Inquest into the deaths of Noah and Wayne Smith

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the deaths of Noah Smith and Wayne Smith Hearing dates: 10-13 and 16 June 2025 Date of findings: 30 March 2026 Place of findings: Coroners Court of NSW, Lidcombe Findings of: State Coroner, Judge Teresa O’Sullivan Catchwords: CORONIAL LAW – filicide – intentional self-harm – domestic and family violence – use of licensed firearm – history of anxiety and depression – NSW Firearms Registry – revocation of firearms licence on grounds of mental health concerns and seizure of firearms – subsequent reinstatement of firearms licence and return of firearms File number: 2023/176593; 2023/176635 Representation: Counsel Assisting: Donna Ward SC and Tracey Stevens, instructed by James Prindiville of the Crown Solicitor’s Office Counsel for the Commissioner of the NSW Police Force: Rob Bhalla, instructed by Stuart Robinson of the Office of the General Counsel, NSW Police Force Counsel for Dr David Hope: Ben Bradley, instructed by Suzanne Wallace of Moray & Agnew Counsel for Dr Fiona Couper: Teni Berberian, instructed by Sarah Stevens of Unsworth Legal Counsel for Dr Stewart Hase: Jess Chapman, instructed by Summer Dow of Barry Nilsson Lawyers Protective orders: Non-publication orders have been made. A copy of these orders can be found on the Registry file.

Publication order: In accordance with s 75(5) of the Coroners Act 2009 (NSW), I make an order permitting the publication of a report of the proceedings as I consider that it is desirable in the public interest to permit a report of the proceedings of the inquests to be published.

Findings in relation Identity to Noah Smith: The person who died was Noah Smith.

Date of death He died on 1 June 2023.

Place of death He died at 23 Kookaburra Court, Yamba NSW 2464.

Cause of death The cause of death was a gunshot wound to the head.

Manner of death The gunshot wound to the head was inflicted by a person known to him.

Findings in relation Identity to Wayne Smith: The person who died was Wayne Smith.

Date of death He died on 1 June 2023.

Place of death He died at 23 Kookaburra Court, Yamba NSW 2464.

Cause of death The cause of death was a gunshot wound to the head.

Manner of death The gunshot wound to the head was intentionally self-inflicted.

Recommendations: To the Minister for Police and Counter-terrorism and the Commissioner of Police, I recommend that:

1. Consideration be given to statutory reform enabling amendment of processes within the Firearms Registry so as to require applicants seeking the re-issue of a firearms licence on the basis of recreational hunting/vermin control to demonstrate current permission from a landowner at time of renewal.

2. The Firearms Registry additionally consider steps to improve the rigour of the information required in support of an application or re-application for a firearms licence in reliance upon recreational hunting/vermin control as the genuine reason for the issue of the licence.

3. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss how GPs can be encouraged to routinely ask patients if they have a firearms licence (just as they might ask whether patients have a driver’s licence).

4. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the NSW Ministry of Health, the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss the possibility of introducing a statutory obligation requiring health practitioners to report to Police if they have safety concerns for a patient who is a firearms licence holder.

5. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to requiring any applicant for the issue/re-issue of a firearms licence who has experienced suicidal ideation in the previous five years, provide a Mental Health Risk Assessment from two separate assessors (preferably their current treating GP and separately a psychiatrist or psychologist).

6. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to statutory reform that enables the reassessment of licence holders as an alternative to relying upon the imposition of special conditions to firearms licences.

7. Consideration be given to statutory reform enabling the introduction of criteria to demonstrate a ‘good reason’ to acquire additional firearms.

Contents

INTRODUCTION 1 THE ROLE OF THE CORONER 1 BACKGROUND FACTS AND EVIDENCE 2 ISSUES FOR CONSIDERATION 2 ISSUE 1 – WAYNE SMITH’S LONG TERM HISTORY OF DEPRESSION AND SUICIDAL IDEATION LEADING TO MEDICAL AND PSYCHOLOGICAL INTERVENTION IN MID-2020 AND FOLLOWING 3 (A) RECORD-KEEPING 3 (B) TREATMENT PROVIDED BY DR HOPE UP UNTIL APRIL 2020 5 (C) TREATMENT PROVIDED BY DR HOPE AND THE GRAFTON COMMUNITY MENTAL HEALTH SERVICE IN MID-2020 6 (D) REFERRAL TO DR HASE AND DR HASE’S SUICIDE RISK ASSESSMENT IN MID-2020 7 (D) WAYNE’S TWO FURTHER APPOINTMENTS WITH DR HASE IN 2020 9 (E) WAYNE’S APPOINTMENT WITH DR HASE ON 24 AUGUST 2021 11 (F) WAYNE’S MENTAL HEALTH TREATMENT FROM NOVEMBER TO DECEMBER 2021 12 (G) CONCLUDING REMARKS ABOUT THE TREATMENT PROVIDED BY DR HOPE 12 (H) WAYNE’S MENTAL HEALTH TREATMENT PROVIDED BY DR COUPER IN JUNE - JULY 2022 13 ISSUE 2 - A FURTHER ACCUMULATION OF STRESSORS IN THE MONTHS LEADING UP TO MAY 2023 (A) THE STRESSORS BETWEEN SEPTEMBER 2022 AND MAY 2023 13 (B) APPOINTMENT WITH DR COUPER ON 10 MAY 2023 15 (C) WAYNE’S CONTACT WITH HUNTERLINK ON 23 MAY 2023 15 (D) WAYNE’S APPOINTMENT WITH DR COUPER ON 24 MAY 2023 AND THE QUESTION OF HOSPITALISATION AND AVAILABLE COMMUNITY AND HOSPITAL-BASED OPTIONS FOR MENTAL HEALTH TREATMENT 16 (E) ASKING PATIENTS ABOUT ACCESS TO FIREARMS 18 ISSUE 3 – NOAH’S MENTAL HEALTH AND EXPOSURE TO HIS FATHER’S ILLNESS 18 ISSUE 4 – THE MEDICAL AND PSYCHOLOGICAL EVIDENCE PROVIDED IN SUPPORT OF WAYNE’S APPLICATION TO HAVE HIS FIREARMS LICENCE REINSTATED AND HIS FIREARMS RETURNED TO HIM, AND WHETHER THE EVIDENCE IN SUPPORT WAS REASONABLY BASED 19 (A) THE MEDICAL CERTIFICATE DATED 24 AUGUST 2021 19 (B) THE REPORT OF DR HASE TO THE FIREARMS REGISTRY DATED 1 DECEMBER 2021 21 ISSUE 5 – THE REASONING BEHIND THE DECISION OF THE NSW FIREARMS REGISTRY TO REINSTATE WAYNE SMITH’S FIREARMS LICENCE IN OCTOBER 2022 AND SUPPORT THE RETURN OF HIS FIREARMS IN DECEMBER 2022 22 ISSUE 6 – SINCE MAY 2023, WHAT, IF ANY, CHANGES HAVE BEEN MADE TO THE NSW FIREARMS REGISTRY’S REGIME OF ASSESSING A PERSON’S SUITABILITY TO POSSESS FIREARMS? 25 (A) FIREARMS STATISTICS IN NSW AND AUSTRALIA 25 (B) GENUINE REASONS FOR HAVING A FIREARMS LICENCE 26 (C) WAYNE’S PREVIOUS NON-DISCLOSURE TO THE FIREARMS REGISTRY ABOUT HIS HISTORY OF MENTAL ILLNESS 27 (D) CHANGES TO THE FIREARMS REGISTRY SINCE NOAH’S AND WAYNE’S DEATHS 27

FINDINGS 30 RECOMMENDATIONS 31 CONCLUSION 35 ANNEXURE A 36

INTRODUCTION

1. This inquest concerns the deaths of Noah Smith and his father, Wayne Smith. This case involves a parent killing a child – an act known as filicide. Noah was shot by his father, Wayne, who then shot himself.

2. Noah was 15 years old when he died on 1 June 2023. Noah was a much-loved Son, Grandson, and friend who lived an active and full life. From an early age, Noah enjoyed spending time outdoors and took part in a wide range of sports, including motorcross racing, go-karting, basketball, rugby, golf, and soccer. As he grew older, he developed a keen interest in fishing and boating – passions shared by his family. Noah is remembered as a caring, affectionate, and loyal young person who was deeply connected to his Grandparents, his Mum, and his Dad.

3. Wayne was 58 years old when he died on 1 June 2023. He too was a much-loved son who had the support of a committed family and close friends. Wayne had a longstanding history of depression and in the period leading up to 1 June 2023 was experiencing a complex constellation of psychosocial stressors alongside a significant deterioration in his mental health. These pressures profoundly affected his coping capacity and daily functioning despite the considerable efforts of those around him to provide care and assistance.

4. Wayne’s deteriorating mental health necessarily affected Noah and there were times when Noah assumed responsibilities and emotional burdens beyond what would ordinarily be expected of a young person. While Wayne’s behaviour clearly had an impact on Noah, it reflected the significant challenges he was experiencing and was not driven by any intention to harm or distress his son. Importantly, there was no evidence of intentional coercion, maltreatment, or prior violence of the kind frequently observed in filicide cases. The available evidence indicates that Wayne loved and cared for Noah throughout his life, that they shared a close and loving bond, and that the events of 1 June 2023 occurred in the context of an acute and escalating mental health crisis.

THE ROLE OF THE CORONER

5. Pursuant to s 81 of the Coroners Act 2009 (NSW) (the Act), the role of the coroner is to make findings as to the identity of the deceased person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death.

6. Under s 82 of the Act, a coroner may also make recommendations arising from the evidence in relation to matters that have the capacity to improve public health and safety in the future. I considered a number of proposed recommendations in these inquests, which I refer to below.

BACKGROUND FACTS AND EVIDENCE

7. The Court took evidence over four hearing days. The Court also received extensive documentary material in a three-volume brief of evidence as well as additional exhibits that were tendered during the course of the hearing.

8. Prior to and during the hearing, counsel assisting drafted a comprehensive chronological summary of the key facts concerning these deaths that was based on the evidence before the Court. Following the hearing, this document was updated with suggested additions from the parties. I attach a copy of that document as an annexure to these reasons (Annexure A) and I adopt its content as a set of Agreed Facts.

ISSUES FOR CONSIDERATION

9. A list of issues to be considered at the Inquests was prepared and circulated to the parties on 17 April 2025 before the commencement of the hearing. The issues identified in that list were as follows: Issue 1: Wayne Smith’s long term history of depression and suicidal ideation leading to medical and psychological intervention in mid-2020 and following; Issue 2: A further accumulation of stressors in the months leading up to May 2023; Issue 3: Noah’s mental health and exposure to his father’s illness; Issue 4: The medical and psychological evidence provided in support of Wayne’s application to have his firearms licence reinstated and his firearms returned to him, and whether the evidence in support was reasonably based; Issue 5: The reasoning behind the decision of the NSW Firearms Registry to reinstate Wayne Smith’s firearms licence in October 2022 and support the return of his firearms in December 2022; and Issue 6: Since May 2023, what, if any, changes have been made to the NSW Firearms Registry’s regime of assessing a person’s suitability to possess firearms.

Issue 1 – Wayne Smith’s long term history of depression and suicidal ideation leading to medical and psychological intervention in mid-2020 and following

(a) Record-keeping

10. One issue that was explored in these proceedings was the quality of the clinical records of both Dr Hope (Wayne’s GP from the 1980s to November 2021) and Dr Hase (Wayne’s psychologist in 2020 and 2021).

11. Dr James Jeong, general practitioner who was engaged by the Court as an expert in these proceedings, was critical of Dr Hope’s record-taking and clinical notes, stating that the notes had “no sense of ‘individuality’ or anything that reflects ‘personal attention’ in any of the consultations”.

12. Counsel assisting submitted that Dr Hope’s record-keeping in relation to Wayne was very poor, noting that he used prompts on his computer program to list the presence and/or absence of listed symptoms or signs but rarely explained within his notes anything personalised to Wayne (such as likely triggers for deterioration in his presentation, the severity of symptoms, the response to medication, or other plans for his care).

13. It was further submitted that the clinical records in relation to Wayne were generic in nature and that Dr Hope was overly reliant on his memory of things that were discussed at previous appointments with Wayne.

14. Dr Hope’s evidence was that he was a very busy practitioner until Dr Couper joined his practice and that he had many other patients who he had seen over a long time, such as Wayne. The Court also heard evidence that as at 2022 there were approximately 2400 patients (shared between two general practitioners) on the books at Dr Hope’s practice.

15. Counsel assisting submitted that given memories can be fickle, the taking of contemporaneous and adequate notes is important and that these notes are essential in allowing other practitioners (such as a locum doctor, a new doctor to the practice, or an allied health professional) in understanding something about a patient’s history. Dr Hope acknowledged that had more detail been set out in his clinical notes, it would have been easier for later practitioners such as Dr Couper to understand Wayne's long and personal history.

16. An example of the inadequate history recorded in Dr Hope’s notes was the referral letter he wrote to Dr Hase on 21 July 2020. The “past history” on the first page of that

letter only included the period of 2004 to 2009, which meant that there was no history provided for the intervening eleven years. This also meant that the very important events in May 2020 concerning Wayne’s threat of suicide were omitted from that letter.

While Dr Hase gave evidence that he did not in fact receive this letter, it is accepted that the same history was repeated in the letters of referral that Dr Hope wrote in relation to Wayne. Counsel for Dr Hope conceded that the threat of suicide in May 2020 which precipitated Wayne’s referral to the Grafton Community Mental Health Service was relevant information that should have been listed in the referral letter.

17. Counsel assisting also queried whether Dr Hope knew how to fully use the software package to auto-populate an up-to-date list of past history summaries. On a related point, counsel for Dr Hope disagreed with Dr Jeong’s opinion that Dr Hope’s clinical notes were cut and paste from previous records, noting that while the notes are consistent in presentation or format, they do vary as to when Wayne presented with new symptoms. Dr Hope explained in his statement that when managing a patient with a mental health presentation, he would run through the prompts in the MyDoctor program and record the presence of symptoms as reported by the patient. While Dr Jeong accepted this as a reasonable practice, he stressed the importance of individuality in the notes which would assist those reading the notes and remove the need to rely solely on memory.

18. Dr Hope did not dispute counsel assisting’s submission that his clinical notes could have and should have had more detail. Counsel for Dr Hope did, however, submit that the lack of detail in the notes does not reflect the level of care that Dr Hope, in fact, provided Wayne over the years.

19. Counsel for Dr Hope also noted that Dr Hope’s practice was accredited by the Accredited General Practice Accreditation Limited, which had not raised any criticism about his clinical notes during the accreditation process.

20. On this issue of Dr Hope’s record-keeping, it is apparent that Dr Hope’s notes were not thorough enough and I accept Dr Jeong’s criticism that the record-keeping was poor. It was an appropriate concession from Dr Hope that his clinical notes could have and should have had more detail as this would have been beneficial to new doctors (such as Dr Couper). I also accept that Dr Hope was a caring doctor who provided an important support to Wayne over the many years he visited Dr Hope.

21. I turn now to consider the issue of Dr Hase’s record-keeping. Dr Hase gave evidence before the Court and he also provided a helpful statement in the week preceding the

hearing. Dr Hase was a good witness who made appropriate concessions and whose evidence was helpful in informing the recommendations that I will ultimately make.

22. In relation to his records, Dr Hase readily conceded in response to the criticism made of him by Dr Alison O’Neill, clinical psychologist engaged by the Court, that he did not take adequate clinical notes of his consultations with Wayne. Dr Hase explained that he has since improved his clinical practice with his note-taking.

23. I consider this concession to be entirely appropriate and Dr Hase’s evidence about his improved clinical practice was positive.

(b) Treatment provided by Dr Hope up until April 2020

24. The evidence demonstrated that Wayne experienced chronic depression with anxiety and that while he was prescribed antidepressant medication since at least 2004, he was not in a perpetual state of crisis. According to the limited records of Dr Hope and broadly supported by the evidence from Wayne’s family and friends (and some of the other treating professionals), Wayne seemingly had periods of stable mood.

25. In relation to Wayne’s deterioration in his depression in early 2006, Dr Hope changed Wayne’s medication to Effexor XR 75mg, which was titrated upwards to 150mg until Wayne’s mental state had stabilised. Dr Hope sought to engage a psychiatrist, Dr George, and also provided Wayne with counselling, which Dr Jeong accepted were appropriate steps. Following the fluctuation in Wayne’s mental state in 2006, Dr Hope documented symptoms of depressed mood and poor sleep. Wayne's mental state and presentation appears to have remained stable with medication. I accept that this indicated that Dr Hope was providing responsive care during that period.

26. According to Dr Hope, it was not until early 2018 that there was a change in Wayne’s symptoms. In his statement, Dr Hope indicated that the change in symptoms occurred when Wayne presented with new anxiety symptoms, panic attacks, and irrational fears.

While these new symptoms are recorded in Dr Hope's notes, the notes do not include details about these symptoms.

27. Dr Hope then changed Wayne's medication; first, by trialling Pristiq and, second, when that did not give the result he wanted, by introducing Avanza and Lexapro. In tandem with his pharmacological management, Dr Hope also called in support from a psychologist, Ms Potappel, in 2018. Dr Hope's referral letter stated that the stressor at that time was work stress and Dr Hope documented that Wayne was wondering if his

job was stable. Dr Hope also identified various protective factors, including "Living with wife and son. Sleep is okay. Interests include fishing and outdoor things."

28. Counsel for Dr Hope submitted that the titration of medication, frequent counselling as set out in his clinical notes, and engagement of special mental health practitioners were all appropriate measures that were responsive to Wayne's change in presentation in early 2018.

29. Furthermore, when Wayne returned to see Dr Hope in April 2020 following the death of his father in 2019, Dr Hope attempted to engage a psychologist for Wayne.

However, Wayne refused this and Dr Hope then provided Wayne with counselling in a “long consultation”. Counsel for Dr Hope submitted that these were appropriate and responsive steps taken by Dr Hope.

