A mother of two tragically lost her life in a brutal attack by a “severely unwell and dangerous” individual after missed chances to treat his significant mental health condition, according to findings by a coroner.

In 2020, Jayden Tanee Lowah, 25, was acquitted of the murder of 36-year-old Michelle Foster on the grounds of mental incompetence. The incident occurred near an Adelaide shopping center in October 2018.

Following the SA Supreme Court’s decision for him to undergo indefinite mental health supervision, Deputy State Coroner Naomi Kereru conducted an inquest to scrutinize the events leading to Michelle’s demise.

In finding Michelle’s death was not preventable, she noted “lost opportunities for the trajectory of Mr Lowah’s illness to have been altered”.

The coroner said that throughout the inquest, there were comments from witnesses about the resourcing of the mental health system, including Chief Superintendent James Blandford.

“[During] 43 years of policing, taking people backwards and forwards … to Glenside [hospital] where they were actually given asylum and care, to now a public hospital or a GP, they are out before my people have finished the paperwork because there are … no facilities for people who are in crisis,” he said.

Kereru recommended the attorney-general consider broadening the definition of “high risk offender” for an extended supervision order, with an additional category for offenders identified as an unacceptable risk to the community.