Coronial
VICcommunity

Finding into death of Sacha Timothee Louis Lefebvre

Deceased

Sacha Timothee Louis Lefebvre

Demographics

52y, male

Coroner

Coroner Simon McGregor

Date of death

2024-12-02

Finding date

2026-03-27

Cause of death

Complications of chronic cardiac failure in the setting of ischaemic heart disease and chronic anaemia

AI-generated summary

Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions including heart failure, unstable angina, type 2 diabetes, and microcytic anaemia, alongside mental health issues and substance use. Despite contact with Boroondara Community Outreach, his homelessness and inability to access stable housing contributed significantly to his premature death. The coroner emphasised that homelessness itself is an independent risk factor for mortality, and that early intervention with housing and wrap-around support (such as the Better Health and Housing Program) could have prevented this death. The case highlights system-level failures in housing policy and healthcare accessibility for vulnerable populations, rather than individual clinical errors.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyemergency medicinepsychiatrygeneral practice

Error types

systemdelay

Drugs involved

methylamphetamineamphetaminecannabis

Contributing factors

  • homelessness and lack of stable housing
  • non-compliance with cardiac medications
  • chronic anaemia
  • ischaemic heart disease with double vessel coronary artery atherosclerosis
  • inadequate access to primary healthcare
  • mental health comorbidities including anxiety, obsessive-compulsive disorder, and psychiatric symptoms
  • substance use (amphetamine and cannabis)
  • systemic barriers to healthcare access for homeless populations
  • lack of coordinated wrap-around support services at scale
  • social determinants of health (poverty, housing affordability crisis)

Coroner's recommendations

  1. That the Victorian Government, in line with recommendations outlined in the reports from the Legislative Council Legal and Social Issues Committee on The rental and housing affordability crisis in Victoria and the Inquiry into Homelessness in Victoria, consider including the right to adequate housing in the Charter of Human Rights and Responsibilities Act 2006
  2. That the Victorian Government consider the suitability of the Better Health and Housing Program (BHHP) for further rollout in conjunction with other public hospitals and specialist homelessness sector providers across the state
Full text

IN THE CORONERS COURT COR 2024 007013 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: Sacha Timothee Louis Lefebvre Date of birth: 8 September 1972 Date of death: 2 December 2024 Cause of death: 1a : COMPLICATIONS OF CHRONIC

CARDIAC FAILURE IN THE SETTING OF ISCHAEMIC HEART DISEASE AND CHRONIC ANAEMIA Place of death: Hawthorn Library 584 Glenferrie Road Hawthorn Victoria 3122 Keywords: Natural causes death, Homelessness; Charter of Human Rights and Responsibilities Act 2006;

INTRODUCTION

  1. Sacha Timothee Louis Lefebvre was 52 years old when he passed on 2 December 2024 after he suffered a heart attack whilst sleeping rough. Although he was in contact with certain services, at the time of his death, Sacha was homeless and as such would usually be described in the public record as living at ‘No Fixed Abode’.

  2. Sacha was born in Western Australia, and was the middle of three siblings, idolising his older brother. Sacha was an intelligent and popular child who went to three different schools across his educational journey, but as his parents separated in his early teenage years, he became anxious and distracted.1

  3. After high school, Sacha experimented with drugs and began behaving erratically. In 1995, he followed his older brother to Melbourne as he pursued a career in television, but did not leave his drug use behind, even as his brother arranged him some work in the television and construction industries.

  4. His ongoing drug use was too much for his brother, and he moved out to various share houses and boarding houses around St. Kilda. His brother continued to help him find work and gave him money when he could not pay his rent, and the extended family noticed intermittent psychiatric symptoms.2

  5. After an angry outburst at his brother’s 40th birthday party back in Perth in 2009, his mother had to maintain an arms length relationship with Sacha. His drug use and poor mental health spiralled downward between then and 2013 after his brother moved to Bali.3

  6. In 2016, Sasha was admitted to St Vincent's Hospital’s psychiatric ward when he believed someone was trying to kill him. During that admission, the hospital’s multidisciplinary triage process noted many other chronic ill health co morbidities.