30. I accept that Dr Hope provided adequate care during this period of 2018 to April 2020.

(c) Treatment provided by Dr Hope and the Grafton Community Mental Health Service in mid-2020

31. When Wayne was at his baseline, he was well enough to go to work, go fishing with Noah, meet up with his friends, see his mother, and generally get on with things. The evidence demonstrates that Wayne also had periods where his mood deteriorated and he became extremely unwell, sometimes in response to traumatic life events. This is what happened in May 2020 which, according to Wayne, was the worst he had felt since the onset of his depression (which he linked back to an accident with the lawn mower in the early 2000s).

32. In May 2020, Wayne was having thoughts of hurting himself every day and he had a plan to hang himself. He expressed that he wanted the emotional pain, despair, and anxiety to stop and that he felt hopeless about the possibility of change.

33. Wayne managed to get help. He was put on new medication and he had some regular support from the Acute Care Service (ACS) through the Grafton Community Mental Health Service along with Dr Hope. It is probable he had greater support from his family and friends, as they recognised and responded to the crisis in Wayne’s mental health.

34. Wayne started to report an improvement in his mood. This is observed in the ACS records on 17, 20, and 30 May 2020 and was corroborated by what Noah’s Mother said to the ACS on 30 May 2020. Wayne’s improved mood was also recorded in the ACS notes from 8, 21, and 22 June 2020, as well as from 3 July 2020, when the ACS decided it was time to close their period of care with Wayne. In the discharge letter, it

was noted that Wayne's mental state and mood had improved, he had nil further acute mental health risks at this time, and that Wayne reported that he was well-supported by Dr Hope.

35. Counsel for Dr Hope highlighted that, consistent with the advice of Dr Abass (psychiatrist at the ACS), Dr Hope maintained the medication recommendations of the ACS, including prescribing Lithicarb. Dr Hope requested surveillance pathology (including of lithium levels) and he also made referrals for a psychologist and a psychiatrist, which would have required Dr Hope to prepare a mental health plan in accordance with the Medicare requirements in place at the time.

36. The slow improvement in Wayne’s mood is further corroborated by the things that Noah said to his school counsellor on 24 June 2020, such as “Dad’s getting better I think. He’s getting up and going fishing and doing things again.”

37. On 3 July 2020, Dr Hope spoke with a registered nurse at the Grafton Community Mental Health Service and informed her that there were “nil acute mental health risks identified” when Dr Hope saw Wayne two days earlier and that Dr Hope was agreeable to providing ongoing supports.

38. It is apparent that Wayne’s improvement did not track in a neat line – there were still good days and some very bad days. For instance, the records indicate that on 21 July 2020 Wayne was still reporting that he was not coping with everyday life during a phone consult to Dr Hope. However, the overall trend was one of slowly improving mood. Despite these small improvements, when Wayne first saw Dr Hase on 12 August 2020, Dr Hase thought that Wayne was suffering from a major depressive disorder.

39. On 18 August 2020, Wayne had a consult with a psychiatrist, Dr Scurrah (with Dr Hope sitting in). According to the records, Wayne told Dr Scurrah he was no longer suicidal.

Dr Scurrah’s assessment was one of chronic depression with anxiety. Dr Scurrah advised Wayne to stay on his medication and continue with counselling and reviews with Dr Hope.

40. I find that the treatment and care provided to Wayne during this period by Dr Hope and the ACS was appropriate.

(d) Referral to Dr Hase and Dr Hase’s suicide risk assessment in mid-2020

41. The referral letter from Dr Hope to Dr Hase dated 21 July 2020 stated:

“I seek your opinion regarding Counsel please under the medicare funded mental health scheme. Long standing depression on and off. Loss of father; grief. Difficulty coping with everyday life. Requires psychological support.”

42. There was no reference within the referral letter to the threat of suicide in May 2020 and the urgent involvement of the ACS, which had only concluded a couple of weeks earlier. Nor was such detail provided within the GP management plan that accompanied the referral letter. As noted above, Dr Hope accepts that the events of May 2020 should have been communicated to Dr Hase in the referral letter.

43. It is apparent that Dr Hase did not have the full picture from Dr Hope and he did not obtain the full picture from Wayne. Nevertheless, Dr Hase seems to have established a good rapport with Wayne at intake and over two further sessions in 2020, obtaining a history from Wayne but not the full history. Dr Hase was aware Wayne had experienced suicidal ideation and depression and he was also aware that Wayne’s care of Noah was a protective factor in guarding against suicide.

44. At the first session with Dr Hase, Wayne was tearful, agitated, and very depressed in affect, thought, and action. Dr Hase was grateful that Wayne was already seeing a psychiatrist because, in Dr Hase's opinion, Wayne needed a satisfactory chemical solution. Wayne also told Dr Hase he was feeling a little bit better on lithium.

45. Dr Hase assessed Wayne's risk of suicide at the intake session. Dr Hase explained his process to the Court: "I use a fairly standard approach to suicide assessment, and that is to ask certain questions about previous attempts at suicide, thoughts of suicide, preventative actions… Like in Wayne's case, he referenced his son as something that would stop him from committing suicide."

46. Dr Hase said he considered levels of agitation and impulsivity, which are fairly standard questions regarding suicide assessment that he commonly uses in his practice.

47. Following this approach, Dr Hase assessed Wayne's risk of suicide at the first appointment in mid-2020 as low. Dr O'Neill was critical of Dr Hase's approach to that suicide risk assessment, even in light of the limited information provided to him on referral. In her view, Dr Hase should have undertaken a more comprehensive suicide risk assessment with more structured questions and use of psychometric tests.

48. Counsel for Dr Hase submitted that the questions that Dr Hase would have asked Wayne as part of the assessment were pointed enough to reveal a full history (if Wayne

had wished to or been willing to provide that information), that Dr Hase was ultimately at the mercy of Wayne as to how and how much information was disclosed, and that no paper questionnaire or psychometric tests would have changed that.

49. Counsel for Dr Hase also referred to Dr Jeong’s evidence that the style and approach of practitioners in eliciting a mental health history is not one-size-fits-all and that a practitioner is ultimately at the mercy of the patient as to what they will or will not reveal to the practitioner.

50. Dr Hase readily accepted that Wayne's crisis in May 2020 and his threat to end his life by hanging himself were very important pieces of information that he would have factored into his risk assessment if he had known about them. Dr Hase said that this information: "would have changed, probably changed my tack and my plan in seeing Wayne. It would have made me realise it's a much more serious issue than I was aware. That would have been…very helpful."

51. Dr Hase also agreed that it would have been important and very useful to know that Dr Abass had assessed Wayne on 15 May 2020 and considered that Wayne was at medium risk of suicide in the long-term.

52. On this issue, I consider that it was a major failing that the events of May 2020 were not included in the referral letter to Dr Hase and that it is likely that this information would have changed his assessment. I accept Dr Jeong’s evidence about the varying styles of practitioners and I am not critical of the approach that was ultimately taken by Dr Hase in conducting the assessment.

(d) Wayne’s two further appointments with Dr Hase in 2020

53. Dr Hase commenced some cognitive behaviour therapy exercises with Wayne and provided a level of support which Wayne referred to in his later assessment with Dr Scurrah after having attended only one appointment with Dr Hase (Dr Scurrah’s notes referred to the session with Dr Hase having been useful, noting that Wayne said that “Stewart helps”).

54. On 26 August 2020, Wayne had his second appointment with Dr Hase. Dr Hase thought that Wayne had shown some serious improvement, noting that he was fishing (an important recreational activity for Wayne) and he was going out with friends. It appears that Wayne was getting back to some of his normal activities.

55. On 16 September 2020, Wayne had his third appointment with Dr Hase. By this time, his mood appears to have improved and he spoke of enjoying work, going out, and doing things with Noah. Wayne indicated that the medication was having a positive effect. Dr Hase did not consider Wayne to have been experiencing any depressive episode and he thought that the medication was effective.

56. The importance and the challenge of sharing comprehensive clinical information between health practitioners was demonstrated in Dr Hase's oral evidence. When asked about an opportunity to discuss Wayne with Dr Hope, Dr Hase said: "Well, there wasn't an opportunity. Perhaps we could have done. Primary health care in this field is…it's seen as being a team approach, but sometimes getting the team together can be difficult and getting people to be able to talk. But yes, I could see that that could have been useful."

57. Counsel assisting emphasised how rarely opportunities arise to get the team together in primary healthcare to talk about a common patient.

58. It is unfortunate that Wayne only attended three sessions with Dr Hase in 2020. In his evidence, Dr Hase explained that one of the problems in ensuring the continuity of engagement with patients seeking mental health support was that psychology is often seen as problem-based by patients (meaning that people only come to see him to deal with "a problem"). Dr Hase said: "But what happens sometimes is – and I think this is what happened in this case – is that the person starts to feel better because their problem is now resolved, and so they're feeling better. They might still have underlying MDD [Major Depressive Disorder] which certainly he had, but they're feeling better, so that they disengage."

59. On this point, counsel assisting submitted that Dr Hase’s evidence is accurate because Wayne was starting to feel better off a low base (in May 2020) and, as a result, he did not continue to see Dr Hase and Dr Hase did not press for further appointments.

Dr Hase directed the Court to recent literature on the average engagement of a patient in Australia under the Better Access Scheme, which indicated that the average is around four to five sessions with a psychologist.

60. Dr Hase conceded that Wayne required a significantly longer than average engagement with a psychologist to address and manage his underlying long-term depression. On this point, Dr O'Neill said that: "So even though three or four sessions may be sufficient for somebody with a mild depressive episode without a longstanding history and without suicidal ideation, it

certainly would not be adequate, I would not think, for somebody with longstanding severe depression and with suicidal ideation.”

61. Counsel assisting also commented that that suicidal ideation can be fleeting and it can come and go at almost opportunistic moments.

62. Counsel for Dr Hase submitted that the treatment he provided to Wayne was thorough and effective in circumstances where Dr Hase had addressed Wayne’s biggest reported stressors (death of his father and work stress with having to use computers) to assist Wayne to improve his mood. His counsel also submitted that the decision to end treatment after three sessions with Wayne was appropriate in circumstances where, in light of Wayne’s previous limited interactions with Ms Potappel and Dr Scurrah, Dr Hase did well in achieving three sessions with Wayne in 2020 and that it was ultimately up to Wayne to return for more help. In this respect, Dr Hase refers to his note that “If you have any symptoms at all, please return”.

63. I consider that the level of care provided by Dr Hase in these appointments was appropriate. It was entirely appropriate for Dr Hase not to insist on Wayne attending more appointments and to leave it open to Wayne to come back for a further appointment.

(e) Wayne’s appointment with Dr Hase on 24 August 2021

64. Following the third appointment with Dr Hase in September 2020, there was a long gap in the medical records. There is no clear picture of Wayne’s progress other than any inference that might be drawn from an absence of crisis or complaint.

65. Wayne did not see Dr Hope again until 24 August 2021, which was over a year after his last consultation with Dr Hope and 11 months after his most recent consultation with Dr Hase. While Dr Hope’s records show that scripts were issued for Wayne on 21 December 2020 and 17 June 2021, there were no actual consultations. It is unclear whether there was any discussion between Dr Hope and Wayne on those dates. Dr Hope gave evidence that it was usual practice to call patients who wanted repeat scripts to see how they were going and whether they needed a face-to-face consult.

There are, however, no details of the phone calls in the clinical notes.

66. Dr Hope accepts the criticism that there are no details of the phone calls in the clinical notes. I consider that as there are no notes of those phone calls taking place, it cannot be confirmed that Dr Hope did speak to Wayne.

67. It appears that the 24 August 2021 consultation with Dr Hope was prompted by Wayne's need for a medical certificate supporting the return of his firearms (which had been seized by police on 19 August 2021), rather than because of any deterioration in his mood. The reason for contact recorded in the medical records refers to "A past history of anxiety and depression controlled." Counsel for Dr Hope submitted that this consultation appears to have been for “getting back to his old self” and that the assessment that Wayne’s anxiety and depression was “controlled” was accurate in light of Wayne’s later presentation to Dr Couper in June and July 2022 (when Dr Couper documented that Wayne’s mood was well-controlled and there was no need to change his medications). I accept that submission.

68. I consider that Dr Hope was put at a real disadvantage when Wayne failed to tell him the reason for the consultation. Had Dr Hope known the truth, this might have prompted more questions from him.

(f) Wayne’s mental health treatment from November to December 2021

69. On 23 November 2021, Wayne had his last appointment with Dr Hope. This was apparently related to physical health complaints. There are no clinical notes recorded for that entry and the plan was focused upon a colonoscopy.

70. In December 2021, Wayne saw Dr Hase for the purpose of a report requested by the Firearms Registry. Dr Hase thought that Wayne was very upbeat, in control of his anxiety, sleeping well, taking his medication regularly, and he had a positive mood.

71. Counsel assisting submitted that by this time there seems to have been a slow improvement in Wayne's mood since the May 2020 crisis and that this state seems to have persisted. In a similar vein, Counsel for Dr Hase submitted that in the period where Dr Hase saw and treated Wayne in mid-2020 to when he saw him in December 2021, the evidence indicates that Wayne was stable and had rebounded from what had happened in May 2020.

72. In my view, the level of care provided to Wayne during this period was appropriate.

(g) Concluding remarks about the treatment provided by Dr Hope

73. Wayne felt well supported by Dr Hope. Wayne consulted Dr Hope for many years and relied upon him for a level of counselling from time to time. Counsel for Dr Hope agreed that Dr Hope was actively involved in caring for Wayne for many years, managing his symptoms as they arose. I accept that the evidence established that Dr Hope was aware of the relevant stresses in Wayne’s life (such as the lawnmower incident, the

death of Wayne’s father, and the breakdown of his marriage) and that Dr Hope provided counselling to Wayne about this.

74. Dr Hope was a support for Wayne for many years and he provided a level of counselling to Wayne. However, as mentioned above, his note-taking was inadequate (which he conceded, to some extent).

(h) Wayne’s mental health treatment provided by Dr Couper in June - July 2022

75. Dr Couper took over Dr Hope’s practice in January 2022. She gave evidence at the hearing and was a good witness who gave helpful evidence.

76. Dr Couper first saw Wayne on 14 June 2022 and recorded that Wayne’s mood was stable. At the appointment, she also arranged for pathology testing to check Wayne’s lithium levels.

77. Dr Couper saw Wayne again on 12 July 2022. By this time, Wayne had completed some blood pressure readings at home just as Dr Couper had asked and they discussed typical physical health matters for a man of Wayne’s age. Dr Couper also went through Wayne’s pathology results, which showed that Wayne’s lithium level was below the therapeutic range. As Wayne indicated that his mood was well-controlled by his medication, Dr Couper did not consider it necessary to change his medication.

78. I accept the evidence of Dr Couper that one prescribes according to the response of the individual patient rather than any need to meet a particular therapeutic level on pathology. In this respect, Wayne's improved mood that followed the introduction of the lithium in May 2020 (and which may have been due to other factors as well) seems to have continued to at least July of 2022.

79. I consider that Dr Couper provided a good service to Wayne and she was very thorough in her treatment.

Issue 2 - A further accumulation of stressors in the months leading up to May 2023

(a) The stressors between September 2022 and May 2023

80. In September 2022, Noah was very badly injured in a boating accident. He was scared and he was in pain. He could not be operated on close to home and needed to go to Newcastle. Almost in parallel to this, NSW Police were conducting an investigation about the accident and interviewing Noah whilst he was still in hospital. Wayne was also dealing with intrusions from a local Boating Safety Officer.

81. One of the most serious things that happened at this chaotic time was that Wayne did not take his medication with him when the family travelled to John Hunter Hospital where Noah was being treated. It is easy to imagine how that this could have happened as Wayne was hurrying to pack some belongings and get out the door. The lithium had been an important part of Wayne's improvement in 2020 and its absence was probably an important part, but not the only part, of his deterioration, particularly in 2023.

82. It is unclear as to why Wayne did not phone his GP for another script or why he did not recommence his medications when the family got back to Yamba. There was a lot going on for Wayne throughout this time. Even when Noah was well enough to come home, Noah still needed a lot of physical care. He also had large amounts of time off from school. All of the family rallied around Noah despite some of the things that were later reported by Wayne to the counsellor at Hunterlink (Wayne’s Employee Assistance Program).

83. The greatest burden of care in looking after Noah on a day-to-day basis fell on Wayne.

84. When Wayne got around to filling his repeat prescriptions on 28 October 2022, he only filled the Lexapro script. It is unclear why he did not fill the lithium script as well.

85. In late 2022, Wayne took some advice from friends and work colleagues and consulted with Hunterlink. Most of these consultations were focused upon how he could help Noah rather than anything directly about his own mental health. In October 2022, Wayne told the counsellor that he was okay with everything that had happened but that he had got very depressed in 2021. At a later appointment he said “things are going well”.

86. In November 2022, Wayne told the Hunterlink counsellor that he was doing much better and whilst he had struggled with depression on and off through his life, he had not felt himself getting depressed through all of this.

87. By the end of 2022, Wayne told Hunterlink he was doing well and that he did not have any updates to provide. However, the evidence establishes that things began to deteriorate in 2023 with finances, day-to-day tasks, work, travelling to John Hunter Hospital, and the probability that Noah would require further surgery, all weighing down on Wayne. Wayne also seems to have stopped taking his medications by this time.

88. The records from the Pharmaceutical Benefits Scheme show that the last lithium script Wayne filled before he died was filled on 20 July 2022. The records also show that he did not fill the scripts for his other mental health medications for the first five months of

89. This is supported by what Wayne eventually told Noah’s Mother in April or May 2023, namely that he was struggling with his mental health and he had stopped taking his medication and that he had forgotten to pack the medications when they went to hospital and he not been taking the medications since then. If that is true, Wayne had been without his medication for months. This is further corroborated by what Wayne later told Dr Couper when he returned to see her on 10 May of 2023.

90. The above stressors were significant and appeared to be a turning point in Wayne’s mental health.

(b) Appointment with Dr Couper on 10 May 2023

90. On 10 May 2023, Wayne walked into his appointment with Dr Couper with all of his tablets in a bag and he told Dr Couper that he had stopped taking his medications (although he had recently reintroduced one tablet, which he thought was one of his antidepressants). When Dr Couper went through the medication in the bag, it turns out that the tablet Wayne had reintroduced was one of his blood pressure medications.

