Deceased
Frances Jeyann Ramirez
Demographics
22y, female
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2023-11-25
Finding date
2025-10-02
Cause of death
Multiple injuries sustained in a motor vehicle incident (pedestrian vs. car)
AI-generated summary
Frances Jeyann Ramirez, a 22-year-old student, was fatally struck by two vehicles while crossing Hopkins Street in Footscray on 25 November 2023. She sustained multiple injuries and died at the scene. The coroner found that inadequate streetlighting at the uncontrolled intersection contributed significantly to both drivers' inability to see her in time to avoid collision. The area has experienced rapid residential development with increased pedestrian traffic, but safety infrastructure upgrades including traffic signals, pedestrian crossings, and streetlighting have lagged behind. The coroner made critical findings that existing streetlighting does not meet current standards and that infrastructure improvements require immediate attention. Key lessons include the importance of ensuring that rapid urban development is matched by timely safety infrastructure upgrades, particularly at high-risk pedestrian locations on arterial roads.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Error types
IN THE CORONERS COURT Court Reference: COR 2023 006574
OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Amended pursuant to section 76 of the Coroners Act 2008 on 10 December 20251 Findings of: Deputy State Coroner Paresa Antoniadis Spanos Deceased: Frances Jeyann Ramirez Date of birth: 3 November 2001 Date of death: 25 November 2023 Cause of death: 1(a) Multiple injuries sustained in a motor vehicle incident (pedestrian vs. car) Place of death: Corner of Hopkins and Hallenstein Streets, Footscray, Victoria Key words: Pedestrian fatality, inadequate streetlighting 1 This document is an amended version of the Finding into Death Without Inquest regarding Frances Jeyann Ramirez dated 2 October 2025. A correction to Recommendation 3 has been made pursuant to section 76 of the Coroners Act 2008 (Vic).
On 25 November 2023, Frances Jeyann Ramirez was 22 years old when she sustained fatal injuries when she was struck by a motor vehicle whilst crossing the street near her apartment building. At the time, Ms Ramirez lived in Footscray with a roommate.
Ms Ramirez was born in the Philippines. She moved to Australia on a student visa to study at Torrens University and was employed at a fast-food store on a casual basis.
Ms Ramirez had previously lived in a share house in South Kingsville. In May 2022, Khyla Sequena moved into the share house, and they became good friends. In December 2022, the two women moved out and into an apartment in Hallenstein Street, Footscray.
Ms Ramirez’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.
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.
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.
The Victoria Police assigned an officer to be the Coronial Investigator for the investigation of Ms Ramirez’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.
This finding draws on the totality of the coronial investigation into Ms Ramirez’s death, 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.2
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased
Medical cause of death
Forensic Pathologist, Dr Hans de Boer, from the Victorian Institute of Forensic Medicine (VIFM), conducted an inspection on 28 November 2023 and provided a written report of his findings dated 6 December 2023.
The post-mortem examination revealed multiple significant injuries consistent with the reported circumstances.
Routine toxicological analysis of post-mortem samples did not detect any alcohol or any commonly encountered drugs or poisons.
Dr de Boer provided an opinion that the medical cause of death was “1(a) Multiple injuries sustained in a motor vehicle incident (pedestrian vs. car)”.
Circumstances in which the death occurred
Ms Ramirez started her shift at work at about 11.00am on the morning of 25 November 2023.
At approximately 9.40pm that evening, she caught an Uber home with her colleague, Mlee Nguyen, who also lived nearby. Ms Nguyen stated that both she and Ms Ramirez wore earbuds and listened to music during the drive home.
2 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.
They were subsequently dropped off at Moreland Street, Footscray, at 9.52pm. After saying their goodbyes, Ms Nguyen walked into her building and Ms Ramirez walked toward her building on the other side of the road. She had her mobile phone in her hand and was still wearing her earbuds.
At about 9.57pm, approaching from Moreland Street, Ms Ramirez began to cross Hopkins Street, Footscray. Moreland Street becomes Hallenstein Street on the other side of Hopkins Street. Ms Ramirez successfully crossed the westbound lanes without incident, reaching the painted island in the middle of Hopkins Street. Mr Ramirez then commenced crossing the eastbound lanes of Hopkins Street walking towards Hallenstein Street.