  7. Sacha also had a number of physical health issues which led to attendances at two other public hospitals, including heart failure, for which he was non-compliant with his medication. He had limited movement and swelling of the legs and was known to several hospitals in the last few months. His medical history also included unstable angina, microcytic anaemia and type 2 diabetes mellitus. He also had weight loss in recent months as well as obsessive compulsive 1 Coronial Brief, Statement of Elisa Lefebvre.

2 Coronial Brief, Statement of Simon Lefebvre.

3 Coronial Brief, Statement of Elisa Lefebvre.

disorder and anxiety diagnoses. He had a history of regular cannabis use and had been diagnosed with Tourette’s syndrome.4

  1. From 2019 until the time of his death, carers at the Boroondara Community Outreach had managed to maintain an ongoing relationship with Sacha, who had been sleeping rough in the local government area for about 18 months before he passed.5

HOMELESSNESS IN VICTORIA AND THE COSTS OF LATE INTERVENTION

  1. Many Victorians will still recall that during the difficult years of the COVID-19 pandemic, when public health objectives were prioritised in the policy sphere and funded accordingly, homelessness was practically eliminated by utilising the hotel capacity that was temporarily vacant in the absence of tourism.

  2. With those initiatives now discontinued, Sebastian Salay of the Council to Homeless Persons advised me that the number of people experiencing homelessness in Victoria is steadily increasing, with 105,125 people seeking help from the specialist homelessness sector during 2024-25.6 Homelessness is complex and multifactorial, so we must bear in mind that this number does not capture those unable or unwilling to seek such help, and so in reality there is actually a significantly higher number of people experiencing homelessness.

  3. Like Sacha, around 10 per cent of St Vincent’s Health Service (SHS) clients in 2024-25 were sleeping rough when they first sought assistance. This number has increased by 25 percent in the past five years, concurrently with Sacha’s own journey. Mr Salay explained that,7 …homelessness is not caused by individual deficits or mistakes, but by external factors including an inadequate safety net of income support payments, unaffordable rents in the private rental market, and a lack of social housing. As an illustration of this, just 127 of 16,219 rentals (0.8 per cent) available in 2024 were affordable for at least one household type on income support payments.

  4. Victoria has the lowest proportion of social housing by jurisdiction in Australia. 8 The nexus between homelessness and the coronial jurisdiction comes via common health issues which, if left untreated, become life threatening. The life expectancy of people experiencing 4 See medical records from Peninsular Health, The Austin and St Vincents hospitals.

5 Coronial Brief, Statement of the Rev. Natalie Dixon-Monu.

6 Coronial Brief, Statement of Senior Policy Officer Sebastian Salay.

7 Ibid.

8 Ibid.

homelessness is reduced by decades when compared with the national average.9 Mr Salay also alerted me to a hyper-local longitudinal study of people presenting to a Melbourne innercity hospital emergency department evidencing a similar gap between life-expectancy.10 In much the same way that a reputable body of pathologists now view WHO Class III Obesity, which has multifactorial origins, as an independent cause of death, there is now sufficient data correlation to conclude that “homelessness in all its forms is an independent risk factor for premature mortality.”11

  1. Whilst the avoidable costs to society of late intervention in these public health issues might be obvious to public health researchers12 and anyone visiting a crowded hospital emergency room, the poverty that accompanies homelessness also creates avoidable costs and delays in within the justice system.

  2. This too was Sacha’s journey, although I note that the police he encountered treated him with such dignity and compassion as the law permitted, despite his mounting verbal outbursts no doubt disturbing the local community.13

  3. Australia spends $15.2 billion on ‘late interventions’ each year,14 and the younger the homeless person is, the more expensive this ‘tail’ of costs will be. For instance, in 2016, youth homelessness alone cost $626 million nationally in avoidable health and justice costs – which is more than the entire national budget of the specialist homelessness sector that same year. 15 9 Whilst the National Coronial Information System 2023 Deaths of people experiencing homelessness in Australia.

https://www.mercyfoundation.com.au/wp-content/uploads/2024/02/Deaths-of-people-experiencing-homelessness-inAustralia.cleaned.pdf put ‘homeless’ life expectancy at age 44, it must be noted this part of the data is skewed downward by the inclusion of accidental deaths, as well as natural cause deaths, that are reported to coroners. The proposition is more reliably established at an international level in Slockers M et al, “Unnatural death: a major but largely preventable cause-of-death among homeless people?”, The European Journal of Public Health, 28(2), 2018, pp.248-252; Aldridge RW et al, “Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England”, Wellcome Open Research, 2019, 4:49; Nilsson SF et al, “Lifeyears lost in people experiencing homelessness and other high-risk groups in Denmark: a population-based, registerbased, cohort study”, Lancet Public Health, 10(1), 2025, pp.e-762-e773; Fornaro M et al, “Homelessness and health‑related outcomes: an umbrella review of observational studies and randomized controlled trials”, BMC Medicine, 2022, 20(1), p.224.