91. Wayne told Dr Couper that his mood had started to deteriorate in the last few months.

Dr Couper sat with Wayne and she took him through his medications and she wrote on each packet of tablets what they were for so he would know what each tablet was supposed to help with. Dr Couper also requested pathology testing for him and she restarted one of the antidepressants at a low dose so she could monitor any sideeffects as she reintroduced the medication to him.

92. Dr Couper arranged for Wayne to come back and see her earlier than the normal appointment wait time and she recorded in her notes for this consultation “previous history of depression and suicidal thoughts”. The clinical notes also indicate that Wayne had told Dr Couper that he was not suicidal at that time and that he was the sole carer for Noah and “wants to be around for him”.

93. In my view, this was a very important and positive step taken by Dr Couper to support Wayne who was overwhelmed at this stage. Dr Couper’s arrangement for Wayne to come back to see her earlier than normal was entirely appropriate as this is something he obviously needed at the time.

(c) Wayne’s contact with Hunterlink on 23 May 2023

94. On 23 May 2023, Wayne reconnected with Hunterlink, which was months after his last telephone consult with them in early February. This was not a scheduled appointment and he spoke to someone new on intake. Wayne said that he was struggling and he

asked about being admitted to hospital. The person at Hunterlink said that if he felt that this was what he needed then he should go to hospital. She also offered him an early appointment with another counsellor at Hunterlink. However, Wayne indicated that he would prefer to wait to speak with the counsellor that he had previously spoken to.

(d) Wayne’s appointment with Dr Couper on 24 May 2023 and the question of hospitalisation and available community and hospital-based options for mental health treatment

95. On 24 May 2023, Wayne attended a further appointment with Dr Couper. Wayne told her that he had not improved, things at home were falling apart, and he had re-engaged with the counsellor he had spoken to in the past (Hunterlink).

96. Dr Couper’s notes for this consultation recorded “no thoughts of self-harm or suicide or any p[a]st history of it”. Although not made plain in the progress note, Dr Couper gave evidence that the note was referring to the account that Wayne had given her during the appointment. Therefore, the account Wayne gave to Dr Couper on 24 May 2023 was inconsistent with what he told her on 10 May 2023 (and also inconsistent with his actual past history).

97. Dr Couper was concerned about Wayne. She further increased his antidepressants and she added a short-term script for temazepam to try and help Wayne with his sleep.

She also gave him a medical certificate for some time off work and made an appointment for him to come back and see her earlier than the normal appointment wait time. Dr Couper told Wayne to come back even earlier than that if he needed to.

98. Despite Wayne’s deterioration, Dr Couper did not think that Wayne would be accepted if he were to be referred back to the ACS because he would not have been seen as sick enough by the ACS to warrant their intervention.

99. There is evidence that Wayne told at least one friend that he had said to Dr Couper that he wanted to go to hospital and that Dr Couper said he was not that bad. However, Dr Couper says there was no discussion about going to hospital in her consultation with Wayne. There is also no reference to this in Dr Couper’s clinical notes. Counsel assisting submitted that in the face of Dr Couper’s evidence, Wayne’s account about this part of the conversation with Dr Couper should not be accepted. I accept this submission.

100. Dr Couper gave evidence that even if Wayne had taken himself to the hospital on or around 24 May 2023, he likely would have ended up being referred to the Community

Mental Health Team, which (as noted above) was unlikely to take him on as a patient.

Dr Jeong agreed that the hospital would have assessed Wayne for immediate risks and referred him back to the Community Mental Health Team. Dr Jeong also indicated that sometimes a hospital referral causes more stress for a patient.

101. Prior to May 2023, there had been discussions with Wayne about hospitalisation and Wayne had resisted going to hospital. Hospitalisation was first raised with Wayne on 15 May 2020 by the psychiatrist and the team at the ACS of Grafton Community Mental Health. The first entry on their treatment plan for Wayne was an admission to hospital.

Their discussion with Wayne seems to have incorporated talking about both public or private hospital admission. The Court heard evidence that the nearest private hospital with an adequate mental health wing would have been in Currumbin, Queensland. At that time, Wayne resisted the idea of an admission to hospital.

102. On 18 August 2020, Wayne was again offered hospitalisation during his consultation with Dr Hope and Dr Scurrah but he again declined. As referred to above, on 23 May 2023, the intake worker at Hunterlink told Wayne to go to hospital if he thought he needed to be admitted, however, it is clear he decided not to do so.

103. As for the available community and hospital-based options for Wayne, the evidence in these proceedings touched upon the lack of such options in the region where Wayne lived, back in 2023 and presently. For example, Dr Couper indicated that the average wait time to see a private psychiatrist in the area could take up to six months (if their books were not already closed). Dr Jeong indicated that this gave context as to the limited range of actions that Dr Couper could take in that GPs can become stuck between trying to organise a private referral and there being no halfway type of care that is readily available (noting that a similar situation applies in metropolitan Sydney).

104. I consider that it was open to Wayne to go to hospital if he thought he needed to be admitted. However, according to Dr Couper, based on her experience, he was not at a level that she could schedule him. I accept Dr Jeong’s evidence that it was unlikely the hospital would have accepted Wayne had he gone to hospital.

105. Furthermore, the issue concerning mental health resourcing and funding is often repeated in this Court and is something that has been specifically considered by the NSW Parliamentary Inquiry into Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote NSW and the NSW Special Commission of Inquiry into Healthcare Funding. This is obviously a concern that requires close consideration.

(e) Asking patients about access to firearms

106. Dr Couper gave evidence that it is her practice that if a patient has expressed suicidal ideations to her she would ask them how they intended to harm themselves (including whether they have any weapons or firearms at home). Her evidence was that she would ask questions such as: "Have you had any specific thoughts about using that firearm? Where do you keep it?

Is it locked? Whilst you're feeling like this, would it be a good idea to place that key with somebody that you trust? How can we make that firearm in your house safer so that if there is a moment where things are getting really awful that you're not tempted to use it?"

107. Dr Jeong indicated that he adopts a similar approach. Dr Couper’s evidence was that she did not ask these questions of Wayne because he was not suicidal at the times she saw him.

108. I was impressed by the way in which Dr Couper approached this issue. Her evidence about the questions she would ask patients about firearms was encouraging if this is common practice amongst GPs.

Issue 3 – Noah’s mental health and exposure to his father’s illness

109. Counsel assisting highlighted two important points on this issue. Firstly, Noah was attuned to Wayne’s mental health and, second, when a caregiver is so sick that they cannot get out of bed, children notice.

110. On this issue, I was assisted by the evidence of Dr Alison O’Neill, clinical psychologist.

Her evidence was most helpful in understanding the relationship between Wayne and Noah.

111. In her evidence, Dr O’Neill acknowledged the love and the bond between Wayne and Noah. She also acknowledged that because of Wayne’s history of periods of chronic depression and anxiety, there may well have been episodes during Noah’s childhood when Wayne was less than emotionally available to Noah. This may well have contributed to what is described as an “insecure attachment”. This is not to say that Wayne and Noah were not attached, however, Noah was “parentified” to an extent.

112. In May 2020, it was Noah talking to Wayne and reassuring him that meant that Wayne did not go through with plans to kill himself at that time.

113. Noah was a protective factor for Wayne. This is borne out in the text messages from 2023, which show that Noah was parenting Wayne to the extent he was looking out for him. The messages show that Noah was checking in on him during the day, trying to monitor whether he had eaten breakfast, asking whether he had gone to see his Grandmother, insisting they stay at his Grandmother’s for a few nights, and insisting he go home with Wayne when Wayne had to collect his medication. Noah’s Grandmother also indicated that Noah would follow Wayne from room to room around the house. This was likely both driven by this insecure attachment between them.

114. It is also apparent that Noah’s impetus in trying to protect his dad and taking on a kind of care-giving role towards Wayne may have contributed to Wayne reporting to clinicians that Noah at times was stifling and too clingy.

115. Dr O’Neill characterised the relationship between Noah and Wayne as being a very loving relationship with a very complex father-son dynamic.

116. The Court also received evidence about Noah not getting and/or not engaging with support for his mental health. For example, the involvement with the school counsellor was only brief, Noah did not want to talk about things with his mum when she tried to talk to him about it, and Noah refused to engage with the therapist from Compassionate Enquiry when Wayne arranged an online session for Noah.

117. As noted above, it is clear that Noah was not receptive to the attempts made to provide him with therapeutic support. Sadly, his focus was on his father’s wellbeing rather than on his own.

Issue 4 – The medical and psychological evidence provided in support of Wayne’s application to have his firearms licence reinstated and his firearms returned to him, and whether the evidence in support was reasonably based

118. The medical and psychological evidence that was provided in support of Wayne’s application to have his firearms licence reinstated and to have his firearms returned to him was deficient.

(a) The medical certificate dated 24 August 2021

119. As part of Wayne’s application, Dr Hope provided Wayne with a medical certificate dated 24 August 2021. Dr Hope’s last physical consultation with Wayne seems to have been over one year prior, on 18 August 2020. The medical certificate from Dr Hope relevantly stated:

"This is to certify that Mr Wayne Smith is receiving treatment for anxiety/depression due to personal issues and his fathers recent death, His issues have since resolved and he has been completely stable on medication for the past five yrs [sic].”

120. In relation to the first sentence, the death of Wayne’s father in 2019, along with other things, did contribute to a deterioration in Wayne’s mental health in the lead up to May

121. In that regard, the first sentence was a broadly accurate account. This comment was clearly lacking in detail in circumstances where the medical certificate did not say anything about the severity or persistence of Wayne’s anxiety/depression.

122. In relation to the words “his issues have since resolved” in the second sentence of the medical certificate, this appears to be accurate in the sense that, by August 2021, this is what Wayne would have reported to Dr Hope and that Wayne had not seen Dr Hope physically in over a year.

123. In relation to the words “he has been completely stable on medication for the past five years”, Dr Hope accepted that this ought not to have been included in the medical certificate and that these words were wrong and unexplainable. This concession was appropriate in circumstances where these words completely overlooked the most serious events of May 2020.

124. In writing these words, Dr Hope’s memory had failed him. Putting aside the lack of note-taking in the previous consultations, Dr Hope’s own correspondence with the ACS back in 2020 would have clearly reminded him that Wayne had been seriously unwell, and at risk of suicide, in May 2020.

125. On this point, Counsel for Dr Hope noted that the evidence did not establish why he wrote these words. In his statement, Dr Hope indicated that he was under a lot of stress in his personal life at around that time and that, in hindsight, he should have ceased practising rather than agree to see long-term patients who had wanted to see him.

126. Furthermore, Counsel for Dr Hope disagreed with Dr Jeong’s opinion that Wayne was “completely unstable” after May 2020, noting that there was evidence that Wayne was working, caring for his son, enjoying activities. It was further submitted by counsel for Dr Hope that Wayne was not “completely unstable” from the end of 2020 to at least in late 2022, when Noah was involved in a boating accident. I accept that Wayne may not have been completely unstable, however, it was not accurate to describe Wayne as being “completely stable on medication for the past five years”.

(b) The report of Dr Hase to the Firearms Registry dated 1 December 2021

126. By way of letter dated 1 December 2021, Dr Hase provided the Firearms Registry with a report in support of Wayne’s application to have his firearms licence re-instated and his firearms returned to him. In that letter, Dr Hase was able to draw upon his three consultations with Wayne in 2020 and one consultation in 2021.

127. Counsel for Dr Hase submitted that based on the information that was available to him in December 2021, the contents of his letter dated 1 December 2021 was accurate.

Counsel for Dr Hase considered that the basis for the improvement in Wayne’s mental health since Dr Hase started treating him was the combination of medication and the Gestalt therapy (noting that neither the therapy nor the length of Dr Hase’s treatment were criticised by Dr O’Neill).

128. In his evidence to the Court, Dr Hase stated that he could not recall nor find any correspondence about how Wayne came to make the fourth appointment with him on 1 December 2021. Notably, Dr Hase had no record of receiving the letter of referral from Dr Hope, which stated “This man requires a psych assessment for his firearms licence” or receiving the letter dated 24 September 2021 that was sent by the Firearms Registry to Wayne (and which contained the Firearms Registry risk assessment questionnaire). Dr Hase told the Court that he had purchased software to search for any relevant records about this, however, he was not able to locate anything.

129. In terms of the risk assessment, Dr Hase explained in oral evidence that he would have undertaken the same kind of suicide risk assessment as he did in Wayne’s intake session. Relevantly, he stated that he did not have the benefit of the Firearms Registry questionnaire (which set out a list of questions to be addressed in the psychologist’s assessment) in drafting the resulting letter to the Firearms Registry dated 1 December

130. Dr Hase did, however, recall preparing a letter to the Firearms Registry on behalf of another client and that he was able to access that report to broadly guide the issues he covered in his letter for Wayne.

131. Dr Hase accepted that it was a failure on his part not to find out more about what was required of him for the risk assessment. The fact that Dr Hase did not have the Firearms Registry questionnaire was unfortunate, particularly because access to that document might have prompted further questioning that might have led to Dr Hase discovering that he had never had the full picture of what led to Wayne attending upon him in 2020. That is, if Dr Hase had gone through the questions posed within the questionnaire, he might have uncovered the true extent of Wayne’s illness in May

132. However, it cannot be said that having access to the questionnaire would have necessarily led to this information emerging, noting that it is unclear how much information Wayne would have volunteered in December 2021 given he had not volunteered information about his illness in May 2020 when he saw Dr Hase in 2020.

133. When Dr Hase was asked at the hearing whether he would have assessed the suicide risk in 2021 differently had he had knowledge of Wayne’s complex prior mental health history, Dr Hase was clear that he would have.

134. I consider that it was an appropriate concession of Dr Hase that he ought to have done more to find out about the risk assessment and what was required of him. As noted above, there was a major gap in his knowledge and understanding of the seriousness of Wayne’s condition and that, had he known of the events in May 2020, it is likely that he would have assessed the risk in December 2021 differently.

Issue 5 – The reasoning behind the decision of the NSW Firearms Registry to reinstate Wayne Smith’s firearms licence in October 2022 and support the return of his firearms in December 2022

133. The Firearms Registry was alerted to Wayne’s mental health history by the reapplication form he submitted through the Gun Safe system on 2 August 2021. Wayne had never previously disclosed in any of his previous applications to the Firearms Registry a diagnosis of depression or anxiety nor being treated by antidepressants. It is known, however, that Wayne had been on antidepressants since at least 2004.

134. The Firearms Registry Adjudication Officer who reviewed Wayne’s re-application form that was submitted on 2 August 2021 suspended his licence. This led to Wayne’s firearms being seized. On 20 September 2021, the Firearms Registry received correspondence from Wayne, which included the medical certificate from Dr Hope dated 24 August 2021.

135. On 24 September 2021, the Firearms Registry wrote to Wayne requesting he obtain a mental health risk assessment. The bundle of material sent from the Firearms Registry to Wayne included a letter addressed to a GP requesting a referral to a psychiatrist or psychologist to undertake the risk assessment.

136. On 11 February 2022, the Firearms Registry received a bundle of material from Wayne in response to the material sent to him dated 24 September 2021. This comprised: i. A copy of the letter from the Firearms Registry to Wayne dated 24 September 2021 requesting that Wayne obtain the mental health risk assessment.

ii. A completed medical report authorisation form dated 5 October 2021.

iii. A one-page document that said, “I seek your opinion regarding this man requires a psych assessment for his firearms licence” (being one page of the referral letter Dr Hope had prepared, which was intended to go to Dr Hase for the purpose of preparing a report but which did not appear to ever be received by Dr Hase).

iv. A receipt from Dr Hase.

v. The letter from Dr Hase to the Firearms Registry dated 1 December 2021.

137. There was then a long delay before a decision was made at the Firearms Registry on 5 October 2022 to reinstate Wayne’s firearms licence. In the record outlining the reasoning of the Firearms Registry Adjudication Officer’s recommendation for Wayne’s firearms licence to be re-issued, the Adjudication Officer expressly referred to having read “the GP letter and Psychologist report”, gave credit to Wayne for having been honest on his licence re-application, and confirmed that Wayne had held his firearms licence since 1998 with no concerns.

138. Counsel for Dr Hope submitted that it is not clear whether the “GP letter” referred to in the Adjudication Officer’s records relates to the one-page referral letter sent from Dr Hope to Dr Hase (which was sent by Wayne to the Firearms Registry on 11 February

2022. or the medical certificate dated 24 August 2021 completed by Dr Hope.

Nevertheless, Counsel for Dr Hope conceded that the medical certificate dated 24 August 2021 was on the Firearms Registry’s file, some of its contents were wrong, and it may have contributed to the decision made on 5 October 2022.

139. Counsel assisting pointed my attention to five issues concerning the material that the Firearms Registry had regard to in reaching the decision to re-instate Wayne’s firearms licence and to have his firearms returned to him.

140. Firstly, the medical certificate from Dr Hope that Wayne relied on did not refer to the serious events of May 2020. The certificate also referred to the fact that Wayne was on medication, however, the Firearms Registry Adjudication Officer marked the medication box on the Mental Health Report Review form as “not applicable”.

141. Second, the medical certificate gave a false assurance that Wayne had been stable for five years.

142. Third, while the report from Dr Hase was understandably based upon his own involvement with Wayne, this occurred in ignorance of important aspects of Wayne's history (particularly his threat of suicide, daily thoughts of self-harm, and plan to kill himself in May 2020, which prompted the urgent involvement of the ACS and the introduction of lithium).

143. Fourth, the Firearms Registry Adjudication Officer understood that the recent depressive episode had been linked to the death of Wayne's father. While this was accurate, it did not properly understand the events from that recent depressive episode.

144. Fifth, the letter dated 24 September 2021 requesting a mental health risk assessment sent by the Firearms Registry to Wayne set out 13 questions (with some questions being split into several parts). While the document on its face asks the psychiatrist or psychologist assessing Wayne to address the 13 questions in the letter, the letter also noted that the expert was not confined to those questions. Dr Hase provided his letter dated 1 December 2021 without access to the questionnaire and, instead, by drawing upon the broad criteria he infers he was answering when preparing a report for a different client.