Hopkins Street travelling east is a two-lane paved carriageway with a righthand turning lane to Moreland Street. Approaching Hallenstein Street, there is a bus stop in the eastbound lanes.
At the time, Hopkins Street was a 60 kilometres per hour (km/h) speed zone. Signs indicating the speed limit were clear and applicable to drivers travelling on Hopkins Street. However, at the particular section of Hopkins Street where Ms Ramirez was crossing there were no visible signs for drivers travelling east, the last one being before the intersection of Whitehall and Hopkins Street to the west.
The distance between the Whitehall Street to the west and Joseph Road to the east of the location of the incident (at or near Hallenstein/Moreland Streets) is approximately 260 metres.
Bother intersections were controlled by traffic control signals/lights which also controlled the pedestrian crossings.
The closest intersection to the place where Ms Ramirez began crossing Hopkins Street was the Hallenstein/Moreland Streets intersection with Hopkins Street where there was no pedestrian crossing or traffic lights. This intersection is about 120 to 130 metres from both Whitehall Street and Joseph Road.
Hopkins Street is a major arterial in the Footscray area which accommodates moderate to heavy traffic flow at most times of the day. It is used by heavy vehicles leaving freight yards on Dynon Road and travelling to Geelong Road. In this section of Hopkins Street there is a high number of newly built residential apartment buildings, with a high volume of pedestrian movement and a primary school on the corner of Hopkins Street and Whitehall Street.
On the evening of 25 November 2023, it was dark, the road was wet from earlier rain, and visibility was average to poor. Traffic was light on the eastbound side.
As Ms Ramirez began to cross the eastbound lanes of Hopkins Street, a 2005 Volkswagen Beetle (the Volkswagen) travelling east collided with her, causing her to fall to the ground in the second eastbound lane. The driver immediately stopped and exited the vehicle and began to wave down other road users to prevent them from colliding with Ms Ramirez. He then began assisting Ms Ramirez.
A 2004 Ford Falcon (the Ford) travelling east along Hopkins Street at this time subsequently struck Ms Ramirez in the second lane. The driver engaged his brakes as he collided with Ms Ramirez. He immediately pulled over and ran to the collision scene.
Picture 1: Depiction of the relevant intersection
Ms Ramirez sustained significant injuries as a result of the two collisions. Members of the public began performing cardiopulmonary resuscitation (CPR) whilst awaiting the arrival of emergency services. Victoria Police members were the first responders to the scene at 10.02pm and continued CPR.
Ambulance Victoria paramedics arrived at the scene at 10.04pm and quickly assessed Ms Ramirez as deceased. Resuscitation was not attempted. Ms Ramirez was formally confirmed deceased at 10.06pm.
Police determined that at the time of impact, the Volkswagen had been travelling between 50 and 62 km/h. It was not possible to determine the speed of the Ford at impact.
The drivers of the Volkswagen and Ford both provided a blood samples which did not reveal any substance that would impair their ability to drive a vehicle.
Neither vehicle involved in the collision had any identified mechanical issues that would have caused or contributed to the collision.
According to Senior Constable Roxanne Leishman, Coronial Investigator, the evidence demonstrated Ms Ramirez intended to cross Hopkins Street in a northly direction, which was a direct route to her apartment building. It appears she did not use the pedestrian crossings available in the area as they were out of her way.
Senior Constable Leishman described the relevant section of Hopkins Street as poorly lit and believed that pedestrians would have been less visible to drivers travelling east or west. Due to the time of the evening, poor lighting, wet road surface and Ms Ramirez’s dark clothing, it would have been difficult for the driver of the Volkswagen to see her walking/running across the road in time to react to avoid the collision.
It remains unclear if Ms Ramirez was walking or running at the time she was crossing the road. Several witnesses described her as running. It appears she had her phone in her hand and was wearing earbuds. She may have been distracted whilst looking at her mobile phone and/or listening to music.
I note Senior Constable Leishman described the location at which Ms Ramirez was crossing Hopkins Street as poorly lit. It is an area that is highly populated by pedestrians as it is close to a train station, universities, and student accommodation. Three large apartment blocks have been developed over the last several years with no apparent improvement to the intersection or lighting at the time of Ms Ramirez’s death.
