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The sale of chemical used by three transgender women who took their own lives should be restricted by the federal government, the Victorian coroner says, after an inquest heard it has been used in dozens of suicides in the state.
Victoria’s coroners court last year held an inquest into the suicides of five transgender women who died between 2020 and 2021, including that of Matt Byrne, 25, who took her life after a botched back yard surgery.
The coroner, Ingrid Giles, on Thursday morning handed down her findings, including that at least three of the woman in the cluster – Byrne, Heather Pierard and a woman referred to by the pseudonym AS – used the same chemical. They each also directly knew at least one other person in the cluster.
The inquest had found Byrne was able to obtain the chemical, sodium nitrite, from an Australian-based online company, while AS obtained it from another Australian seller. It was unclear how Pierard acquired it, Giles said.
In naming the chemical, Giles acknowledged there were risks in drawing attention to suicide methods, but said they were counter-balanced by the “prevention imperative” of reducing its availability.
Giles concluded there was likely some discussion about the chemical, including with a New South Wales person who died on 23 July 2021 by the same method.
“The fact that four people (including one in NSW) who were socially linked to one another all used this method, within a matter of months, suggests very strongly that there was information-sharing between them, or between other members of the community, about the method,” she said.
Giles said the chemical was used in 52 suicides in the state between 2017 and 2023, and it had been investigated in a recent inquest into the suicide of a Victorian man who used it to take his life.
She recommended the federal assistant minister for mental health and suicide prevention investigate ways to further restrict the online sale and distribution of sodium nitrite in Australia.
Giles also called for urgent consideration of increased funding to meet the growing demand for public-funded health services delivering gender-affirming care to transgender and gender diverse people to reduce waitlists.
She said the connections between some of the deceased suggested that “contagion” played a role and some of the deceased, including those who did not know each other personally, were aware of other deaths.
Byrne died on 30 March 2021. AS, 19, died on 9 May 2021 and Pierard died two days later.
The inquest heard that Byrne sought gender-affirmation surgery from an unlicensed non-medical person, which resulted in an aborted procedure before GPs referred her to a qualified surgeon.
Giles said the fact that Byrne resorted to back yard surgery was “confronting” and an example of the need to improve the accessibility of gender-affirming surgery.
She also found several deficiencies in Victoria police’s investigation into Bridget Flack, 28, who died between 30 November and 11 December 2020.
Flack had been seeking admission to a private mental health facility before going missing on 30 November 2020. Her body was found by members of the LGBTQ+ community near a billabong in eastern Melbourne almost two weeks later.
Police recorded Flack’s risk level as “medium” when she was missing, the inquest heard.
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Giles said there was a failure to appropriately identify and record the risk to Flack in the initial missing person report filed on 1 December which “infected the time critical steps in the investigation”.
Giles said Victoria police failed to capture risk factors which were known to police, including her transgender status, which carried an “increased vulnerability of violence and risk of suicide”.
The initial request to have Flack’s phone location searched via triangulation was not approved, the court heard. This was due to a legislative requirement for there to be an imminent threat, which has since been removed.
When a police investigator took over the case on 4 December, Flack’s location could not be found because her phone appeared to have been switched off.
Giles said the decision to not authorise triangulation of Flacks’ phone on the first request led to the search for her being based on less reliable data and delayed the discovery of her body.
“This led to considerable distress for her sister and for Mx Leigh [Flack’s sister’s husband] it also led to significant disquiet, fear, and outrage in the LGBTIQA+ community, a sentiment that unfurled and swelled in the days that followed and during which Bridget remained missing,” Giles said.
She recommended Victoria police implement all five recommendations from its review into Flack’s death, including identifying risks specific to priority communities such as LGBTQ+ people in missing person cases.
Giles also recommended mandatory LGBTQ+ training for all police and to improve data collection in relation to transgender and gender diverse people.
A Victoria police spokesperson said the organisation was aware of the recommendations made by the coroner and would consider them.
Outside the court, Flack’s sister Angela Pucci Love remembered Bridget as a fierce and dedicated activist.
“She was an artist, smart in every sense, a loyal and passionate person who loved to look after people around her and support causes very special to her,” she said.
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