145. In my view, the major failing was in the inaccurate information from Dr Hope, which led to Dr Hase not having the full picture of the events in May 2020 and true nature of Wayne’s condition when he prepared his letter in December 2021. It was also unfortunate that Dr Hase’s letter did not prompt further enquiry by the Firearms Registry to Dr Hase about why he had not completed the questionnaire because, as a result, the Firearms Registry was not able to accurately assess Wayne’s risk. The Firearms Registry did not have the information that they should have had to make an appropriate decision regarding the reinstatement of Wayne’s licence and the return of his firearms.

146. Furthermore, the failure to tick the medication box was an obvious failure. Had that box been ticked and had the Adjudication Officer had information about the events in May 2020, it is likely there would have been further questions asked before Wayne’s firearms licence was reinstated and his firearms returned to him.

147. It is significant that when the letter from Dr Hase was received by the Firearms Registry, this did not prompt a request from the Firearms Registry to go back to Dr Hase asking him to specifically address the detailed list of questions set out within the questionnaire. Counsel for Dr Hase submitted that the Firearms Registry should have

identified that Dr Hase’s letter was old/outdated and contained anomalies and that it should have been realised that the questionnaire had not reached him. The Court was told that, as at 2022, that was not the practice of the Firearms Registry. This was a significant limitation in the way the Firearms Registry’s system concerning mental health risk assessments operated in 2022.

Issue 6 – Since May 2023, what, if any, changes have been made to the NSW Firearms Registry’s regime of assessing a person’s suitability to possess firearms?

148. Janelle Green, Associate Director of the Firearms Registry, gave evidence at the hearing about the changes to the NSW Firearms Registry. I was greatly assisted by her evidence and was particularly struck by the firearms statistics she provided to the Court.

(a) Firearms statistics in NSW and Australia

149. According to figures produced by the Firearms Registry, there were 258,027 firearms licence holders in New South Wales as at 4 May 2025. About two-thirds of licence holders are based in regional locations, with high distribution in the western and southern regions of the State, whereby leaving about one-third of licence holders in the Sydney metropolitan region. Men aged between 30 to 55 are the most common demographic of people holding a firearms licence and men account for approximately 87% of firearms licence holders.

150. As at May 2025, there were 1,134,893 registered firearms in New South Wales.

Ms Green gave evidence that, as at the time of the hearing, the Firearms Registry was receiving between 400 to 500 new applications for firearms licences per week and approximately 800 to 900 re-applications per week.

151. Ms Green referred in her evidence to a 2021 article in the Medical Journal of Australia entitled Gun violence in Australia, 2002-2016: a cohort study. According to the authors of that article, the overall firearm injury rate declined between 2002 and 2016. This was primarily because of a decline in injuries caused by assault or accident events. The annual rate of firearm-related self-harm injuries remained stable at about 0.8 per 100,000 population. The rate of self-harm injuries were higher for older people and for residents in outer regional and rural remote areas.

(b) Genuine reasons for having a firearms licence

152. Wayne had held a firearms licence for many years without incident prior to June 2023.

Wayne's genuine reason for possessing and using a firearm as required under the Firearms Act 1996 was for “recreational hunting/vermin control”. Ms Green told the Court that this is one of the most common “genuine reason” categories under the Firearms Act 1996.

153. In relation to recreational hunting/vermin control being the genuine reason of having a firearms licence, there is relatively little corroboration of the evidence said to demonstrate this genuine reason. For example, one landowner can provide a statutory declaration or letter confirming that they will give the licence holder permission to shoot on their property, which would be sufficient to establish that “genuine reason” under the Firearms Act 1996.

154. Unless the licence holder provides an update reporting a relevant change in circumstance of the landowner, the initial permission to shoot lasts indefinitely. The licence holder is not limited to shooting on the nominated property and not limited in the number of firearms they can accumulate (although there are some limitations on the number of particular types of firearms).

155. Ms Green noted that a recent operation had been undertaken whereby the Firearms Registry had been alerted to a high number of letters of authority being provided from one particular property, which prompted a review and led to a number of firearms licenses being revoked.

156. Counsel assisting submitted that the current scheme arguably does little more than pay lip-service to demonstrate a genuine reason by means of evidence of permission to shoot. Counsel assisting further submitted that this is not a rigorous safeguard and that this warrants careful review and, if indicated by that review, statutory reform.

157. Counsel assisting submitted that a wider review could be conducted by the Firearms Registry to improve the quality of the evidence relied upon in support of an initial application or a reapplication for a firearms licence relying upon the genuine reason of recreational hunting/vermin control. Such a review could look into questions such as how many licence holders does a landowner need for the purpose of vermin control on one property and/or how many licence holders should a landowner be permitted to endorse for the purpose of a recreational hunting licence.

158. As I refer to below, amendments have been made to the Firearms Act 1996 and Firearms Regulation 2017 since the hearing of this inquest. However, these amendments do not appear to address this concern about the evidence required to demonstrate a genuine reason of recreational hunting/vermin control. In my view, this gives rise to the making of a recommendation for appropriate review and statutory reform, which I return to below.

(c) Wayne’s previous non-disclosure to the Firearms Registry about his history of mental illness

159. Up until Wayne’s application to renew his firearms licence in August 2021, Wayne had never disclosed to the Firearms Registry a long history of chronic depression and treatment via antidepressants since at least 2004.

160. Counsel assisting submitted that there is no suggestion that Wayne deliberately lied on his forms over the years; rather, the wording of the older version of the application for renewal form was not entirely clear and may have prompted genuine confusion.

Nevertheless, Wayne did not declare his health and safety of mental illness nor his medication regime in circumstances where the Firearms Registry expected that this type of history should have been disclosed. It was submitted by counsel assisting that this shows that there was a clear disconnect between the expectations of the Firearms Registry and the reality of Wayne's disclosures.

161. I accept counsel assisting’s submission on this point and I am hopeful that changes are being made that might improve the situation.

(d) Changes to the Firearms Registry since Noah’s and Wayne’s deaths

162. There have been significant changes to the Firearms Registry since Noah’s and Wayne’s deaths.

163. First, a new firearms licence application form asks individual questions on important matters (such as health history) rather than rolling up several questions into one question. There is less chance that an applicant can genuinely misunderstand what they are being asked to respond to when the new form carefully steps them through a number of separate and specific questions about their health.

164. Second, greater guidance to Firearms Registry Adjudicators now requires them to request a health risk assessment if the applicant falls into one or more of the following criteria:

i. Has engaged in threats, actions, or behaviours associated with self-harm, suicide, or violence towards others and that has been related to mental illness or impairment.

ii. Has reported within the past 15 years feelings of depression, anxiety, or alcohol or drug dependence.

iii. Has responded “yes” to any of the application questions regarding suicide, selfharm, mental illness, alcoholism, or drug dependence.

iv. Has been diagnosed or suffered from any mental, neurological, or physical condition, including an intellectual or other disability which may affect the understanding or ability of the licence holder to safely use firearms.

165. The requirement to consider a 15-year history of mental health (which may then trigger a mental health risk assessment) is particularly significant in the circumstances of this matter.

166. Third, a new health risk assessment form (which is the subject of ongoing consultation) was introduced at the end of 2024. The new form is detailed, it directs the health professional to specific topics that they must address, it provides guidance as to how much detail should be included, and it is to be completed after the health professional has read the accompanying guidance titled Health Risk Assessment Guidance for Health Practitioners. This form has been carefully developed for use by health professionals (usually general practitioners but not exclusively). The implementation of this form means that there will be no more letters from treatment providers who must “do their best” to estimate the sort of information that the Firearms Registry requires.

167. Fourth, the health professional completing the new health risk assessment form is required to try to access at least five years of the applicant's documented medical history (not just mental health history) and, if they are unable to do so, the health professional is specifically asked to say whether or not they have sufficient information and knowledge of the applicant to accurately assess the applicant’s fitness to possess and use a firearm.

168. Fifth, these new forms are now returned directly to the Firearms Registry by the health professional. This lessens the chance that the form might be improperly altered by an unscrupulous licence holder and increases the prospect that the health professional will be candid in their opinion expressed directly to the Registry.

169. Sixth, health professionals are now encouraged to decline to provide the risk assessment report, and instead, refer the patient to another expert if they do not feel that they can support the application.

170. Seventh, the health risk assessment form is reviewed much sooner after it is received at the Firearms Registry. In Wayne's case, the report from Dr Hase was ten months old by the time the adjudication decision was made. Ms Green gave evidence that through a concerted effort at the Firearms Registry, 95% of reports were being reviewed within 28 days of receipt.

171. Eighth, the Firearms Registry adjudicators are empowered to seek further information from the health professional. For example, if the health professional fails to tick a box answering “yes” or “no” to a particular condition on the form, this will be followed up by the Firearms Registry. Failure to reply to the Firearms Registry’s follow-up will result in the refusal of the licence.

172. Ninth, special conditions for reassessment are now available so that, for example, if an applicant has a documented mental health history that is well-controlled with medication, the licence can be granted subject to the applicant needing to provide further updating health assessments if requested. Counsel assisting submitted that while this has been incorporated into the Firearms Registry’s practice, ideally this would be reflected within the Firearms Act 1996 or the Firearms Regulation 2017.

Counsel assisting proposed a recommendation to this effect, which I refer to below.

173. Tenth, health professionals who provide a health risk assessment are now notified by the Firearms Registry if a firearms licence is issued. The Court heard evidence that the Firearms Registry would like to see general practitioners routinely asking about firearms licences and access to firearms at intake appointments (just like doctors might ask patients about whether they have a driver's licence). It seems sensible to first raise this topic with a patient as part of a routine review rather than waiting until a point of crisis to ask the question (noting that it will probably need to be asked again if the patient reaches a point of crisis). There is merit in the Firearms Registry further exploring this topic with the health professions.

174. The Court also heard evidence that the Firearms Registry would like to oblige health practitioners to notify the Firearms Registry if they believe a patient is no longer able to safely use their firearms. Counsel assisting submitted that further discussion between the Firearms Registry and the health professions about this type of reporting

obligation is to be encouraged. This is a matter that forms part of a recommendation, referred to below.

175. I commend the Commissioner and the Firearms Registry for the changes that have been made since Noah’s and Wayne’s deaths.

FINDINGS

176. The findings I make under s 81(1) of the Act in relation to Noah Smith are: Identity The person who died was Noah Smith.

Date of death He died on 1 June 2023.

Place of death He died at 23 Kookaburra Court, Yamba 2464.

Cause of death The cause of death was a gunshot wound to the head.

Manner of death The gunshot wound to the head was inflicted by a person known to him.

177. The findings I make under s 81(1) of the Act in relation to Wayne Smith are: Identity The person who died was Wayne Smith.

Date of death He died on 1 June 2023.

Place of death He died at 23 Kookaburra Court, Yamba 2464.

Cause of death The cause of death was a gunshot wound to the head.

Manner of death The gunshot wound to the head was intentionally self-inflicted.

RECOMMENDATIONS

178. Notwithstanding the good work that has been done by the Firearms Registry since these tragic deaths, the evidence in these proceedings gives rise to the potential to make recommendations aimed at ensuring the safety of the community and preventing similar tragedies occurring in the future.

179. In this regard, at the conclusion of the hearing, counsel assisting proposed seven recommendations, all of which were endorsed by those representing the Commissioner of Police in these proceedings. Those representing the Commissioner have provided an updated position on these proposed recommendations (outlined below) in light of the following: i. Since the hearing of these inquests, there have been significant changes to the firearms laws at both State and Federal levels in light of the terrorist attack at Bondi Beach on 14 December 2025. Namely, on 24 December 2025, the NSW Government passed the Terrorism and Other Legislation Amendment Bill 2025 (the Bill), which makes various amendments to the Firearms Act 1996 and Firearms Regulation 2017.

ii. Many of the recommendations proposed by counsel assisting referred to the post implementation review into the new Health Risk Assessment Framework that was taking place in 2025. That review has now concluded and a report is in the process of being finalised.

180. Before turning to the discussion of the recommendations specific to this matter, I note that on 20 January 2026, the Federal Government passed the Combatting Antisemitism, Hate and Extremism (Firearms and Customs Laws) Bill 2026. As part of that Bill, the Federal Government set up a national gun buyback scheme, whereby persons in possession of a firearm are able to receive compensation for surrendering the firearm to a police station or collection point.

Proposed recommendation 1

181. Counsel assisting proposed that consideration be given to statutory reform enabling amendment of processes within the Firearms Registry so as to require applicants seeking the re-issue of a firearms licence on the basis of recreational hunting/vermin control to demonstrate current permission from a landowner to shoot at time of renewal.

182. The Commissioner endorses this recommendation and notes that upon proclamation of the Bill, recreational hunters will be required to be a member of a gun club (through the insertion of s 19(2)(a1) into the Firearms Act 1996), which will provide an extra layer of rigour to firearms licencing processes.

Proposed recommendation 2

183. Counsel assisting proposed that the Firearms Registry additionally consider steps to improve the rigour of the information required in support of an application or reapplication for a firearms licence in reliance upon recreational hunting/vermin control as the genuine reason for the issue of the licence.

184. The Commissioner endorses this recommendation on the same basis as proposed recommendation 1.

Proposed recommendation 3

185. Counsel assisting proposed that during the post implementation review into the new Health Risk Assessment Framework, consultation occur with the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss how GPs can be encouraged to routinely ask patients if they have a firearms licence (just as they might ask whether patients have a driver’s licence).

186. The Commissioner has indicated that, as part of the post implementation review, medical practitioners were sent a Health Risk Assessment Framework consultation survey in which they were asked if they routinely collect or record information about patients’ access to firearms and weapons. In response, 62.07% of medical practitioners answered either ‘yes’ (27.59%) or ‘sometimes’ (34.48%). The Firearms Registry supports a focus on improving GPs routinely asking and recording if patients have a firearms licence and if they have access to firearms.

Proposed recommendation 4

187. Counsel assisting proposed that during the post implementation review into the new Health Risk Assessment Framework, consultation occur with the NSW Ministry of Health, the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss the possibility of introducing a statutory obligation requiring health practitioners to report to Police if they have safety concerns for a patient who is a firearms licence holder.

188. The Commissioner notes that following the post implementation review, a recommendation is to be added to the post review report highlighting an opportunity for the mandatory reporting by medical practitioners to police if they have safety concerns for a patient who is a registered firearms licence holder, and that such a process would work in a similar framework to the mandatory reporting regime presently in place for child abuse matters.

Proposed recommendation 5

189. Counsel assisting proposed that during the post implementation review into the new Health Risk Assessment Framework, consideration be given to requiring any applicant for the issue/re-issue of a firearms licence who has experienced suicidal ideation in the previous five years, provide a Mental Health Risk Assessment from two separate assessors (preferably their current treating GP and separately a psychiatrist or psychologist).

190. This recommendation is supported by the Firearms Registry.

Proposed recommendation 6

191. Counsel assisting proposed that during the post implementation review into the new Health Risk Assessment Framework, consideration be given to statutory reform that enables the reassessment of licence holders as an alternative to relying upon the imposition of special conditions to firearms licences.

192. This recommendation is supported by the Firearms Registry. Those representing the Commissioner indicated that this issue is being addressed by the Bill, which will amend the firearms legislation to require a firearms licence to be renewed after two years.

Proposed recommendation 7

193. Counsel assisting proposed that consideration be given to statutory reform enabling the introduction of criteria to demonstrate a “good reason” to acquire additional firearms. Such criteria might include consideration of the number of firearms already licenced to a particular licence holder.

194. The Commissioner supports this recommendation, noting that the Bill will limit the number of firearms a person can acquire depending on their genuine reason for holding their firearms licence. For someone like Wayne whose “genuine reason” for holding a firearms licence was “recreational hunting/vermin control”, it appears that the limit will be four firearms.

195. Having considered the above, I make the following recommendations pursuant to s 82 of the Act: To the Minister for Police and Counter-terrorism and the Commissioner of Police i. Consideration be given to statutory reform enabling amendment of processes within the Firearms Registry so as to require applicants seeking the re-issue of a firearms licence on the basis of recreational hunting/vermin control, to demonstrate current permission from a landowner at time of renewal.

ii. The Firearms Registry additionally consider steps to improve the rigour of the information required in support of an application or reapplication for a firearms licence in reliance upon recreational hunting/vermin control as the genuine reason for the issue of the licence.

iii. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss how GPs can be encouraged to routinely ask patients if they have a firearms licence (just as they might ask whether patients have a driver’s licence).

iv. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the NSW Ministry of Health, the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss the possibility of introducing a statutory obligation requiring health practitioners to report to Police if they have safety concerns for a patient who is a firearms licence holder.

v. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to requiring any applicant for the issue/reissue of a firearms licence who has experienced suicidal ideation in the previous five years, provide a Mental Health Risk Assessment from two separate assessors (preferably their current treating GP and separately a psychiatrist or psychologist).

vi. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to statutory reform that enables the reassessment of licence holders as an alternative to relying upon the imposition of special conditions to firearms licences.

vii. Consideration be given to statutory reform enabling the introduction of criteria to demonstrate a “good reason” to acquire additional firearms.

CONCLUSION

196. Finally, I thank counsel assisting, Donna Ward SC and Tracey Stevens, and their instructing solicitor, James Prindiville of the Crown Solicitor’s Office, for their hard work and invaluable assistance throughout these proceedings.

197. My thanks also go to the officer in charge of the coronial investigation, Detective Senior Constable Evan Porou, for compiling the initial brief of evidence and providing ongoing assistance to the Court and the family throughout the inquest. His measured and considerate approach in dealing with these tragic deaths is commendable.

198. I offer my sincere condolences to Noah’s and Wayne’s family and friends for their tragic losses. I thank Noah’s Mother and Grandmother for attending the hearing. I acknowledge that listening to the evidence about their loved ones would have been incredibly difficult for them. Their grace and dignity throughout these proceedings was remarkable.

