The sale of the chemical used by three transgender people who committed suicide should be restricted by the federal government, Victoria’s coroner has said, after an inquest heard the chemical was used in dozens of suicides in the state.
Last year, the Victoria Coroner’s Court held an inquest into the suicides of five transgender people who died between 2020 and 2021, including 25-year-old Matt Byrne, who committed suicide after a botched operation in her backyard.
Coroner Ingrid Giles released her findings on Thursday morning, including that at least three of the women in the cluster – Byrne, Heather Pierard and a woman identified by the pseudonym AS – used the same chemical. They also all knew at least one other person in the cluster.
The investigation had found that Byrne had been able to obtain the chemical, sodium nitrite, from an Australian online company, while AS obtained it from another Australian seller. It was unclear how Pierard had obtained it, Giles said.
In mentioning the chemical, Giles acknowledged there were risks in drawing attention to suicide methods, but said those risks were outweighed by the “preventative need” to reduce its availability.
Giles concluded that there had likely been some discussion about the chemical, including with a person from New South Wales who died in a similar manner on 23 July 2021.
“The fact that four people (including one in NSW) who were socially connected to each other all used this method, within a few months, very strongly suggests that there was information sharing between them, or between other members of the community, about the method,” she said.
According to Giles, the chemical was used in 52 suicides in the state between 2017 and 2023. It was also examined in a recent investigation into the suicide of a Victorian man who used the substance to take his own life.
She advised the federal assistant minister for mental health and suicide prevention to investigate how to further restrict the online sale and distribution of sodium nitrite in Australia.
Giles also called for urgent consideration of increasing funding to meet the growing demand for publicly funded health services that provide gender-affirming care to transgender and gender-diverse people, in order to reduce waiting lists.
She said the connections between some of the deceased suggested “contamination” played a role and that some of the deceased, including those who did not know each other personally, were aware of other deaths.
Byrne died on March 30, 2021. AS, 19, died on May 9, 2021, and Pierard died two days later.
The investigation found that Byrne sought gender confirmation surgery from an unlicensed medical professional, resulting in the surgery being aborted before her GPs referred her to a qualified surgeon.
Giles said Byrne’s resort to backyard surgery was “confronting” and an example of the need to improve access to gender confirmation surgery.
She also found several shortcomings in Victoria Police’s investigation into Bridget Flack, 28, who died between November 30 and December 11, 2020.
Flack attempted to enter a private mental health facility before disappearing on November 30, 2020. Her body was found nearly two weeks later by members of the LGBTQ+ community near a billabong in Melbourne’s east.
The investigation found that police had assessed Flack’s risk level as “medium” when she went missing.
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Giles said there had been an error in properly identifying and recording the risk to Flack in the initial missing person report filed on December 1, which “infected time-critical steps in the investigation”.
Giles said Victoria Police had failed to identify risk factors known to police, including her transgender status, which put her at “increased vulnerability to violence and risk of suicide”.
The initial request to triangulate Flack’s phone location was denied, the court heard, because of a legal requirement that there be an imminent threat, which has since been withdrawn.
When a police detective took over the case on December 4, Flack’s location could not be found because her phone appeared to be turned off.
Giles said the decision not to grant permission for triangulation of Flacks’ phone at the initial request led to the search for her being based on less reliable evidence and delayed the discovery of her body.
“This caused significant distress to her sister and to Mx Leigh (Flack’s sister’s husband). It also caused significant anxiety, fear and outrage within the LGBTIQA+ community, a sentiment that unfolded and swelled in the days that followed as Bridget remained missing,” Giles said.
She recommended that Victoria Police implement all five recommendations from the investigation into Flack’s death, including identifying risks specific to priority communities, such as LGBTQ+ people in missing persons cases.
Giles also recommended requiring all police officers to provide LGBTQ+ training and improving data collection on transgender and gender diverse people.
A Victoria Police spokesperson said the organisation was aware of the coroner’s recommendations and would consider them.
Outside court, Flack’s sister Angela Pucci remembered Love Bridget as a fierce and dedicated activist.
“She was an artist, smart in every way, a loyal and passionate person who loved to care for those around her and support causes she cared about,” she said.