10 Seastres, RJ, Hutton, J, Zordan, R, Moore, G, Mackelprang, J, Kiburg, K. and Sundararajan, V 2020 ‘Long-term effects of homelessness on mortality: a 15-year Australian cohort study’ Australian and New Zealand Journal of Public Health vol. 44, no. 6, pp. 476-481. https://doi.org/10.1111/1753-6405.13038.

11 Ibid; Morrison, David S. 2009, ‘Homelessness as an independent risk factor for mortality: results from a retrospective cohort study’ International Journal of Epidemiology vol 38, pp. 877-883.

12 Davies, A and Wood, L 2018 Homeless health care: meeting the challenges of providing primary care.

https://www.mja.com.au/system/files/issues/209_05/10.5694mja17.01264.pdf. at p.230.

13 Coronial Brief, Statement of SC Caibiran Deas.

14 Teager, Fox and Stafford, How Australia can invest in children and return more: A new look at the $15b cost of late action, Early Intervention Foundation, The Front Project and CoLab at the Telethon Kids Institute, Australia, 2019.

15 Flateau, P, Thielking, M, MacKenzie, D, and Steen, A 2016 The cost of youth homelessness in Australia: Research Briefing. https://researchoutput.csu.edu.au/ws/portalfiles/portal/20343727/1000008507_published_report.pdf.

  1. In contrast, early prevention investment providing housing and wrap-around support for young people showed that every $1 invested delivers $2.60 in benefits over 30 years. 16

  2. Prevention investment in the homelessness space reduces avoidable health care and justice costs, develops productivity and decreases mortality, 17 but as then State Coroner Judge Cain recently observed, 18 the Australian Institute of Health and Welfare reported in 2022 that Victorian specialist housing support services were unable to assist 96 clients each day, and that 70% of cases were closed without the client having accessed stable housing.19

THE CORONIAL INVESTIGATION

  1. Sacha’s death was reported to the coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.

  2. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

  3. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.

  4. Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Sacha’s death. The Coronial Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

16 SGS Economics and Planning 2024 Leave No Young Australian Behind: Cost-benefit analysis report.

https://housingallaustralians.org.au/wp-content/uploads/2024/04/Give-Me-Shelter-Youth-Report_110424.pdf.

17 Coronial Brief, Statement of Senior Policy Officer Sebastian Salay. See also Zordan R et al, “Premature mortality 16 years after emergency department presentation among homeless and at risk of homelessness adults: a retrospective longitudinal cohort study”, International Journal of Epidemiology, 52(2), 20-23, p.508.

18 Inquest in the death of Bekkie-Rae Curren COR 2019 006509 (Cain J., 14 October 2024).

19 At [63].

  1. In considering the issues associated with this finding, I have been mindful of Sacha’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006 (the Charter), in particular sections 8, 9, 10 and 13.

  2. This finding draws on the totality of the coronial investigation into the death of Sacha Timothee Louis Lefebvre including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.20

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred

  1. In the days before he passed, Sacha had been sleeping rough with his few personal belongings in a shrubbery at the front of the Hawthorn Library, 584 Glenferrie Road, Hawthorn. The library staff had experienced his pattern of verbal outbursts as they interacted with him.21

  2. At approximately 7:40 am on Monday 2 December 2024, Ms Jane Nolan was arriving to work at the library when she noticed Sacha face down on the ground with his pants down, surrounded by excrement and blow flies. She alerted her supervisor as well as the Salvation Army’s crisis line. Another staff member arrived and although they did not believe he was breathing, they nonetheless called 000 and, after they had put some gloves on, draped his blankets over him to protect his dignity. A nearby council worker also assisted by setting up line of sight and pedestrian traffic barriers.22

  3. Paramedics attended promptly, but were only able to confirm Sacha had passed. My investigators then arrived on the scene at approximately 8.40 am.23 20 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

21 Coronial Brief, Statement of Marcella Russnak.

22 Coronial Brief, Statement of Jane Nolan.

23 Coronial Brief, Statement of Caibiran Deas.

Identity of the deceased

  1. On 12 December 2024, Sacha Timothee Louis Lefebvre, born 8 September 1972, was visually identified by his former sister-in-law, Ms Tamara Lefebvre. Identity is not in dispute and requires no further investigation.

