it was “troubling that no recommendations have been implemented several years on due to what is ostensibly an IT issue”.

Victoria Police’s internal assessment had deemed Flack a “medium” risk, despite being repeatedly warned about fears of self-harm and suicide.

Giles said Flack’s case was handed over to the Melbourne Crime Investigation Unit, but despite the best efforts of officers, the investigation was already compromised.

A police officer, who made a second request to triangulate Flack’s phone after the first request had been rejected, told the inquest by that time “it was evident that the missing person was in considerable risk of harm, and that all that could be done to locate her should be.”

Giles recommended police urgently implement changes to its missing person risk assessments, improve data collection to capture all gender identities and roll out mandatory LGBTQI training for all police.

Giles said Flack’s disappearance had stirred up anger, fear and distress in the LGBTQI community, who felt they had been left by police to “search for one their own”.

One of the people who found her body later told Giles: “I want to make it known that trans lives matter.”

The police approach to Flack’s disappearance was just one element in the landmark and wide-ranging inquest.

Giles also called for the federal government to urgently investigate ways to restrict the online sale and distribution of a dangerous chemical substance, which The Age has chosen not to name, that had been ingested by three of the five women. One woman had purchased it on eBbay, and another for a minimal sum from an Australian-based online store, before it was delivered to their door by Australia Post.

She said there appeared to be an element of “suicide contagion” and that there was evidence the women had engaged in such discussions on online forums before their deaths.

Giles’ other recommendations included an urgent increase in resources by the Victorian government to ensure publicly funded health services delivered gender-affirming care and that training for healthcare workers be developed under the guidance of trans and gender-diverse communities.

Last year, the inquest heard devastating testimony from the families of the women. Relatives described them as beautiful young women with their lives ahead of them, but who also faced discrimination, dislocation and isolation as members of the trans community.

Flack’s sister, Angela Pucci Love, wiped away tears on Thursday as the recommendations were read out over two hours in the Coroner’s Court. Outside the court, she said her sister was a fierce and dedicated activist, who always stood up for what she believed in.

Angela Pucci Love, whose sister Bridget Flack died by suicide, hugs a loved one outside the Corner’s Court on Thursday.Credit: Jason South

Last year, Pucci Love told the Coroner’s Court of her anguish and frustration as she battled to convince police to take her sister’s disappearance seriously, revealing one officer even suggested she call the fire brigade.

Pucci Love said police had failed to understand the level of risk to her sister’s life, including that shortly before her death, she had been calling hospitals seeking a mental health admission after receiving a GP referral, but was turned away.

“There is a sense of relief and vindication in knowing that there were failures in the handling of Bridget’s disappearance by Victoria Police and I sincerely hope the recommendations are heard and actioned,” Pucci Love said.

Giles acknowledged the “grief, devastation, dignity, grace and patience” of the women’s loved ones throughout the inquest.

Pucci Love said it was heartening Victoria Police had conducted a review into its handling of her sister’s case, but frustrating none of the recommendations had been implemented.

“Until those changes start being implemented, they don’t mean a lot,” she said.

She said she wanted her sister to be remembered for who she was when she was alive: kind, artistic, smart, loyal and passionate.

Transgender Victoria chief executive Son Vivienne said the coroner’s recommendations echoed what the LGBTQ community had been calling for over many years.

Vivienne said it was crucial all frontline staff understood the increased risk trans and gender-diverse people faced through stigma and discrimination, and recognise this could be a barrier to how the community responded in matters such as missing person searches.

Click here to read the coroner’s recommendations and findings in full.

For help, visit Lifeline at lifeline.org.au, call 13 11 13 or text 0477 13 11 14.

The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.