Senior Constable Leishman submitted that the streetlighting in the area need to be upgraded and pedestrian crossing and/or traffic signals be installed at the intersection of Hopkins Street, Moreland Street, and Hallenstein Street.
To better understand the location of the incident and the factors that may have played a role, I attended a “view” of the scene accompanied by a coroner’s solicitor and a member of the Police Coronial Support Unit. Although the view was during daylight hours, the extent of recent development in the area was apparent, as was the sparse placement of street lighting that would have been operating at the time of the incident both to light Ms Ramirez’s way and to provide aid the drivers’ ability to see her crossing Hopkins Street.
Moreover, travelling east on Hopkins Street, through the Whitehall Street intersection and towards Hallenstein Street, the roadway slopes up towards a crest entirely obscuring the drivers’ view of Ms Ramirez for some distance before levelling out shortly before the Hallenstein/Moreland Street intersection where the incident occurred.
My concerns about existing road infrastructure in a what appears to be a population growth area aligned with those of Senior Constable Leishman. To assist my investigation, I made enquiries about planned improvements for safety of pedestrians in the area to prevent similar deaths or significant injuries.
I note the location of the incident was adjacent to the Joseph Road Precinct, which has been undergoing redevelopment of industrial precinct to a mixed-use precinct in recent years. The Joseph Road Precinct Development Contributions Plan (DCP) sets out planned works in the area and who is responsible. Maribyrnong City Council is both the Collecting Agency and the Development Agency under the DCP.
Initial enquiries
Following my request for information on any safety-related improvements made at the collision scene following Ms Ramirez’s death, Senior Constable Leishman contacted the Department of Transport and Planning to confirm whether any safety-related improvements/works had been undertaken in the location of the collision.
Davin Nguyen, Senior Traffic Engineer - Movement and Safety Inner 1, Transport Services, provided an email dated 20 August 2024 to Senior Constable Leishman as follows:
DTP [the Department of Transport and Planning] has implemented a speed limit reduction along Hopkins St to 40km/h between Moore St to Sims St to improve safety for bike riders and pedestrians. Maribyrnong City Council has also recently delivered a series of safety enhancements at the intersection of Joseph Road and Hopkins Street.
In which the primary focus was to improve the safety for pedestrians and cyclists crossing over Joseph Road as they travel along Hopkins Street. This section will be marked as a shared user path. Additional improvements include the relocation of the stop line further north to enhance visibility for drivers, the installation of improved signage, and the remarking of a section of the bike lane.
In addition to the above, DTP along with the Maribyrnong City Council will continue to investigate improvements for cycling along the Hopkins Street and Dynon Road corridor including building setbacks to provide more space for walking and cycling, considering bridge widths and signal timings. Importantly the completion of the West Gate Tunnel and redirection of freight traffic will open significant opportunities to improve this strategic cycling connection.
DTP has reviewed road safety in the vicinity of the pedestrian-operated signal crossing on Whitehall Street near St Monica’s Catholic Primary School. To improve safety for pedestrians, in the first half of 2024, DTP installed additional warning signs and made improvements to line marking which are to reinforce compliant driver behaviour and delivered a safer reduced speed limit of 40 km/h on Whitehall Street between Bunbury Street and Hopkin Street.
DTP will continue to collaborate with Council to review safety along the Joseph Road precinct and Hopkins Street as part of ongoing monitoring of the arterial road network.
On review of the Department’s email, Senior Constable Leishman noted: There is a focus on Joseph Road and Hopkins Street east of Hallenstein Street, for improvements. However, a large number of pedestrians, cyclists and volume of vehicles are entering Hopkins Street at Hallenstein Street from the two large apartment buildings. There was no discussion about improving the lighting on this intersection or safety for vulnerable road users attempting to cross Hopkins Street.
She added that as at 20 August 2024, there had been no further maintenance works carried out on Hopkins Street to improve lighting, pedestrian crossings at Hallenstein Street / Moreland Street, or resurfacing works.
Maribyrnong City Council
Traffic signals and footpath upgrades
Mr Jess noted that detailed design works are currently being undertaken for future traffic signals at the intersection of Hopkins / Hallenstein / Moreland Streets and footpath upgrades along the north side of Hopkins Street.