199. I close this inquest.

Judge Teresa O’Sullivan NSW State Coroner Coroners Court of NSW, Lidcombe 30 March 2026

ANNEXURE A Agreed Facts Date Information 25 February 1965 Wayne born (aged 58 at time of death) Wayne and his father, David, while working for Marine Rescue, respond to sinking vessel near Yamba, young boy killed during the rescue, Noah’s Mother recalls Wayne and his father being affected by this for some time Wayne holds firearms licence (1991 is when Police data converted to the 29 June 1991 Integrated Licensing System, Wayne’s licence pre-dates this system) Wayne lodges a “re-application” for a category AB firearms licence 401177907, 16 June 1993 licence issues, due to expire 16/06/98 Wayne and Noah’s Mother meet 1994 - At the Pacific Hotel in Yamba through mutual friends

• Dated for two years before getting married Wayne and Noah’s Mother marry in Maclean

• Noah’s Mother said: “During the early years of our relationship into our early 5 April 1997 married years, our relationship was good. We purchased a block of land and built a house at 23 Kookaburra Court, Yamba during this time.” Wayne lodges application for a category AB firearms licence 406770504, “genuine 9 June 1998 reason” likely Recreational Hunting/Vermin Control Wayne registered 2 firearms:

1. .22LR calibre LITHGOW model 12 bolt action rifle (serial number 2065) 10 August 1998 (NSW Registration 706891327)

2. .303 calibre UNKNOWN model Unknown bolt action rifle (serial number C5370) (NSW Registration 706891343) 24 September 1998 Category AB firearms licence issued for 5 years, expiry date 02/10/03 Wayne updates nominated residential address with firearms registry to 23 21 November 2001 Kookaburra Ct, Yamba According to Noah’s Mother, Wayne had a falling out with his parents and brother, Early 2000s didn’t speak for about two years Wayne has accident with lawn mower at work, Wayne lost index finger and part of 3rd finger on right hand Wayne was right-handed

• Noah’s Mother said: “Wayne was right hand dominant and took this very hard.”

• Noah’s Mother said: “During this period Wayne seemed to become depressed and suffer from mental health issues” but seemed to get back to Early 2000s his normal self once he got back to full time work According to Noah’s Mother, Wayne went through many surgeries trying to save parts of his hand, took this very hard, became depressed but battled through and eventually got back to full duties at work and seemed to be back to his old self According to Alan Jones, Wayne would sometimes nearly get back to himself after the accident but was never quite the same Noah’s Mother said: “During this same period, Wayne and I experienced the normal ups and downs of a marriage, but our relationship was otherwise good.” According to Noah’s Mother, Wayne and his family reconcile after his accident According to Noah’s Mother, she and Wayne spend some time trying to get pregnant, IVF failed and several miscarriages Wayne’s re-application for firearms licence, Category A and B

• “genuine reason” Recreational Hunting/Vermin Control evidenced by “Permission to Shoot Authorities” by 2 different landowners 15 September 2003 - Re-application received by Firearms Registry on 3 October 2003

• Refers to small game such a rabbits, hares and birds and larger game such as foxes, goats and pigs etc, regarding special need for Category B firearm “animal control, humanely put down larger game”

Date Information 2 October 2003 Wayne’s category AB firearms licence re-issued (expiry 2 October 2008) Wayne subjected to firearms safe storage inspection of firearms and safe keeping 8 March 2004 facilities, no discrepancies identified Wayne consultation with Dr Hope and others at the practice for depression (amongst other things) 12 August August – October

• Poor sleep, early morning waking, depressed mood, panic attacks 2004 Prescriptions by Dr Hope

• Efexor (antidepressant) 37.5 mg 1 bd mdu

• Normison (temazepam, benzodiazepine) (short term) Wayne consultation with Dr Hope for depression and blood pressure

• Mood improved, planning ahead, increased enjoyment.

12 October 2004 Prescriptions by Dr Hope

• Coversyl 2mg

• Efexor (antidepressant) Wayne 2x consultations with Dr Hope for depression 1 April

• Poor sleep, early morning wakening, depressed mood, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no April 2005 suicidal thoughts, no substance abuse 26 April

• Poor sleep, early morning wakening, depressed mood, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse Wayne consultation with Dr Hope for depression

• Poor sleep, early morning wakening, depressed mood, low self esteem, no 26 July 2005 irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse Wayne consultation with Dr Hope for depression

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 18 January 2006 no hallucinations, no suicidal thoughts, no substance abuse Prescription

• Efexor 37.5 mg ceased

• Efexor 75mg 1 nocte Wayne 2x consultations with Dr Hope for depression (and bronchitis) 8 February

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, no panic attacks, no compulsive behaviours, no delusions, no February – March hallucinations, no suicidal thoughts, no substance abuse 2006 8 March

• Poor sleep, early morning wakening, depressed mood, normal self-esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse Dr Hope referral letter to Dr Graham George (psychiatrist) 8 February 2006

• “I seek your opinion regarding depression from accident” Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse.

4 April 2006

• Amputation of fingers

• Depression Prescription

• Efexor 75mg changed to Efexor 150mg Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, normal mood, low self esteem, no 11 May 2006 irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Depression and bronchitis

Date Information Prescription

• Efexor 150mg 1 nocte Wayne Consultation with Dr Hope for depression (amongst other things)

• Poor sleep, no early morning wakening, depressed mood, low self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 18 May 2006 no hallucinations, no suicidal thoughts, no substance abuse Prescription

• Efexor 150mg 1 nocte Wayne and Noah’s Mother bought a caravan and Landcruiser and drove around Mid 2006 Australia and Noah’s Mother fell pregnant Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, normal mood, low self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no 16 October 2006 hallucinations, no suicidal thoughts, no substance abuse

• Depression and bronchitis Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 3 April 2007 no hallucinations, no suicidal thoughts, no substance abuse

• Mole check and Depression Prescription

• Efexor 150mg 1 nocte Noah born (aged 15 at time of death) 25 June 2007 Noah’s Mother said: “Wayne and I were ecstatic to have a baby and Wayne was particularly excited to have a son” Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no 31 August 2007 hallucinations, no suicidal thoughts, no substance abuse

• Depression Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 19 February 2008 no hallucinations, no suicidal thoughts, no substance abuse

• Depression Prescription

• Efexor 150mg 1 nocte Wayne’s re-application for a personal firearms licence (application dated and 9 April 2008 signed 28/3/08) Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 19 May 2008 no hallucinations, no suicidal thoughts, no substance abuse

• Depression and high blood pressure Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, 10 June 2008 no hallucinations, no suicidal thoughts, no substance abuse

• Depression and high blood pressure Prescription

• Efexor 150mg 1 nocte Wayne 2 x consultations with Dr Hope August 2008 11 August

Date Information

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• High blood pressure and depression Prescription

• Efexor 150mg 1 nocte Wayne’s category AB firearms licence re-issued for 3 years (expiry 2 October 02 October 2008 2011) Wayne 2 x consultation with Dr Hope

• Various reasons (vaccinations, lesions checked) March – July 2009 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions September 2010 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions February 2011 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, normal mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no 4 July 2011 hallucinations, no suicidal thoughts, no substance abuse

• High blood pressure and bronchitis Prescription

• Efexor 150mg 1 nocte Wayne’s re-application for personal firearms licence received by Firearms 19 July 2011 Registry (application dated 16 July 2011) Wayne’s category AB firearms licence re-issued for 5 years, (expiry 2 October 2 October 2011 2016) Wayne consultation with Dr Hope December 2011 - Reason for consultation not clear

• “Document saved – Workcover NSW” Wayne, Noah’s Mother, and Noah (4 years old) took 3 months off work and travelled around Australia

• Noah’s Mother said: “Noah did so well we were able to do long stints in the 2011 car. Noah was a very adventurous child and loved his fishing. I remember on this trip he caught a 1.2m barramundi and loved being outdoors, particularly being on the water. Noah was born with sea legs.” Wayne 2x consultation with Dr Hope January – March - Prescriptions 2012 Prescriptions

• Efexor 150mg 1 nocte Wayne and Noah’s Mother had a fire at their house shortly after returning from their travels around Australia

• The family were out of the house for 7 months 2011 or 2012? - Noah’s Mother said: “This time was a nightmare and caused us a lot of financial and emotional stress in dealing with our insurance company. As a result of the fire, all of our possessions, including Noah’s toys were either damaged or destroyed.

Wayne subjected to firearms safe storage inspection at 23 Kookaburra Drive, no 29 April 2012 discrepancies identified Wayne consultation with Dr Hope

• Blood pressure check August 2012 Prescription

• Efexor 150mg 1 nocte 2013 Noah started school at St James Catholic School Yamba

Date Information

• Noah’s Mother said: “Noah was phenomenal at maths and drawing and won several school awards for these subjects…Noah continued to love being adventurous and being outdoors. Noah loved fishing and snorkelling with Wayne and continued to race motor cross on his motorbike until he was 7.” Wayne consultation with Dr Hope

• Prescriptions February 2013 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions August 2013 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions January 2014 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope 13 June

• Poor sleep, early morning wakening, depressed mood, low self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no June 2014 hallucinations, no suicidal thoughts, no substance abuse

• Depression, high blood pressure, bronchitis

• Medical certificate created Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope 12 September

• Poor sleep, early morning wakening, depressed mood, normal self esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, September 2014 no hallucinations, no suicidal thoughts, no substance abuse

• High blood pressure, depression, other reasons (testicular lump, for testing) Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions May 2015 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions October 2015 Prescription

• Efexor 150mg 1 nocte Wayne consultation with Dr Hope

• Prescriptions May 2016 Prescription

• Efexor 150mg 1 nocte 19 August 2016 Wayne’s re-application for a personal firearms licence Wayne’s category AB firearms licence re-issued for 5 years (expiry date 2 October 2 October 2016 2021) Wayne consultation with Dr Hope

• Prescriptions October 2016 Prescription

• Efexor 150mg 1 nocte Temporary National Firearms Amnesty commences, aiming to reduce the number 2017 of unregistered firearms in Australia, amnesty allowed for firearms to be registered, supplied to a dealer or surrendered without fear of prosecution Wayne consultation with Dr Hope April 2017 - Prescriptions Prescription

Date Information

• Efexor 150mg 1 nocte Wayne completed a “Register Firearms in Possession” form under the Amnesty 28 September 2017 and registered 1 firearm as 12-gauge Harrigton & Richardson Model Unknown single barrel shotgun (serial number 682637) (NSW Registration 73086734) Wayne consultation with Dr Cameron (at Yamba Private Clinic)

• Prescriptions October 2017 Prescription

• Efexor 150mg 1 nocte Wayne’s father David diagnosed with rare lung cancer

• David and Wayne very close and visits every day 2017 or 2018

• Noah’s Grandmother thought his father’s diagnosis brought back Wayne’s depression 2018 Dr Couper starts working at the Yamba Private Clinic with Dr Hope Wayne consultation with Dr Hope

• Poor sleep, no early morning wakening, depressed mood, normal self esteem, no irrational fears, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 7 February 2018

• Anxiety / Depression, chest discomfort Prescription

• Efexor 150mg 1 nocte ceased

• Pristiq 50mg 1 nocte commenced (SNRI antidepressant) Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fears, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 19 February 2018

• Anxiety / Depression Prescription

• Pristiq 100mg 1 mane Counselling Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 5 March 2018

• Anxiety / Depression from stress Prescription

• Pristiq 100mg 1 mane Counselling Wayne consultation with Dr Hope

• Mental Health Care Plan

• Anxiety / Depression

• Poor sleep, early morning wakening, depressed mood, low self esteem, 6 March 2018 irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Requires counselling for depression and anxiety “to make appointment for it”

• Counselling visit 25 minutes Wayne saw a psychologist, Christine Potappel, for consultation, following referral 21 March 2018 by Dr Hope for depression Wayne consultation with Dr Hope

• Anxiety / Depression

• Poor sleep, no morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 18 June 2018

• Long counselling visit Prescription

• Pristiq 100mg 1 mane ceased

• Avanza 30 mg ½ nocte commenced

• Lexapro 10mg 1 mane commenced 17 July 2018 Wayne consultation with Dr Hope

Date Information

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Anxiety / Depression and Counselling Prescription

• Avanza 30 mg increased to 1 nocte Wayne consultation with Dr Hope

• Anxiety, EPR, high blood pressure, counselling

• Normal sleep, no early morning wakening, depressed mood, normal self 31 July 2018 esteem, no irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse Prescription

• Avanza 30 mg 1 nocte Wayne consultation with Dr Hope

• High blood pressure, anxiety, depression

• Poor sleep, early morning wakening, depressed mood, normal self esteem, 7 September 2018 no irrational fears, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Medical certificate created Script printed Prescription 13 December 2018

• Avanza 30 mg 1 nocte

• Lexapro 10mg 1 mane Script printed Prescription 7 June 2019

• Avanza 30 mg 1 nocte

• Lexapro 10mg 1 mane David (Wayne’s father) died

• David collapsed at home, Noah’s Grandmother called Wayne and then 000, Wayne performing CPR on his father, didn’t want to stop to allow FRNSW to 18 August 2019 take over because wanted to save his father’s life

• Noah’s Grandmother believes Wayne was in depression a long time after his father’s death Wayne first consultation with Dr Fiona Couper (nee Sharp)

• Wayne not happy to come and see Dr Couper (she thinks because he was probably used to Dr Hope issuing scripts over the phone) 29 November 2019

• Wayne said his mood was fine, issued script for mirtazapine and Lexapro (both anti-depressants)

• Reason for visit “hypertension”, pathology requested Noah starts High School at McAuley Catholic College in Grafton Noah’s Mother moved office for her job and worked at the Grafton office and worked very long hours

• Noah’s Mother said: “During this same period, Wayne and my relationship 2020 started to become strained. I was working longer hours, so I struggled to maintain duties at home and Wayne was always out with Noah. From this I noticed Wayne appeared to become depressed and withdrawn. Wayne would come home from work and go straight to bed. Wayne described his feelings to me as it felt like he was losing control and felt lost and angry” Noah consultation with Dr Fiona Sharp [Couper] (leading to referral to Dr Hodges at Grafton Base Hospital)

• Noah presented with a “long history of headache which has previously been 11 February 2020 diagnosed as migraine … Mum reports that headaches are worsening in frequency and duration and are associated with vomiting”

• “Mum suffers with migraine and type II diabetes” March 2020 Noah’s Mother reports to Noah’s school (by email) about Noah’s migraines Noah consultation with Dr Jessie McKenna (specialist paediatrician)

• Issues: chronic migraine; generalised anxiety; obesity 5 March 2020

• “Noah reports feeling easily stressed and worries about his grades and performance at school. He has a good group of friends. He became very

Date Information teary when I asked about stressful life events, as his pop passed away last year and he was quite close to him” Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Anxiety / Depression 14 April 2020

• “Fath[er] died lost fingers”

• “Plan counselling refused psych long counselling visit 25 minutes’ Prescription

• Avanza 30 mg 1 nocte

• Lexapro 10mg 1 mane Noah’s Mother reports to Noah’s school (by email) requesting counselling for May 2020 Noah Noah’s Mother picked Noah up from school and took him to her parent’s house for the night

• Noah’s Mother said: “The next morning Wayne called me and threatened to hurt himself if I didn’t bring Noah home. I negotiated with Wayne and told him I would return home with Noah if he got help for his mental health issues and he agreed, so I returned home with Noah.” May 2020

• Noah’s Mother said: “To his credit, Wayne sought professional help and seemed to be improving and getting back to his old self.”

• Noah’s Grandmother said: “There was a time when [Noah’s Mother] took Noah to her parents’ house for the day and she was going to stay the night…I just worried about Wayne if Noah wasn’t around …After [Noah’s Mother] left Wayne said: ‘if I don’t have Noah I’ve got nothing’” Wayne consultation with Dr Hope

• “Anxiety Depression Plan Counselling PH Mental Health”

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no 12 May 2020 hallucinations, no suicidal thoughts, no substance abuse Prescription

• Avanza 30 mg 1 nocte Referral letter to ‘Mental Health’ in Grafton due to “WORSENING DEPRESSION

THREAT TO KILL SELF NO PLANS ?” MH Triage, Acute Care Service (ACS) Grafton Mental Health “3rd party triage from GP Dr David Hope, Wayne has managed by GP for depression over the years, however has noticed a worsening mood, flat affect and increased suicidal ideation. Partner took their child, male age 12 yrs, yesterday 12 May 2020 and went to stay with her parents due to issues in the marriage. Wayne rang [Noah’s Mother] (wife) and was threatening self harm…GP is concerned as family are contacting him and stating Wayne is becoming increasingly depressed and unhappy with life.” Mental Health Triage, ACS Grafton Mental Health:

• “GP is concerned as family are contacting him and stating Wayne is 12 May 2020 becoming increasingly depressed and unhappy with life”

• Action Plan “Contact Wayne – 0 1st party triage, Contact wife [Noah’s Mother] for collateral, F2F assessment of MS and risks if indicated” Wayne discussed at assessment team clinical review meeting with ACS Grafton Mental Health, “Client to increase Mirtazapine to 45mg and then see how he is in 13 May 2020 the near future. Consideration to a face to face assessment and a psychiatrists appointment thereafter if clinically indicated. Client for contact today. Liaise with GP Dr David Hope as appropriate” ACS progress notes by Beth Rheinberger, Social Worker, (telephone call) signed at 10.18:

• “Wayne stated this is the worst he has felt since the onset of depression a 13 May 2020 few years ago, coinciding with his accident”

• “Wayne stated is having thoughts to hurt himself every day, and includes a plan to hang himself”

Date Information

• Offered Wayne a face-to-face assessment at Maclean Community Health same day which he accepted ACS Mental Health Assessment: signed at 17:18

• Diagnosis: “Provisional severe depressive episode without psychotic symptoms (working)”

• “Wayne stated crisis point occurred when wife stated she was not coming home to Wayne that night and was staying in Tyndale with her family. Wayne stated he felt isolated and alone at this point and there was no reason to live.

