‘Obviously’ ill woman weighed 35kg at time of death: Coroner

A Coroner says it’s difficult to understand how a mentally ill Bridgewater woman was left to die of starvation despite police conducting a welfare check. His findings >>

Bridgewater Bridge

A Tasmanian coroner has expressed disbelief a woman was able to starve to death in her suburban home — despite police conducting a welfare check.

In his findings released on Wednesday, Coroner Simon Cooper said the woman identified as HJ died between December 9 2021 and January 8 2022.

Mr Cooper said HJ, 71, had been “a hermit” with a long history of mental illness.

The closest person to HJ was her brother KN, however it had been around 10 years since HJ had let KN into her unit.

HJ’s last known contact with anyone was with police officers from Bridgewater station who attended her home on December 9, 2021, to perform a “concern for welfare” check.

Mr Cooper described HJ’s condition as shown in police body worn camera footage.

“She was obviously malnourished and frail. Her hair, grey in colour was matted into large clumps. Her eyes were glazed … She spoke rapidly of various conspiracies involving the police, people from China, Isis and Jesus. It is abundantly plain viewing the footage, which frankly is uncomfortable to watch, that HJ was gravely ill – both mentally and physically,” Mr Cooper said.

“However, without contacting an ambulance, the police left, apparently having reached the view that HJ did not require immediate medical attention.”

Property managers Centacare Evolve Housing were contacted by police and notified repairs were needed to the door as police had forced entry.

One of the attending police said in an affidavit it had been her understanding that by submitting her report on the visit to HJ, services such as CAT2 and Centacare Evolve would be automatically notified.

However there was no mechanism for such a report to be forwarded, so HJ received no follow up visit from anyone.

On January 7, 2022, HJ’s brother KN went to the Bridgewater Police Station to report his grave concerns for HJ’s welfare.

After ringing the buzzer her was told someone might come out or call him back. After waiting half an hour he left the station, but did not receive a call back.

The following morning, KN rang the police again.

This time police responded and went to HJ’s unit, forced entry and found her dead.

Mr Cooper said findings of an autopsy showed HJ’s death was “obviously starvation’ and that she weighed just 35kg.

“HJ’s lonely death, of starvation, in the suburbs of an Australian capital city, raises several issues. First, the decision by attending police on December 9 2021 not to call an ambulance to at least enable a mental state assessment to be carried out was, in my view, wrong,” he said.

“Second, the apparent inaction by HJ’s landlord, 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.”

Despite his concerns, Mr Cooper said he would not make any recommendations as police had been provided with a draft of his findings and had responded.

The police response said the incident was the result of a “misunderstanding” by one officer.

The police manual was also being updated to reinforce the need for police to call mental health services when there was a concern for an individual’s welfare.