Mr Jess noted that while Maribyrnong City Council is supporting this design, the Department of Transport and Planning has ultimate responsibility for its implementation.
Streetlighting
Maribyrnong City Council had no knowledge of any lighting upgrades on Hopkins Street as a result of the Joseph Road Precinct development.
However, Mr Jess stated that the detailed design of new traffic signals at the Hopkins / Hallenstein / Moreland Streets intersection will consider public lighting requirements.
Temporary improvements
Temporary line marking had been installed at the Hopkins Street / Joseph Road intersection to improve safety.
Review of designs of the remainder of projects under the Joseph Road Precinct DCP is currently underway.
Community concerns
Mr Jess noted that residents within the high-rise buildings have formed a Joseph Road Precinct Action Group (JRPAG). The JRPAG have expressed broad concerns regarding pedestrian safety and the timing for new traffic signals at the Hopkins / Hallenstein / Moreland Streets intersection.
Mr Jess also noted that there were still three undeveloped land parcels within the Joseph Road Precinct, which will eventually increase the number of people using and living in the area once developed. He explained that full funding of the DCP and associated timing of infrastructure improvements is reliant on these developments progressing over time.
Department of Transport and Planning
Jennifer Howard, Executive Director – Inner Metro, provided a statement dated 5 December 2024, in which she noted the Department does not have any planned works for the relevant section of Hopkins Street.
Clarification on certain points of Ms Howard’s statement was provided by Andrea Malhotra, Principal Lawyer, on 18 August 2025.
Traffic and pedestrian signals
(a) Maribyrnong City Council is responsible for the area from the back of kerb to the property boundary including the footpath; and
(b) Head, Transport for Victoria is responsible for the roadway that is used by through traffic.
(a) signalisation of the intersection of Hopkins Street / Hallenstein Street / Moreland Street; and
(b) pedestrian operated signals over Hopkins Street.
The Joseph Road Precinct DCP details how signals are to be funded and delivered (Maribyrnong City Council is the Collecting Agency and the Development Agency).
However, Ms Howard noted that Maribyrnong City Council had not constructed either of these DCP-funded projects at the time of writing, despite it being five years after the development was permitted to proceed. Maribyrnong City Council is responsible for imposing planning permit conditions to achieve delivery of the signalised intersection works.
Ms Malhotra clarified that works that change the part of road used by through traffic (such as traffic signals) could be funded either by the State or by external parties (Councils and developers). However, in the present case, the Joseph Road Precinct DCP identifies the infrastructure need for signals at Hopkins Street and Hallenstein Street and provides the mechanism for funding (Maribyrnong City Council is the Agency and Development Agency).
Head, Transport for Victoria authorises the use of traffic signals. With regards to signal installations delivered by external parties (that is, developers and Councils), the process involves the Development Agency submitting a Functional Layout Plan and Traffic Signal Plan to Head, Transport for Victoria for review, which when approved, finalises the layout of the proposed works. Following the approval of the Functional Layout Plan, the Development Agency is required to submit relevant detailed designs for approval prior to works being able to proceed.
Maribyrnong City Council has not yet been given approval for the Functional Layout Plan and Traffic Signal Plan because those documents have been assessed as requiring further development to meet road standards. Head, Transport for Victoria will only sight the detailed designs (including streetlighting designs) for the proposed signal installation works once the Development Agency submits compliant designs after Functional Layout Plan and Traffic Signal Plan approval.
Streetlighting
In regard to streetlighting in the area, the current streetlighting is owned and operated by the power distributor – Jemena Pty Ltd.
The Department of Planning and Transport undertook a site-based assessment of streetlighting in November 2024 and determined the existing streetlighting conditions (as at the time of
Ms Howard’s statement), which are believed to have been installed several decades ago, do not conform with current relevant standards.
Although there is no legislative requirement to upgrade the infrastructure due to the development of adjacent land use, the assessment recommended that the infrastructure should be upgraded to meet modern standards. Ms Howard noted that elements of the streetlighting at locations such as Hopkins Street are expected to be upgraded as part of road improvement projects.