Wayne stated he had planned to hang himself yesterday away from home to protect his son, however he spoke with Noah who begged him to not kill himself and wait until he (Noah) could get home to Wayne. At this point [Noah’s Mother] notified others including GP and people tuned up at the home to assist and support Wayne”

• “Wayne differentiated between suicidal ideation (fleeting thoughts but rationalised ‘that’s not the answer, that’s stupid’ and suicidality forming a plan to hang himself away from the family home so son can’t find him, and ‘just want it all to stop’ (emotional pain, despair, anxiety), applying the latter to his current thought content”

• “Feels hopeless about possibility of change and being a happy, normal person”

• “Wayne demonstrated sound insight, identifying this was the worst he has ever felt and moving from fleeting suicidal ideation to forming a plan” ACS Grafton Mental Health telephone call to Dr Hope, signed at 17:20, advised of concerns about Wayne and changes to medication, Dr Hope to provide new scripts, Dr Hope had spoken with Noah’s Mother yesterday who was very upset for Wayne’s current mental state Letter from ACS, Grafton Mental Health, to Dr Hope:

• “Further to your referral of Mr Smith, the consultant psychiatrist Dr Hassan Abass has recommended increasing the mirtazapine (Avanza) from 30mg 13 May 2020 nocte to 45mg. Mr Smith will be followed up by the Acute Care Service to ascertain the effectiveness of this increase and whether further review with Dr Abass is indicated” ACS Progress note: signed at 17:23:

• “Phone call to Wayne. Confirmed appt for 15/05/20…Advised Wayne that ACS would be calling him daily until Wayne was more stable and feeling better, Wayne accepting of same, thanked writer, Advised Wayne his prescriptions from Dr Hope were ready for collection” Wayne consultation with Dr Hope (seen at 15.12pm)

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 13 May 2020

• Anxiety Depression counselling Prescription

• Avanza 30 mg 1 nocte increased to 45mg

• Lexapro 10mg 1 mane Wayne discussed at ACS Grafton Mental Health clinical meeting:

• Wayne “acutely suicidal” and “Talking to son stopped him do this” 14 May 2020 - “Increase with mirtazapine”

• For contact today by CM – low threshold for admission, For psychiatrist app.15/05 ACS Grafton Mental Health, telephone call to Wayne, call answered by Noah who 14 May 2020 said his father was out to have a haircut, reattempt contact later today Wayne consultation with Dr Hope

• Prescriptions 14 May 2020 Prescription

• Avanza 45 mg 1 nocte

• Lexapro 10mg 1 mane

Date Information ACS Grafton Mental Health progress note signed at 11:43 “Wayne is very anxious about potential hospital admission and is feeling very anxious and overwhelmed.

He is struggling with multiple psychosocial issues as well as depressed mood, grief and loss. Wayne stated his wife said she “can’t hold him up anymore”.

15 May 2020 Wayne’s protective factor is his son Noah, they have a very close relationship.

Wayne has the ability to take extended leave (has over 12 months longs service leave available)…ACS to make phone contact with Wayne daily for MS and risk assessment, in the event of no answer, contact his wife [Noah’s Mother] (NOK/Emergency contact)” Wayne assessed by Dr Abass and Beth, Senior ACS clinician Psychiatrist note signed 19:08 …”there was concern about his safety for having thoughts of hanging himself. Two days ago his wife took their teenage son and went to her parents saying she will not return that night. This made him feel depressed, angry with thoughts of ending his life by hanging. He spoke with his son who talked him out of this thought and both son and mum returned home to support Wayne.

Impression: Major Depressive Disorder/recurrent/in partial remission…risk of suicide is medium on long term.

15 May 2020 Plan:

1. Admission to hospital has been discussed to treat his depression and contain the risk, including admission to a private hospital (he has private funds) and availability of rTMS treatment that can be fast acting. He will discuss this with Noah’s Mother (his wife) and get back to us to facilitate progress.

2. Increase mirtazapine to 45 mg nocte and to continue citalopram unchanged.

3. Commenced lithium carbonate 250 mg bd as augmentation of his antidepressant and as effective anti-suicide medicine.

4. ACS follow up.

Letter from Dr Abass, ACS Grafton to Dr Hope:

• “I assessed Wayne via Skype today in presence of Beth, ACS clinician. There was concern about his safety for having thoughts of hanging himself. Two days ago his wife took their teenage son and went to her parents saying she will not return that night. This made him feel depressed, angry with thoughts of ending his life by hanging. He spoke with his son who talked him out of this thought and both son and mum returned home to support Wayne. Wayne reported depressed mood for more than 16 years duration soon after a lawn mower accident that cost him the tip of his index and middle finger of his right hand. He is treated with mirtazapine 30mg nocte, citalopram 20 mg mane.

Depression became worse when his father was diagnosed with lung cancer and died in November. Wayne performed CPR and brought his father back to life to be cared for in hospital to pass away two days later. He worked with his 15 May 2020 late father who was the harbour master for 33 years after which, Wayne is finding it harder and harder to do his job and not coping at all. The other major stress for Wayne is that he promised his late father to assist his elderly mother with paperwork and paying the bills, this proved very stressful to Wayne as he is not good with paying bills online and started to struggle lately.

Wayne reported waking up tired in the morning with no will or motivation to do anything, this is associated with loss of appetite and weight, worthlessness and helplessness”

• “Impression: Major Depressive Disorder / recurrent / in partial remission ?learning difficulty that was not picked up at school… Risk of suicide is medium on long term.” ACS Grafton Mental Health Plan:

Date Information

1. Admission to hospital has been discussed to treat his depression and contain the risk, including admission to a private hospital (he has private funds) and availability of rTMS [repetitive transcranial magnetic stimulation] treatment that can be fast acting. He will discuss this with Noah’s Mother (his wife) and get back to us to facilitate the process.

2. Increase Mirtazapine to 45mg nocte and to continue Citalopram unchanged.

3. Commenced Lithium Carbonate 250mg bd as augmentation of his antidepressant and as effective anti-suicide medicine.

4. ACS follow up Phone call to Wayne by ACS:

• Reports that his mood remains low but not too bad today in comparison to recent thoughts about his mood

• “Wayne stated that he has decided that no matter how low he may get he will not suicide as his son needs him. Son Noah is a protective factor” 17 May 2020 - Actions/Interventions, safety plan reiterated. Medications discussed, with Wayne denying any side effects. Wayne has looked into his private insurance and does not believe that he is covered for a private hospital admission but is still looking into it. Wayne was advised that the Grafton Mental Health Service would continue to follow up with him. Plan Telephone call to Wayne in the next few days… Phone call to Wayne by ACS, reports that his mood is low but improving

• Taking medication

• Denied any current suicidal thoughts, plans or intents. Denied thoughts to harm others. Reported he has decided to go back to work (worked today).

20 May 2020 Wayne reported that he has been paying bills for his mother and doing some other tasks for her. Wayne reported that he is still anxious but feels better after he has achieved a task. Taking his son to and from school. Feeling more motivated.

Noah session with school counsellor:

• Noah “appeared to lack insight and judgement regarding his issues”

• “Noah stated that his parents are going to split up as a result of his father’s difficulties with mental health, father has depression and was going to kill himself a couple of weeks ago in response to his mother taking herself and Noah to his Nan’s. His father reportedly phoned his mother and said if they did not return home in 20 minutes that he was going to kill himself… His father did not reportedly attempt suicide. Noah stated he really wanted to see his father and was worried about him hurting himself”

• Noah’s biggest fear is that his father will kill himself 28 May 2020

• Noah stated that whilst he was at his Nan’s and after his father said he would end his life, Noah was going to do the same. He stated that he began to walk down the driveway towards the highway with the intention of doing it, thinking his father was going to kill himself. The thought of not being able to see his father again stopped Noah from doing it. Noah stated he has not experienced SI (suicidal ideation) at any other time

• Spoke to Noah’s mother and informed her of Noah’s SI (suicidal ideation)

• [Noah’s Mother] stated that his father has not previously attempted suicide but threatens to “a lot” and she is staying in the relationship as “Noah won’t leave” Phone call to Wayne by ACS Grafton Mental Health:

• Call answered by Noah’s Mother who said Wayne’s mood does seem improved and she hopes he gets the help he needs, Noah’s Mother’s tone of voice seemed suggestive that there is significant emotional distance between them though they reside in the same home 30 May 2020

• Further call to Wayne and “mood low but improving”

• “Wayne was advised that the Grafton Mental Health Service would continue to follow up with him for the moment. It was suggested to Wayne that he makes an appointment with his GP Dr Hope for a referral to a psychologist through a mental health care plan in the near future”

Date Information Phone call to Wayne by ACS Grafton Mental Health:

• Wayne was on a boat fishing with Noah

• reports that his mood is still depressed but improving

• “Reported he has had some fleeting suicidal ideation in the preceding days 8 June 2020 however has been working which he advises is a good distraction for him”

• Reported cannot get an appointment with Dr Hope until 01/07/20 and one of his medication did not have repeats…Wayne was advised that I would mention this to Dr Hope when I call him this week and that I would also ask if there is an earlier appointment that Wayne may be able to get in to.

Script printed Prescription 11 June 2020

• Avanza 45 mg 1 ceased

• Mirtazapine 45mg 1 nocte commenced 19 June 2020 ACS Grafton Mental Health PC to Wayne, nil answer Phone call to Wayne by ACS Grafton Mental Health

• Wayne and Noah on a boat fishing

• Wayne reports that mood is going – improved but does not feel much different from the introduction of lithium 21 June 2020

• Questioned whether he has had a blood test for the levels – states he didn’t know he had to…encouraged him to get a blood test for the levels because it shows whether there’s maybe too little or too much in his system

• Blood test suggested Phone call to Wayne by ACS Grafton Mental Health:

• Wayne reports that his mood is improving 22 June 2020

• Grafton Mental Health Service would continue to follow up with him for the moment with a consideration for a future Psychiatrist’s review Noah session with school counsellor:

• Issue: “Father’s mental health”

• Noah appeared very anxious, said “Dad’s getting better I think. He’s getting up and going fishing and doing things again”. He added that he felt his 24 June 2020 mother and father were ‘okay now’ and did not think they would break up.

• Canvassed as to how his mother reacted after being informed of his SI (suicidal ideation) following the previous session, Noah stated that she had asked him about how he had been feeling but that he told her he didn’t want to talk about it” Wayne consultation with Dr Hope

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• Anxiety, Depression, Manic 1 July 2020

• Counselling visit 25 minutes Prescription

• Mirtazapine 45 mg 1 nocte

• Lexapro 10mg 1 mane

• Lithicarb 250mg 1 bd commenced Dr Hope referral letter for Wayne to Dr Mark Scurrah (psychiatrist) 1 July 2020 - “I seek your opinion regarding anxiety, depression, father died, stress with marriage, could you review” Phone call to Wayne by ACS Grafton Mental Health:

• Wayne’s mood improved, nil further thoughts of suicide, feels well supported by GP Dr Hope, appointments in place for private psychology and psychiatry, had opened up to work friends as well about his depression and feels 3 July 2020 supported by friends Letter from ACS Grafton Mental Health to Wayne, closing episode of care, encouraged to see GP and private psychologist, included “pathways to care should you need to reach out in the future for ongoing mental health supports” ACS Grafton Mental Health phone call to Dr Hope, nil acute risks identified when 3 July 2020 he saw Wayne on Monday, agreeable to provide ongoing support and advised he has already organised psychology and psychiatry supports.

Date Information Letter from ACS Grafton Mental Health to Dr Hope re closing episode of care for Wayne…Wayne’s mental state and mood has improved and has nil further acute mental health risks at this time. Wayne advises is well supported by yourself and has a referral to private psychologist already organised.

Wayne consultation with Dr Hope

• Phone consult, requires counselling, depression

• “Not coping with everyday life”

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse 21 July 2020

• Mental Health Care Plan

• PH Anxiety Depression Bipolar Counselling

• Visit 25 mins Prescription

• Mirtazapine 45 mg 1 nocte

• Lexapro 10mg 1 mane Dr Hope prepared a Mental Health Management Plan for Wayne 21 July 2020 21 July 2020 Dr Hope referral of Wayne to Stewart Hase (psychologist) Wayne first consultation with Stewart Hase (per Hase statement)

• “had only just started taking lithium prior to appointment which was to treat the depression, also taking 10mg Lexapro and 45 mg mirtazapine to help him sleep, several issues causing him stress, recorded episodic major depressive episode, emailed some breathing and relaxation exercises and did some cognitive behaviour therapy” Progress notes:

• “Father died Aug 2019 – still having problems including suicidal ideation and depression, Would not act on it due to son – more a feeling of not caring if didn’t wake up in the morning. Plan in place. Long history of depressive episodes, mainly short, apparently since an accident at age 18…Worries over small things, feels stressed sometimes and feels overwhelmed that seems to lead to his depression - ?Adjustment issues.”

• “Talked about the problem of learning to use computers, which is having a big role in his work – prefers doing practical things. Lack of motivation and negative thinking about his ability. Lack of pleasure in things…Has psychiatric referral”

• Marital issues – he and Noah’s Mother are cordial but sleep in separate 12 August 2020 rooms. She told him the marriage was over prior to father dying. Feels sad that it has come to this but not agitated.” Dr Hase said in oral evidence:

• Consultations provided as part of the Better Access Scheme subsidised by Medicare

• Wayne paid approximately $50 out of pocket expenses per consultation with Dr Hase (with total cost per consultation between $120 - $140)

• Dr Hase was not aware that Wayne had been referred to Grafton Mental Health (ACS) in May 2020 by Dr Hope

• Dr Hase was not aware that Wayne had threatened to end his life by hanging in May 2020

• Dr Hase was not aware that Wayne had attended a consultation with Dr Abass in May 2020

• Dr Hase was not aware that Wayne was diagnosed by Abass with a Major Depressive Disorder, recurrent, in partial remission

• Dr Hase was not aware that Wayne was assessed by Dr Abass as being at ‘medium’ risk of suicide in the long term

• Dr Hase was not aware that Wayne had struggled with learning in school [8 July 2020 but Stewart Hase reporting letter to Dr Hope: date incorrect, likely - “Wayne is suffering from a Major Depressive Disorder. I’m grateful he is 12 August 2020] seeing a psychiatrist because I think he needs a satisfactory chemical solution. He told me that since taking Lithium that he is feeling a little better.

Date Information But he was tearful, agitated, and very depressed in affect, thought and action when I say him today.”

• “Difficulties in his marriage is complicating his recovery along with problems with ongoing grief from his father’s death a year ago. From his history it appear to me that his depression is triggered by stress. That his work is becoming much more focused on using computers seems to be bothering him a great deal. In general, Wayne suffers from problems of adjustment, which leads to depression.”

• ‘We are embarking on CBT with an emphasis on practical things that he might do to alleviate his depression.” Wayne consultation with Dr Scurrah, psychiatrist, as referred by Dr Hope

• “Chronic depression he attributed to a finger accident x years ago”

• Medication:

• Lexapro 10mg

• Mirtazapine 45mg

• lithicarb bd

• “Wife – counselling – relationship – “she says it is over”

• “Suicidal 4/12 ago”

• “Not now”

• Wayne said “Talking about it makes a difference” and “Steward helps"

• Wayne offered hospitalisation but declined 18 August 2020

• Hypomania, paranoia

• Conducted MSE (mental state examination)

• Assessment: Chronic depression with anxiety Dr Hope attended Wayne’s consultation (skype) with Dr Scurrah

• Poor sleep, early morning wakening, depressed mood, low self esteem, irrational fear, panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse

• ‘Skype M Scurrah, Anxiety, Depression, Plan counselling visit 1 hour follow / up’ Prescription

• Lexapro 10mg increased to 20mg Wayne second consultation with Stewart Hase

• “showed some serious improvement, he was fishing, going out with friends, had seen his psychiatrist and they had increased his Lexapro to 20mg from 10mg, showed he had been practising his breathing and was looking towards 26 August 2020 his future and speaking about his retirement” Progress notes:

• “Feels more in control and purposeful. Has been fishing regularly and walking most days. Looking at buying a new boat….Saw psychiatrist last week and increased Lexapro to 20mg…controlling negative and anxious thoughts” Wayne’s third consultation with Dr Hase

• Wayne “wasn’t feeling sad and no side effects from medication, spoke about enjoying work, going with and doing stuff with Noah, didn’t see any depressive symptoms and believed that the medication was having a really positive effect. Told Wayne to keep doing what he was doing and come back if he experienced symptoms again” Progress notes:

• “Reports being very well…Confident and not so anxious. Tolerating 16 September 2020 medication well. No depressive symptoms at all. ? medication seems to be effective…Advised to keep doing what he is doing and come back if experiences any symptoms at all.” Dr Hase said in oral evidence:

• Dr Hase and Wayne did not discuss admission to hospital for treatment for his mental health

• Dr Hase did not discuss the issue of whether Wayne had access to firearms during his consultations in 2020

Date Information Noah’s Mother had abdominal surgery and on return from hospital, she and Wayne started to sleep in separate rooms

• Noah’s Mother said: “This was essentially the end of Wayne and I’s relationship. Wayne remained being a good father to Noah but did not September 2020 support me with any household duties. I remained living in the family home for several months during which Wayne and I fought continuously. Wayne never physically assaulted me but there were times that I felt scared from threats he would make and the demeanour he would have at the time.” From September Wayne and Noah’s Mother separated under the one roof 2020 Script printed Prescription 21 December 2020 - Mirtazapine 45 mg 1 nocte

• Lexapro 20mg 1 mane

• Lithicarb 250mg 1 bd Noah’s Mother moved out of family house

• Noah’s Mother said: “Despite the improvements in Wayne’s mental health, I was still unhappy, and it was evident the relationship was over. Eventually I could not handle living in the family home anymore…Noah remained living with Wayne.”

• Noah’s Mother said: “In the early stages after moving out, I kept asking Noah to come and live with me but he refused saying he didn’t like Grafton and he 12 June 2021 had a sense of obligation to stay and help Wayne. Wayne and Noah were extremely close and Wayne was heavily devoted to Noah. Wayne seemed to idolise Noah.”