Medical cause of death

  1. Senior Forensic Pathologist Dr Victoria Francis from the Victorian Institute of Forensic Medicine (VIFM) conducted an autopsy on 4 December 2024 and provided a written report of her findings dated 16 June 2025.

  2. The post-mortem examination revealed evidence of congestive cardiac failure with a pericardial effusion, bilateral pleural effusions, ascites and peripheral oedema. His heart showed double vessel coronary artery atherosclerosis with some myocardial fibrosis.

  3. Toxicological analysis of post-mortem samples identified the presence of methylamphetamine and amphetamine, consistent with recent amphetamine use.

  4. Dr Francis provided an opinion that the medical cause of death was 1(a) COMPLICATIONS OF CHRONIC CARDIAC FAILURE IN THE SETTING OF ISCHAEMIC HEART DISEASE AND CHRONIC ANAEMIA, and I accept her opinion.

THE RIGHT TO HOUSING IN VICTORIA

  1. Whilst the Charter does not contain an overt Victorian right to housing, this is an element of a patchwork of other first generation human rights, such the ‘home’ aspect of our right to privacy set out in section 13, and the right to life reflected in section 9, albeit that its articulation is consequently somewhat piecemeal.24

  2. Similarly, the Human Rights Act 2019 (Queensland) does not expressly articulate any right to adequate housing, but His Honour Justice Smith has recently held that a local council who evicted rough sleepers and destroyed their belongings had breached their human rights in doing so.25 24 For instance, see United Nations, General Comment No.36 on Article 6: Right to Life, doc. CCPR/C/GC/36, 3 September 2019 at [30].

25 Bobeldyk v Moreton Bay City Council; Eichin & Ors v Moreton Bay City Council [2026] QSC 27 at [553]. The decision considered the right to equality before the law (s.15), the right to life (s.16), the right to protection from degrading treatment (s.17), the right to property (s.24), the right not to have one's privacy arbitrarily interfered with (s.25(a)) and the right for families to be protected (s.26). These fragmented lenses are equally available in Victoria under the Charter

  1. The Australian Capital Territory however now expressly recognises a right to housing in their Human Rights Act 2004.26 It encompasses security of tenure, habitability, accessibility, location, and cultural adequacy.

  2. After initial reviews in 2011 and 2015, the next review of the Charter is yet to be announced, but in the meantime, access to adequate housing remains a fundamental human right that is set out in article 11(1) of the International Covenant on Economic, Social and Cultural Rights (ICESCR), which Australia ratified in 1975. 27

  3. Although Australia has since failed to ratify the ICESCR’s First Optional Protocol complaints procedure, the High Court of Australia has set out a principle of statutory interpretation resolving acknowledged ambiguities in domestic law in a way compatible with the Commonwealth’s accepted international obligations:28 A statute of the Commonwealth or a State is to be interpreted and applied, as far as its language permits, so that it is in conformity with Australia’s obligations under an international convention. Where legislation is ambiguous, an interpretation of Commonwealth or a State statute which is consistent with international human rights obligations should be preferred to one that is inconsistent, all the more so where the legislation is enacted after, or in contemplation of, Australia’s entry into the relevant convention.

  4. After being the first Victorian superior court judge to give detailed consideration to the human right to housing in PJB v Melbourne Health & Anor (Patrick’s case) [2011] VSC 327, His Honour Kevin Bell went on to research and publish in this field with Monash University.29 In this capacity, he singled out the work of Canadian lawyer and former United Nations Special Rapporteur on the right to adequate housing, Leilani Farha, as most succinctly capturing the but as I recommend later, an express right to adequate housing offers a pathway for articulating coherently humane legislation, policy and government decision making.

