A coroner has determined Melba Support Services staff acted "reasonably and appropriately" after the death of a Ballarat East woman under their care.
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Angela Tulloh, 43, went missing from her Specialist Disability Accommodation in Brown Hill on October 31, 2022, triggering a large police and SES search operation.
She was found dead on November 2, 2022, behind the Shell service station on Humffray Street North.
Her death was the subject of a summary inquest at the Coroners' Court on Monday, where Coroner Simon McGregor handed down his findings, and presented a summary of circumstances.
The court heard Ms Tulloh was born in Melbourne and had diagnoses of autism, intellectual disability, borderline personality disorder and depression.
She had a long history of behavioural difficulties and self harm, the court was told, for which she had to be hospitalised seven times in the 16 months prior to her death.
At the time of her death Ms Tulloh was living in supported accommodation provided by Melba Support Services, in Brown Hill.
She lived in a unit with two other women also receiving care from the service, and had around-the-clock supervision from Melba staff.
On October 31, 2022, Ms Tulloh was at home with her disability support worker, seated in the kitchen area as the worker was preparing lunch.
At about 12.25pm the worker left the kitchen to take a phone call from another support worker, during which time Ms Tulloh left the unit.
The worker hung up the phone and began searching around the unit and property, unable to find Ms Tulloh.
Melba staff then began searching the immediate area by car, still unable to locate her.
This resulted in a police search for Ms Tulloh, in which a public call out was made by family members, mounted and canine units were called in and the police helicopter and drone patrols were used.
On the following day, 1 November, 2022, police said a young girl noticed someone lying down behind a Shell service station in Brown Hill.
The young girl noticed a bottle next to the person, who they thought was sleeping.
When the girl returned to the location the next day, the person, who was later identified as Ms Tulloh, was still there, and police and paramedics were alerted to her presence.
On November 9, 2022, Ms Tulloh's cause of death was determined as hypothermia and poisoning.
Bureau of Meteorology figures put the maximum temperature on the day of Ms Tulloh's disappearance at 15.9 degrees, and a low of 9.8 degrees.
On November 1, 2022, temperatures reached a maximum of 10.6 degrees and 4.4 degrees minimum.
Coroner McGregor said Ms Tulloh's death required an investigation by the court due to her residence with Melba.
"It is not necessarily a red flag that there is a coronial inquest," Coroner McGregor said.
"When people live in care and custody... They are particularly vulnerable.
"I am persuaded by those submissions that in Angela's case the care provided by Melba was reasonable and appropriate.
"We have not identified any prevention opportunities."
If you or someone you know is in need of crisis support, phone Lifeline 13 11 14.
Help is also available, but not limited, via the following organisations. The key message is you are not alone.
- Beyond Blue 1300 224 636 or beyondblue.org.au
- Stand By (support after suicide): 1300 727 247
- headspace Ballarat (for 12-25s and parent support): 5304 4777
- Ballarat Community Health: 5338 4500
- Ballarat Mental Health Services: 5320 4100 or after hours on 1300 247 647