• Noah’s Mother said: “Even though Wayne and I were still amicable, I still felt a sense of guilt for moving out and being a bad mother and wife. From this, I struggled with my own mental health. These struggles went on for the best part of a year and a half after moving out. During this time there were periods that I didn’t see much of Noah.” According to Noah’s Grandmother, after Noah’s Mother moved out Noah and Wayne became even stronger, Noah would hardly leave Wayne’s side, even if Wayne would get up from the lounge room to go to the kitchen to get a drink Noah would also get up and follow According to Thomas Commerford, after the separation Wayne seemed happier, they were doing more things together with their sons, would speak to Wayne daily, go fishing According to Vincent (Noah’s paternal grandfather), he had a good relationship with Wayne, even after Wayne and Noah’s Mother separated, Wayne and Noah would go to Noah’s Mother’s parents for a meal about once a fortnight Wayne consultation with Dr Hope

• Prescriptions Prescription 17 June 2021

• Mirtazapine 45 mg 1 nocte

• Lexapro 20mg 1 mane

• Lithicarb 250mg 1 bd Noah’s school sent a notification of ‘chronic absenteeism’ to Wayne and Noah’s July 2021 Mother about Noah’s attendance at school Wayne lodged category AB firearms licence renewal application with the Firearms Registry, discloses attempt suicide or self-harm and depression

• Personal History section “Have you, in the past 12 months, been referred or 2 August 2021 treated for a mental or nervous disorder or illness?”, Wayne answered “No”.

“Have you ever attempted suicide or self harm?”, Wayne answered “Yes”

• Further details provided as “Depression after father passed away talked of self-harm” Wayne’s firearms licence application loaded into ILS for validation processes to 7 August 2021 occur and status of application updated to “Referred for Adjudication” Firearms Registry Adjudication Officer reviewed the re-application 10 August 2021

• created a file note on the personal history declaration

Date Information

• suspended the substantive category AB firearms licence

• prepared a Notice of Suspension for Police service upon Wayne

• created a WebCOPS event reference E82591364 for Police to action the Suspension “Based on the applicant’s responses to the personal history questions, it is not clear whether the applicant has actually attempted self-harm or only talked of selfharm. Nor is it able to be ascertained how recently this occurred. Regardless, concerns are held regarding this disclosure as well as his depression. Checks of previous applications lodged reveal no prior mental health related disclosures…licence is to be suspended and a psych assessment requested once suspended.” Suspension commencement date 10/08/21: “This suspension is valid for 12 months from date of service unless the suspension is lifted or your licence is revoked. A subsequent Notice of Suspension may be served where the matter has not been finalised by the expiry of this notice” WebCOPS Event E82591364 “urgent police assistance is required to seize firearms and serve a Notice of Suspension of a firearms licence or permit…Reason for suspension: Not in the public interest – mental health concerns. SMITH lodged his firearms licence renewal application on 02/08/21 and disclosed he has attempted suicide or self-harm and suffers depression following his father passing away.” WebCOPS event E82591364 verified by a Firearms Registry Team Leader, this 12 August 2021 caused the event to be transferred to a work priority queue for actioning WebCOPS event E82591364 transferred to the Coffs/Clarence Police District by 13 August 2021 the Firearms Registry State Coordinator, Senior Sergeant Troy Hamilton Coffs/Clarence Police District created WebCOPS case C82800372 out of event E82591364, allocated to Senior Constable Nadene Carroll for case management Police attend home 23 Kookaburra Court Yamba and seize 3 firearms (taken to Grafton Police station) 19 August 2021 - Wayne was very cooperative

• Noah’s Mother was present Firearms entered into exhibits forensics information and miscellaneous property system (EFIMS) for safe keeping pending finalisation of a review into Wayne’s licence Wayne consultation with Dr Hope

• “Psych: Normal sleep, no early morning wakening, normal mood, normal self-esteem, no irrational fears, no panic attacks, no compulsive behaviours, no delusions, no hallucinations, no suicidal thoughts, no substance abuse.

Reason for contact ph anxiety depression controlled [sic] Actions: printed 1 medical certificate” 24 August 2021 - Dr Hope provided medical certificate for Wayne for purposes of firearms suspension review Medical Certificate: “This is to certify that Wayne Smith is receiving medical treatment for anxiety/depression due to personal issues and his father’s recent death, His issues have since resolved and he has been completely stable on medication for the past 5 yrs. This certificate was completed on 24/08/2021” Wayne completes (but does not immediately send) correspondence requesting the suspension of firearms licence be reviewed, includes medical certificate from Dr David Hope dated 24/08/21 Wayne’s letter: 25 August 2021

• “… I have been honest and transparent and a law-abiding citizen I haven’t even had a speeding ticket and I am no threat to the public I have held firearms licence permit for years Over 12 months ago I was at a low in my life after the loss of my father, this I believe to be what brought on depression,

Date Information After looking after him for 12 months prior, he had lung cancer on the night he collapsed I gave him CPR until emergency services and police arrived and took over. This didn’t affect me for some time as I have to be strong for my mother at the time. When I had depression I sort help from my local GP I am in good spirit and not suffering from depression…” Firearms Registry receive correspondence from Wayne seeking review of 20 September 2021 suspension Firearms Registry Adjudication Officer reviewed the re-application and recent medical correspondence

• holding status “pending”

• letter requesting Wayne obtain a “Mental Health Risk Assessment”, prepared a “Medical Report Authorisation” form 24 September 2021 - letter to the treating GP requesting referral to psychiatrist or psychologist to undertake a “Mental Health Risk Assessment”

• letter to the psychiatrist or psychologist to ask for a mental health risk assessment (Letter to Psychiatrist/Psychologist sets out matters to address including confirmation has read the letter sent to the customer on this date) Dr Hope completes a referral letter for Wayne to Dr Hase

• Dr Hope stated: “I seek your opinion regarding THIS MAN REQUIRES A PSYCH ASSESSMENT FOR HIS FIREARMS LICENCE Thank you for your care and assistance. I shall await your reply” 11 October 2021 Letter includes reference for consultations for depression in 2004 and prescribing Lexapro (escitalopram), Lithicarb (lithium carbonate) and mirtazapine last issued on 17/06/21 Dr Hase said in oral evidence:

• Dr Hase did not receive the referral letter from Dr Hope Wayne transferred $19,000 to “Northside Marine” (a boat shop) from CBA account 26 October 2021 BSB: 062569 AC: 10052669 (with balance -$23,599) Wayne consultation with Dr Hope (last consultation had with Dr Hope due to his pending retirement)

• Prescriptions 23 November 2021 Prescription

• Mirtazapine 45 mg 1 nocte

• Lexapro 20mg 1 mane

• Lithicarb 250mg 1 bd End of 2021 Wayne contacted Stewart Hase and made an appointment Wayne’s fourth consultation with Dr Hase

• “I went through the criteria and Wayne did not meet any of the criteria under the DSMV. Wayne was speaking about fishing, new responsibilities at work, Wayne was speaking about his relationship with Noah and how well it was going. Wayne was sleeping well and had no cognitive impairment. Wayne was showing no signs of agitation and agitation is a major sign of suicide.” Progress notes:

• “very upbeat despite wife having left him 3 months ago. Feels as if it was inevitable and quite resigned to it. No anger or recriminations. Would take her back if she wanted to but doesn’t expect this. They communicate well 1 December 2021 especially re son Noah. Adjusting to domestic duties…”

• “In control of his anxiety…sleeping well, talkative, positive mood, no cognitive impairment. Taking medication regularly – has confidence in it.”

• “Would like to get gun licence back. Taken away when depressed and having suicidal thoughts in 2019 when father died. Claims has had a licence for many years and owns a 303, 22 and a shotgun. Wants to teach his son to shoot. Needs a letter from me to Police supporting his application.”

• Assessment: None of the DSM criteria for MDE were observed or reported.

No apparent alcohol or drug problems noted as per previous visits. No agitation or anxiety observed or reported. Appears to be as well as he was, if

Date Information not better, than when last seen. Reported feeling well for the past year with no bouts of depression and better management of his anxiety and stress.” Medical report:

• “I have been asked to provide a psychological assessment of Wayne in relation to his suitability to hold a firearms licence. His suitability questioned due to his mental health issues in 2020.”

• “Wayne was a patient of mine in 2020 and I saw him on 3 occasions following his referral by his GP, Dr David Hope, on 21 July 2020. He recovered quickly with appropriate psychological interventions and medication and I discharged him on 16/9/2020. I also saw Wayne on 1/12/2021 in relation to this report and conducted a clinical assessment in relation to his suitability to possess a gun licence. Wayne was in good spirits, emotionally appropriate, talkative, alert, and relaxed. He told me that he has not had any episodes of mental ill health since he saw me and has managed some recent stressors very well.

Wayne has taken on new responsibilities in his role as a Harbour Pilot at Yamba, has purchased a new boat, is taking his son fishing a lot and appears to be enjoying life. Wayne said that he wants to teach his son to shoot and to hunt, and that he has held a firearms licence for many years and is an experienced shooter and hunter. I could not detect any signs of mental ill health during the interview. In summary, I do not believe Wayne suffers from any psychological impediment to his fitness to possess and use firearms. He appears to be a rational person, able to exercise good judgement and has a very positive view of the future. I do not think that Wayne is likely to be a risk to public safety should he possess firearms.” Dr Hase said in oral evidence:

• Wayne did not provide Dr Hase with any Firearms Registry documents (including the Risk Assessment questionnaire) at this consultation

• Dr Hase had read the Risk Assessment questionnaire several weeks before this date in relation to another patient

• Dr Hase wrote the letter addressed to the Firearms Registry for Wayne using a template from another (previous) patient and (largely) used the same final paragraph from that previous template letter because it related to the issue of general risk and firearms

• Wayne told Dr Hase in this consultation that the reason he wanted his firearms returned is so he could teach Noah to shoot and hunt

• Dr Hase gave the letter to Wayne to provide to the Firearms Registry Firearms Registry conducted a review of the Mental Health Risk Assessment process to assess continued relevance and identify potential enhancements, 2022 aimed to modernise the procedure and align it with current thinking on mental health risks associated with firearms possession According to Alan Jones, Wayne started worrying about doing his job properly Approximately 2022 (“saying he was incompetent, it seemed like every little thing was getting harder and harder for Wayne…he became resistant to everything”) Dr Couper took over practice from Dr Hope and his patients

• No formal handover from Dr Hope

• Dr Couper the only GP working in the practice January 2022 - Dr Couper assumed responsibility for, nominally at least, 2,440 patients

• Dr Couper had access to Dr Hope’s electronic files for the patients of the practice (and was not in a position to access and refer to previous handwritten patient files because it was not reasonably possible to do so) Firearms Registry received response from Wayne including:

• copy of original letter requesting MHRA

• completed Medical Report Authorisation form

• extract of the second page of Dr Hope’s referral letter to Dr Hase, referring 11 February 2022 Wayne for psychological assessment, omitting reference to medications prescribed.

• receipt from Registered Psychologist Dr Stewart Hase

• letter from Dr Hase dated 1 December 2021 15 February 2022 Noah’s school sent email to Noah’s Mother:

Date Information

• Noah’s behaviour has not been great over last couple of weeks: “arrived late, disrupted prayer and is continually demonstrating immature behaviour which disrupts the learning of those around him… level of disruption yesterday resulted in him being removed from class altogether to another classroom especially set aside for students who are disrupting the learning process…hopefully been a blip”

• Noah’s Mother responded: “Thanks for getting in touch with me. I will have a discussion with Noah today after school and get back to you” Boating Safety Officer (BSO) alleges Noah bullying his son at school and Wayne allegedly leaking confidential information to Noah about work matters (BSO worked for Maritime NSW), BSO allegedly “affronts” Wayne BSO email to Wayne:

• “Wayne, I am concerned that your son Noah has and continues to bully my son Kobe within the school environment. It is alleged that Noah, bases his bullying behaviour upon my position in Maritime. Noah alleging unreasonable 23 February 2022 boating and compliance activities. I do not apologise for my compliance responsibilities in this regard. In addition I am advised by my son and school representatives that the bullying is also alleged to be based upon operational & potentially sensitive information, perhaps privy or otherwise known to only you. This allegation may present as a breach of personal privacy and of sensitive cooperate information. I am hoping that the bullying desists, and the matter does not need to be further examined by Government.” Noah’s Mother emails Noah’s school about the fact that Noah was placed on ‘stage 2’:

• Noah’s Mother’s email: “I feel that it is time for me to have a meeting to address the issue. Noah felt that the deputy principal was trying to get him to change his story on Friday that he was not punched and the fact that he was pushed first has not been addressed just because the teacher may not have 28 March 2022 seen this didn’t mean it didn’t happen. I believe the truth needs to be addressed before Noah will feel he can move on and have advised him that if he is pushed tomorrow that he is to advise the teacher that he wishes to have me there as I will not have bullied. Yes Noah pushed the kid away from him to protect himself and asked the child to stop and when King hit he still didn’t hit back.” [email suggests this was second incident for Noah in 2022] Noah’s school year advisor emailed Noah’s Mother

• “Noah has been placed on Stage 2 for pushing another student. …Students would usually be placed on Stage 1 (the warning stage) for a first offence of this nature. However, given that Noah has had 41 Schoolworx, some of which were for hands-on behaviour, he was moved directly to Stage 2 as a result of 29 March 2022 what happened on the bus back from sport last week. We are aware Noah was punched by another student …after getting witness statements from a variety of students, as well as the teacher that observed the incident, I am confident that we are aware of everything that occurred between the boys on the bus.” Firearms Registry introduced revised guidelines to assist staff in determining when to request a Mental Health Risk Assessment, included the identification of mental June 2022 health disorders with specific risk factors related to self-harm or violence and expanded to included consideration of non-psychological conditions such as dementia and serious head injuries Wayne attends consultation with Dr Couper

• “mood stable” Prescription

• Mirtazapine 45 mg 1 nocte

• Lexapro 20mg 1 mane 14 June 2022

• Lithicarb 250mg 1 bd

• Actions Lithicarb Tablet 250mg dosage changed from 1 b.d. Oral – Swallowed (include active ingredient on script) to 1 b.d Oral – Swallowed (include active ingredient and brand name on script

• Pathology requested

Date Information Dr Couper says in her statement:

• “blood tests showed lithium levels low however Wayne reported his mood was well controlled, gave a script for blood pressure tablets but no antidepressants at this stage” Wayne sent email to Firearms Registry stating this is a “follow up letter to regain my firearms licence”

• Wayne’s email: “it has been months since I have forward letter from doctors 7 July 2022 with information to Firearms Registry” and “I have seen Doctor DW Hope, who referred me to Doctor Stewart Hase, registered psychologist 01/12/2021”

• Attached copies of the assessment letter; receipt from Dr Hase; referral from Dr Hope and medical report authorisation Wayne consultation with Dr Couper

• Hypertension

• “lithium level below therapeutic range through [sic] feels his mood is well 12 July 2022 controlled with it. No need to change meds/doses” Prescription by Dr Couper

• Amlodipine (high blood pressure) Wayne transferred $13,300 to “GFAB Trailer Limited” (a boat trailer company) 16 July 2022 from CBA account BSB: 062569 AC: 10052669 (with balance -$21,402) Wayne filled repeat prescription from Dr Couper (prescribed 14 June 2022)

• Lithium 20 July 2022

• Lexapro

• Mirtazapine Wayne transferred $13,300 to “GFAB Trailer Limited” (a boat trailer company) 11 August 2022 from CBA account BSB: 062569 AC: 10052669 (with balance -$16,368) Wayne filled repeat prescription from Dr Couper (prescribed 14 June 2022) 15 August 2022 - Lexapro

• Mirtazapine Noah’s school teacher sent an email to Noah’s Mother about Noah and he has 18 August 2022 “continued to make poor behaviour choices” and has been disruptive in class Wayne filled repeat prescription from Dr Couper (prescribed 14 June 2022) 21 September 2022 - Lexapro

• Mirtazapine Noah breaks leg in boating accident when away with friends at Brooms Head, Noah ultimately taken to John Hunter Hospital, Noah didn’t return to school for end of school year COPS E90983218…Noah staying with friends (and their family) at Sandon River Camp Ground during school holidays…remote area camp ground…two boys in each boat (aged 12, 15, 15 and 16), master of each boat sees sandbar and attempt to navigate around it…collision and all four occupants ejected into water, no one wearing life jacket… conflict between witness statements (masters and 26 September 2022 passenger other than Noah) and physical evidence re damage to vessels…caretaker of camp ground informed police he had reports from other patrons of the camp that the persons involved had been driving erratically all week….early inquiries reveal boats travelling at 20 knots in an 8 knot sign posted area Sgt James Etches from Coffs Harbour Water Police investigates Both parents with Noah at Grafton Hospital Noah flown to John Hunter Hospital for surgery on left leg (broken femur) and both 27 September 2022 parents present on ward

Date Information Sgt Etches contacts BSO via phone and sends email so he could complete a vessel incident report (VIR), said that Police would pursue the investigation due to serious nature of the collision, would inform BSO of the outcome of the investigation, asked BSO to provide the Master’s involved maritime antecedents as would assist in deciding what course of action to take against the drivers 28 September 2022 BSO emails Police with maritime antecedents of Master’s involved Text from BSO to Wayne 8:42am BSO texts Wayne “Hi Wayne, [BSO] from Maritime give me a call please” 2:39pm BSO rings Wayne 2:40pm Wayne text BSO “Can’t talk at John Hunter Hospital” 28 September 2022 BSO texts “Hope Noah is okay. Police have asked me to do Maritime background checks. I can’t find a record for Noah. Guess that’s a good thing, but I thought he would have a license?” 6:15pm BSO texts “Wayne, I am sorry Noah is involved. I need to provide the info requested. Does Noah hold a Boating License or have previous offences or some record with Maritime??” Police interview Noah in Hospital After the interview, Wayne spoke to Police about ongoing interactions he had been having with BSO from Transport NSW Maritime, showed Police various SMS messages from BSO about the vessel collision Wayne forwards SMS from BSO to NSW Police, SMS to police says “Hi Mick, If u need more information re boat accident sandon river both Noah and I happy to help. Your [sic] welcome to visit any time you’re up our way Yamba pilot station I’ll shout the coffee…” BSO calls Wayne twice whilst Wayne with police. Wayne doesn’t answer phone 29 September 2022 but shows incoming call details to Police 2:02pm BSO leaves voice mail for Wayne “Hi Wayne, [BSO], just following up on seeing how Noah is and I still need some information about his licence if he has one, other record with Maritime. I can’t seem to find anything which, like I said, I guess is good, but it surprises me we don’t have anything. I’m thinking there is a data error name spelling or date of birth, something like that. Give me a call back thank you” Details provided to Sgt Etches who called BSO direct supervisor (on unknown date), raised concerns regarding BSO and advised that Police had carriage of the matter and BSO should not be contacting Wayne re the incident Etches receives phone call from BSO, asked if planned to take any form of legal action against Noah, Etches said highly unlikely, BSO appeared to be frustrated and said words to the effect “It doesn’t always take one person to be in control of Approximately 29 the steering and propulsion of a vessel”…“Have you ever heard of proper September 2022 lookout”…“I need to know if Noah Smith has a boat licence so I can complete my VIR”… “Our records show he does not have a boat licence” Etches told BSO the investigation was a police matter and he should cease interjecting in it Etches speaks with Senior BSO Brett Ryan and brings to his attention BSO involvement again, Ryan said BSO had been advised to distance himself from the investigation and had not yet completed and finalised his VIR for the incident [Wayne’s record of incident states 14 September 2022, this must be incorrect as the incident occurred on 26 September 2022] Date not known BSO approached Wayne at the Pine Wood Corner Coffee Shop in Yamba and commenced talking to Wayne about previous attempts to speak with him, Wayne