26 See section 27D of Part 3A.

27 International Covenant on Economic, Social and Cultural Rights, opened for signature 16 December 1966, 993 UNTS 3 (entered int force 3 January 1976): “The States Parties to the present Covenant recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food, clothing and housing, and to the continuous improvement of living conditions” at https://www.ohchr.org/en/instrumentsmechanisms/instruments/international-covenant-economic-social-and-cultural-rights. See also United Nations Committee on Economic, Social and Cultural Rights, General Comment No 4: The Right to Adequate Housing (art 11(1)), UN Doc E/1992/23 (13 December 1991) at [8] regarding “affordability”.

28 Minister of State for Immigration and Ethnic Affairs v. Ah Hin Teoh, [1995] HCA 20 at [26].

29 Bell K, Housing: The Great Australian Right, Monash University Publishing, Clayton, 2024.

guiding principles of a policy framework capable of tackling homelessness. Such a framework should be: 30 a) based in law or legal standards; b) prioritise those most in need and ensure equality; c) comprehensive across the whole of government; d) granting rights based participation; e) accountable via budgeting and tax justice; f) human rights based goals and timelines; g) accountable and monitored; h) ensuring access to justice; i) clarifying the obligations of private actors and regulating financial, housing and real estate markets; and j) implementing international cooperation and assistance.

  1. After noting that the Australian Human Rights Commission broadly supports a similar approach, Bell commented that the obvious similarities our colonial heritage, First Nations populations and middle tier national economies make Canada an excellent source of comparative law and policy. I agree and have endeavoured to do so in these Findings.31

PREVENTION OPPORTUNITIES

  1. Whilst I commend the Rev. Natalie Dixon-Monu and her care team at Boroondara Community Outreach for the contact and care they were able to maintain with Sacha in these difficult circumstances, coronial investigations are a recognised moment when the effectiveness of other modalities of care can also be considered.

30 Ibid at p.65. See also United Nations, Report of the Special Rapporteur on Adequate Housing as a Component of the Right to an Adequate Standard of Living, note by the secretariat, doc. A/HRC/37/53, 15 January 2018.

31 Ibid. See also Hohmann J, ‘A Right to Housing for the Victorian Charter of Human Rights and Responsibilities?

Assessing Potential Models under the International Covenant on Economic, Social & Cultural Rights; the European Social Charter; & the South African Constitution' (2022) 48(2) Monash University Law Review 132; and Hohmann J, ‘Toward a right to housing for Australia: Reframing Affordability Debates through Article 11(1) of the International Covenant on Economic, Social and Cultural Rights’ (2020) 26(2) AJHR 292.

  1. People experiencing homelessness often face barriers, including stigma or exclusion, when accessing primary care. Research in Canada has shown that primary health providers are able to better support and access a significant population of this cohort when partnering with homeless shelters/services.32

  2. Mindful of this “inextricable” and expensive intersection between the chronic preventable health conditions often experienced by homeless people and our very busy public health system, I asked Andrew Chan, Manager of the Healthcare for the Homeless Services at St Vincent's Hospital to explain the Better Health and Housing Program (BHPP) that his hospital has run in conjunction with Launch Housing and the Brotherhood of St Laurence since 2022:33 It is a housing led healthcare model providing people experiencing chronic homelessness opportunities to stabilize and address their health needs, and transition to secure housing post exit with wrap-around healthcare supports. In doing this, the BHHP provides residents with accommodation for up to six months in a facility co-located with health and housing support staff. In addition to the six-month residential support period, residents have the option of receiving six months of post-stay support from [St Vincent's] staff to ensure connections with local health services are embedded and the needs of the residents are handed over to community support.

  3. Only two years later, more than 70 frequent users of their emergency department have been through the program.34 With each of the hospital admissions usually costing an average of just under $8,000 per inpatient,35 the BHHP is an innovation that has both improved outcomes for its clients, the hospital’s capacity to serve the remainder of the community and its budget.