As a referral planning authority, the Department of Transport and Planning is accountable for assessing the impact of development on the safety and operation of arterial roads. The Department can include planning permit conditions for developers to undertake works to mitigate the impact of development and maintain a safe and efficient road network for all road users.
Streetlighting is considered during the detailed design stage of all road improvement projects, including those that are proposed to be delivered as part of the Joseph Road Precinct DCP.
Any lighting upgrades determined during the detailed design stage will be included in the approved designs, which are then delivered to the satisfaction of the Department of Planning and Transport.
The installation of traffic signals at the intersection of Hopkins Street and Hallenstein Street, as part of the Joseph Road Precinct DCP, requires streetlighting at the intersection and on the approaches to the intersection to be upgraded to current relevant standards.
Ms Malhotra further explained that the Department of Transport and Planning provides guidance as to where Head, Transport for Victoria shall provide road lighting on arterial roads, which includes (but is not limited to) locations with roundabouts, traffic signals, zebra or signalised pedestrian crossings. However, lighting for the benefit of service roads, footpath pedestrian traffic, security, and the amenity of adjacent land use, are the responsibility of councils.
The responsible road authority may install street lighting on roads or parts of roads where it is the coordinating road authority or responsible road authority to the extent and in a manner which it considers appropriate having regard to its road management functions. However, Head, Transport for Victoria does not perform the functions of a responsible road authority with respect to lights on an arterial road that are operated by an electricity distribution
business. But, Council may initiate the installation of lighting for an arterial road, provided Council funds the installation work.
Temporary improvements
(a) the identity of the deceased was Frances Jeyann Ramirez, born 3 November 2001;
(b) the death occurred on 25 November 2023 at corner of Hopkins Street and Hallenstein Street, Footscray, Victoria;
(c) the cause of Ms Ramirez’s death was multiple injuries sustained in a motor vehicle incident (pedestrian vs. car); and
(d) the death occurred in the circumstances described above.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.
The location at which Ms Ramirez sustained her fatal injuries has dramatically changed in recent years. The precinct – encompassing Whitehall Street, Hallenstein Street, Joseph Road, Moreland Street, and Hopkins Street has undergone major development with a number of apartment buildings being erected in the area, with some yet to be finalised. With this development has come a significant increase in pedestrian and road traffic.
The Department of Transport and Planning has indicated the existing streetlighting does not conform with the relevant standards.
For whatever combination of reasons, the upgrade of traffic signals, pedestrian crossings, and streetlighting has lagged behind development in the area.
The upgrade and implementation of safety improvements in the area needs immediate attention in the interests of improved pedestrian safety.
Maribyrnong City Council referred to design works for future traffic signals at the intersection of Hopkins / Hallenstein / Moreland Streets and footpath upgrades along the north side of Hopkins Street. And that a detailed design of new traffic signals at the Hopkins / Hallenstein / Moreland Streets intersection will consider public lighting requirements.
However, while Council has developed a concept for these improvements, little if anything has been done to address the safety of the growing population in that area. Maribyrnong City Council’s Functional Layout Plan and Traffic Signal Plan – which sets out the layout of signal installations and streetlighting designs – is yet to be approved as the documents require further development.
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following recommendations:
That Maribyrnong City Council immediately prioritises the Joseph Road Precinct DCP Functional Layout Plan and Traffic Signal Plan for approval by Head, Transport for Victoria.
That Maribyrnong City Council and Head, Transport for Victoria work together to urgently prioritise the design, approval, and implementation of upgrades to signalling and streetlighting
along Hopkins Street, Footscray, where it intersects with Whitehall Street, Hallenstein/Moreland Streets and Joseph Road.
I convey my sincere condolences to Ms Ramirez’s family for their loss.
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: Mayne and Jay Ramirez, senior next of kin Jeroen Weimar, Secretary, Department of Transport and Planning/ Head, Transport for Victoria Celia Haddock, Chief Executive Officer, Maribyrnong City Council Senior Constable Roxanne Leishman, Victoria Police, Coronial Investigator Signature: ___________________________________ Deputy State Coroner Paresa Antoniadis Spanos Date: 02 October 2025 Re-signed: 10 December 2025 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.
3 ‘Maribyrnong City Council’ amended to ‘Head, Transport for Victoria’ pursuant to section 76 of the Coroners Act 2008 (Vic).
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