  4. Whilst I do not have the exact equivalent figures from BHHP, Canadian experts estimated that whilst it costs at least $20,000 CAD to keep someone hospitalised for a month, and $12,000 CAD to house a prisoner for the same period, it only costs around $2,500 CAD to provide housing and wrap around support for a homeless person across that time.36 32 Saragosa M., Morales-Vazquez M., Roerig M., Carbone S., & Allin S, Rapid Review - Delivering Primary Care in Non-traditional Healthcare Settings to Individuals Experiencing Homelessness, April 2022, available online at: https://naohealthobservatory.ca/wp-content/uploads/2022/04/NAO-Rapid-Review-34_EN.pdf 33 Coronial Brief, Statement of Manager Andrew Chan.

34 Ibid.

35 Coronial Brief, Statement of Senior Policy Officer Sebastian Salay.

36 Galloway M, Why a place to call home can be the best medicine, CBC Canada Radio, 14 October 2024, https://www.cbc.ca/player/play/audio/9.6535409 , interviewing Dr Andrew Boozary of the Gattuso Centre for Social Medicine Innovation, Dunn House, at the Toronto University Health Network. At this hospital, 1% of patients were unhoused but accounted for 15% of emergency room visits and 32% of in-patient visits. See also Roumeliotis I, Hospital invests in new treatment to save lives: housing, CBC News, 18 April 2023. See also Garrett D, The Business

  1. For these reasons, I shall recommend the State of Victoria review the suitability of the BHHP programme for further rollout in conjunction with other public hospitals and specialist homelessness sector providers.

FINDINGS AND CONCLUSION

  1. Pursuant to section 67(1) of the Act, I make the following findings: a) the identity of the deceased was Sacha Timothee Louis Lefebvre, born 8 September 1972; b) the death occurred on 2 December 2024 at Hawthorn Library 584 Glenferrie Road Hawthorn Victoria 3122, from 1(a) COMPLICATIONS OF CHRONIC CARDIAC

FAILURE IN THE SETTING OF ISCHAEMIC HEART DISEASE AND CHRONIC ANAEMIA; and c) the death occurred in the circumstances described above.

  1. Having considered all of the circumstances, I am satisfied that the public health and justice systems’ engagement with Sacha was reasonable and appropriate, within the limits of Victoria’s current homelessness paradigm.

COMMENTS I make the following comment(s) connected with the deaths under section 67(3) of the Act:

  1. Homelessness is a preventable yet expensive cause of increased morbidity, and as such is a phenomena which would benefit the State of Victoria to better understand, through both an actuarial and a public health lens.

  2. Incorporating a right to adequate housing into the Charter of Human Rights and Responsibilities Act 2006 would provide a whole of government lens for articulating coherently humane legislation, policy and government decision making.

Case for Ending Homelessness: Having a home improves health reduces health care utilisation and costs, AHDB online (American Health & Drug Benefits), Vol 5, No.1, January/February 2012.

RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations: A. That the Victorian Government, in line with recommendations outlined in the reports from the Legislative Council Legal and Social Issues Committee on The rental and housing affordability crisis in Victoria37 and the Inquiry into Homelessness in Victoria,38 consider including the right to adequate housing in the Charter of Human Rights and Responsibilities Act 2006; and B. That the Victorian Government consider the suitability of the BHHP programme for further rollout in conjunction with other public hospitals and specialist homelessness sector providers across the state.

I convey my condolences to Sacha’s family for their loss, but hope that in a civilised society such as Victoria, the sharing of such stories has some rational prospect of triggering positive change.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Elisa Lefebvre, Senior Next of Kin Andrew Chan, St Vincent’s Health Sebastian Salay, Council to Homeless Persons Hon. Jacinta Allen, Victorian Premier Hon. Sonya Kilkenny, Victorian Attorney-General Peta McCammon, Secretary to the Department of Families, Fairness and Housing 37 Available online at: https://www.parliament.vic.gov.au/4a9242/contentassets/0c6d61c7d86d4971bf50c2573cb534b2/inquiry-intohomelessness-in-victoria---final-report.pdf 38 Available online at: https://www.parliament.vic.gov.au/495e8d/contentassets/90eeac3a41ca4c498ca4e1cfffe125eb/committee-finalreport.pdf

Jenna Atta PSM, Secretary to the Department of Health Senior Constable Caibiran Deas, Coronial Investigator Signature: ___________________________________ Coroner Simon McGregor Date: 27 March 2026 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.

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