Date Information said “Stop right there [BSO]. This isn’t appropriate and it has got nothing to do with you, back off. It’s got nothing to do with Noah. Police are running the investigation and Noah has given a statement” BSO said “Yes it does. It’s like when an owner of a vessel that is involved in an accident, I can investigate the owner of that vessel” Wayne said “Noah never had a boat down there. He never had a registered boat there. I never had a boat there either so it’s not appropriate – not on.” BSO said “yes it does” Wayne was embarrassed that his personal business was to be shouted out by someone that had nothing to do with the boating incident or the investigation, BSO had no right to approach him out of uniform and to start to question him. He said that he told BSO his actions were inappropriate but BSO continued to the point of harassment which caused Wayne stress and anxiety According to Sergeant Etches Wayne told him he had a strong dislike for BSO…said BSO had fronted him in a coffee shop in Yamba demanding he comply with his investigation powers to investigate the marine vessel collision. Etches could tell that Wayne was becoming increasingly frustrated with BSO as he said “If he comes near me or my family again I will knock his fucking head off”…Etches provided advice to direct BSO to Etches, he would speak to BSO’s supervisor again, Wayne should make a formal complaint to NSW Maritime re BSO’s behaviour and discussed avenue of pursuing a Personal Violence Order if he felt the need to [Wayne’s record of incident and text messages states 18 September 2022, this must be incorrect as the boating incident occurred on 26 September 2022] 9:02am: BSO submits Vessel Incident Report (VIR) outlines police investigation and that Police were yet to interview and obtain a statement from Noah [which was incorrect] 1:01pm: BSO sent text to Wayne: “Wayne, I draw your attention to Powers conferred to me under section 117 of the Marine Safety Act 1998. You have refused to cooperate, although I made four separate requests for information from Date not known you in relation to a boating incident. I draw you attention [to] section 125 of the same Act providing Penalty for refusing to co-operate and caution you accordingly. I will discuss the matter with you in the coming days.” 5:20pm: Wayne sent text to BSO: “[BSO], thank you for your concern. Under no circumstances are you to approach or speak to my son in relation to this matter.

Under no circumstances are you to attend at my home address. Under no circumstances are you to approach me and speak to me in relation to this incidents. This matter has been investigated by the Police and finalised. Any further correspondence is to be directed to them. Please do NOT Text me again in relation to this matter. Wayne” October – Noah did not attend school in term 4 due to his injury and admissions to hospital December 2022 and recovery (Term 4) Noah transfers from John Hunter Hospital back to Grafton Hospital, both parents present 2 October 2022

• AirMed Nursing report refers to “lovely young man travelling with his dad Wayne” 4 October 2022 Noah discharged from Grafton Hospital According to Noah’s Grandmother, when Wayne and Noah came home, Noah completely dependent upon Wayne for care, Wayne took fair bit of time off work to help Noah, very hard on Wayne 5 October 2022 Firearms Registry Adjudication Officer reviewed the MHRA:

Date Information

• prepared a Mental Health Report Review

• recorded decision to recommend a firearms licence

• status of licence application updated in ILS to “Recommend to Issue”

• “After reviewing the situation [sic]. This applicant suffered an episode after the passing of his father. I do not believe after reading the GP letter and the Psychologist report that this person does not [sic] suffer an ongoing MH condition. He was honest on his licence reapplication. There is no indication on Webcops of any concerns and this person has held his licence since 1998 with no concerns. Licence updated to recommend to issue.” Wayne contacted Firearms Registry through PoliceLink requesting update to 7 October 2022 review of firearms licence suspension, advised of status “Recommend to Issue” Wayne’s Category AB firearms licence photograph advice approved, automated 8 October 2022 response based on status moving to “Recommend to issue” According to Thomas Commerford, after Noah broke his leg Wayne started to spiral and his depression started to get worse, would often go to Thomas’ house and be a nervous wreck, wasn’t crying but would shake and bite at his fingers Firearms Registry sent a ‘photograph advice letter’ to Wayne approving his firearms licence: 10 October 2022 - “The Commissioner of Police has approved the issue of your Firearms licence or permit” and set out that Wayne was required to attend a NSW Service centre to obtain his licence 14 October 2022 Noah attended Fracture Clinic at Grafton Hospital Police investigation into boat accident completed:

• Determined each operator of the vessels had driven the vessels in a negligent manner which had caused the collision to occur

• Driver of boat Noah had been in was issued with an infringement notice for 17 October 2022 “Operate recreational vessel negligently not cause death or GBH – First Offence”, other diver two infringements “Operate recreational vessel negligently not cause death or GBH - First Offence’ and “operate master nonPWC vessel without boat driving licence” Wayne SMS to Police “Hi Mick. Noah is doing very well as per phone conversation. Could we please get a copy of his statement that you took in Newcastle that would be awesome. I am still getting harassed by BSO. James at 20 October 2022 Mac Coffs Harbour has been great and has all the details. [BSO] had been spoken to and still continues to harass me about Noah in Olmert [involvement] in the incident. FYI I will follow up with a formal complaint letter to address to RMS” Wayne’s intake appointment with Sharnie from Hunterlink (though EAP (Employee Assistance Program))

• Wayne’s son Noah had a boating accident

• “son has had significant trauma from the incident. He is quite anxious and is upset at having to have surgery. Wayne isn’t really sure how to deal with situation” 21 October 2022 - “Wayne is ok with everything that has happened but is more wanting to get things off his chest”

• “Wayne is also worried about his son, his son has been raised by him and his mother has not been in the picture. The son has rung his mum asking for her to visit him and she said she cannot. His son has been crying on and off for hours.” Wayne’s second consultation with Sharnie from Hunterlink

• Separation between Wayne and Noah’s Mother very hard

• “Noah is very angry and distraught over his mother not ringing or visiting him.

Noah is having “rage” episodes where he says he wants to “stab her” and 24 October 2022 outbursts of that nature. Wayne doesn’t know how to deal with it. I talked Wayne through by helping Noah to process the rage, through punching a pillow, the lounge or a mattress…I advised Wayne the most healthy way is to let Noah know it is ok to be upset and angry and his abandonment. I explained to Wayne that we all have different parts to us. There is a part of

Date Information Noah who loves his mum and wants his mother’s love and there is a rageful part that is hurt he has been abandoned.”

• “Wayne said he got ‘very depressed’ [last year] but he is ok now” Wayne filled repeat prescription from Dr Couper (prescribed 14 June 2022) 28 October 2022

• Lexapro Wayne’s third consultation with Sharnie from Hunterlink

• Wayne said “things are going well” and that home is going well right now.

Wayne took his son to see his wife’s parents and they all went out for dinner.”

• Wayne said that his ex-wife’s parents have been “amazing” and ring Noah every day. Noah’s grandfather will go with them to Newcastle in two week’s time for Noah’s hospital appointment”

• “Wayne said Noah ‘freaked out” ‘the other night when he was leaving the 31 October 2022 house to go to the shops for 10 minutes. Noah became incredibly upset.

Wayne had to assure him he was returning. Wayne said he told him ‘you have got to get it through your head I am not going anywhere. We talked about Noah’s abandonment issues.

• “I recommended to Wayne that Noah get some counselling and he said he has been trying to talk to him about that but he just ‘locks up’. We talked about why that might be happening and that it may be that he gets help when he is a bit older and more mature” Wayne attends Service NSW to verify identity and have licence photo taken, 3 November 2022 Category AB firearms licence re-issued (backdated to 2 October 2021, expiry date of the previously issued licence, new expiry date of 2 October 2026) Wayne’s fourth consultation with Sharnie from Hunterlink

• “Wayne has been struggling with a marriage breakdown and his son has been struggling with the fact that his mother has chosen to remain absent from his life.”

• “Wayne has engaged Hunterlink to help navigate this situation with his 15 year old son. His son also had a boating accident and was injured, requiring 7 November 2022 surgery.”

• “Wayne was doing much better this week. This morning Noah’s mother called him to have a talk, Wayne was ecstatic about this development…Wayne has struggled with depression on and off throughout his life, however he has not felt himself getting depressed during all of this.

Wayne is not suicidal” Wayne complaint to NSW Ombudsman about conduct of BSO, Ombudsman 10 November 2022 suggests referral to Transport for NSW Roads and Maritime Wayne contacted the Firearms Registry through PoliceLink requesting advice 11 November 2022 about regaining access to his firearms, advised to contact local Police 14 November 2022 Follow up x-ray for Noah Wayne sent email to Senior Constable Jeffcoat:

• “I had my firearms & ammunition taken from me approx.. a year ago, as my Firearms licence permit wasn’t renewed at that time. I have since regain my 23 November 2022 Firearms Licence Permit …see attached photos. I am now in the process of finding how and what to do to have my firearms & ammunition returned.

Appreciate your help in the return of my firearms/ammunition, that would be awesome” Senior Constable Carroll received email from SC McColl, Grafton Exhibit Officer, 24 November 2022 noting that Wayne’s firearms licence had been reinstated and to contact Wayne regarding return of firearms Wayne’s fifth consultation with Sharnie from Hunterlink

• “Wayne has been sick with flu past 2 weeks,”

• “Noah has been speaking to his mum regularly and she said she “might” see him for Christmas but is not sure…Wayne has had a “blow up” with Noah last 5 December 2022 night as Wayne jokingly said to him “I might get you a new mum for Christmas” and Noah got very upset and took it as Wayne leaving him. He got so angry he started throwing things. Wayne said that every time he leaves the house Noah thinks he is leaving him and sometimes Wayne and

Date Information him fight and Wayne will go into the next room and Noah comes in and will sit on top of him and freak out thinking he will leave him”

• “Wayne is not suicidal and has no thoughts of suicide”

• “I suggested to Wayne that he tries to get Noah to engage in counselling” Wayne transferred $166,092 to “Yamba Boat” from CBA account BSB: 062569 9 December 2022 AC: 10052669 (with balance -$77,276) Wayne filled repeat prescription from Dr Couper (prescribed 14 June 2022) 9 December 2022 - Lexapro

• Mirtazapine According to Noah’s Grandmother, Noah was nagging Wayne to buy him a bigger boat, cost about $50 000 and Wayne borrowed money on the house to purchase it, it was also Wayne’s big dream, motor still in Brisbane and Wayne was trying to get it painted and this was stressing him out Senior Constable Jeffcoat email to Wayne

• “Hi Wayne, sorry for the delay in replying to you, I had been on leave for a 12 December 2022 few weeks. I will look at the matter today and confirm your licence status. If everything is above board I will arranged for the firearms to be collected from Grafton and returned” 13 December 2022 Wayne sent reply email to Senior Constable Jeffcoat Wayne’s sixth consultation with Sharnie from Hunterlink 13 December 2022 - “spoke to Wayne, he is going well, he doesn’t have anything to update me on so he doesn’t feel he needs session today” 14 December 2022 Firearms returned to Wayne (by SC Lavendar) According to Noah’s Grandmother, when Wayne given his firearms back “I wasn’t worried at all. Wayne was in a very good place.” Noah attended Grafton Hospital with post operative complications

• “has been progressing along well but pain since went out in boat yesterday, since then feels like knife stabbing in hip, not a constant pain, every now and then but not at same part of stride, waves of pain about 5 secs apart shary [sic] and burning pain, describes a more nerve like pain, nearly like sciatic but 19 December 2022 in wrong locations – much more lateral on thigh…relief at rest…Imp MSK pain +/- some nerve component from being on boat yesterday, already improved from yesterday, plan: activity modification…paracetamol and nurofen, script for 10 endone tabs ½-1 tab BD PRN for severe pain, discussed would not expect him to need anymore than this” According to Vincent (Noah’s paternal grandfather), in the last six months things started to change a bit for Wayne, such as bit of financial trouble over the boat, not eating properly and not looking after Noah properly, Wayne said Noah 2023 wouldn’t let Wayne out of his sight, Vincent thinks this is because Noah knew Wayne wanted to harm himself and felt like if he wasn’t with Wayne, Wayne would hurt himself February – April Noah’s attendance at school was 33% (related to injury, recovery and 2023 (Term 1) rehabilitation following his accident) Wayne called Hunterlink (EAP) and spoke with Renee to book an appointment 6 February 2023 - “he said he that he was going to be sent some tools that he could use for his son”

Date Information Wayne consultation with Hunterlink (clinical record says ‘Sharnie’ but Sharnie says in her statement that her last consultation was December 2022):

• “Wayne got in touch as he wanted some advice on his son.”

• “His son’s bird died, he got caught in the lounge and suffocated. Noah was distraught”

• “Wayne said it is all getting too much for him and wants some advice on where Noah should reach out to get some help. As Noah is only 14 I 7 February 2023 recommended headspace. I let Wayne know that Noah has got an anxious attachment style. Wayne finds him clingy and needy and feels suffocated”

• “Wayne has been informed that his wife has a new boyfriend that she is living with now. He has not told Noah as he knows this will not be received well”

• “Noah is terrified of being abandoned. Wayne is doing well with the communication and helping Noah through his feelings but feels it is “beyond him” and that for his sake as well as Noah’s he needs some help”

• “Wayne will get in touch again when he feels the needs to” 16 February 2023 NSW Ombudsman referred Wayne’s complaint re BSO to ICAC Noah attended John Hunter Hospital via telehealth:

• “progressing well, has some pain over lateral hip ?trochanteric bursitis…Plan 6 March 2023 more xrays, FU this Friday in T2 clinic with XR via telehealth and discuss options - ?referral to private local surgeon for removal of hardware” Noah attended John Hunter Hospital: x-ray shows fracture uniting, follow up 10 March 2023 telehealth with x-ray prior in 3 months Wayne made an email inquiry with ‘Compassionate Inquiry” for counselling or psychotherapy for Noah on recommendation of Sharnie Everton from Hunterlink 26 March 2023

• “Can we book an appointment on computer via camera I would like to be present for the appointment” April – May 2023 Noah’s attendance at school was 58% (with absences reported to be explained by (Term 2) Wayne) Email correspondence between Wayne and Rati Riccardi (psychotherapist from 21 April 2023 ‘Compassionate Inquiry) for consultation for Noah Wayne and Noah’s consultation (online) with Rati Riccardi

• “In the 30 minute consultation with Wayne, he expressed what happened to them. He was searching for help with his son who was affected heavily from his mum leaving. Wayne told me that Noah didn’t want to go to school, he didn’t want to go out, he was staying home all the time and really depressed” 26 April 2023

• “At some point, Wayne invited his son Noah to come in front of the camera.

Wayne and I continued talking about issues…Noah got emotional and looked like he was about to cry” and left the camera

• “My thoughts on the session are that it was very clear that both Wayne and Noah were both depressed” Approximately April According to neighbour, Wayne in back yard near their dividing fence, Wayne or May 2023 burning things, Wayne said he was just burning memories (wedding photos) According to Noah’s Mother, Wayne rang and said he was struggling with his mental health and had stopped taking his medication, had forgotten to pack his medication when he went to be with Noah after the accident and hadn’t been April or May 2023 taking it since, said he had stopped going to work but assured Noah’s Mother he was not suicidal but was struggling badly with day to day living, said he had arranged a doctor’s appointment to get back onto medication.

Wayne stops working at Port Authority According to Alan Jones, a few weeks before Wayne died he stopped going to May 2023 work and he had spoken to the Executive (and they told him they would help as much as they could and he should take some time off work) Alan Jones knew Wayne was going to see Dr Couper and offered to take him but Wayne refused. Alan wanted to go with Wayne because he wasn’t sure Dr Couper knew how bad Wayne was:

Date Information

• house was a mess, curtains and blinds down

• Wayne stopped cooking for himself

• Wayne would say “I’m useless, I can’t even cook” and “If I went into hospital who would look after Noah?” According to Noah’s Grandmother, Wayne said he couldn’t cope with going back to work, worried about how work was progressing with new technology and worried about the safety of people, Noah’s Grandmother knew he was in a bad place but still didn’t think for one second that anything would happen Wayne and Noah started going to Noah’s Grandmother’s house for dinner every night 8 May 2023 Noah’s Mother and Wayne text each other about payment of car insurance Wayne attended consultation with Dr Couper Progress notes:

• “previous depression and suicidal thoughts. Feels in the last few months mood has begun to deteriorate, feeling anxious, not suicidal, sole carer for 15 year old son, Noah, wants to be around for him, not sleeping, waking in the early hours and struggling to get back to sleep”

• “stopped all meds inc BP meds last week”

• “restarted atacand 6 days ago thinking it was his anti depressant”

• “all meds labelled”

• “continue with atacand, restart mirtazapine though at 15mg at night, review in 2 weeks, bloods”

• Pathology requested Dr Couper prescribed:

• Candesartan (high blood pressure)

• Mirtazapine 15 mg 1 nocte Dr Couper said in her statement:

• Wayne said he started taking his antidepressant tablets again about a week prior, said mood had started to deteriorate in the last few months, feeling anxious but not suicidal, said he was the sole carer for Noah and wanted to be around for him

• Wayne brought in all of the tablets he had, Dr Couper labelled them to let him know what they were for. From this they worked out the tablets Wayne thought were his anti-depressants were his blood pressure tablets, issued 10 May 2023 script for 15mg mirtazapine daily Dr Couper said in oral evidence:

• The reference in clinical notes to ‘stopped all meds inc BP meds last week’ is not accurate as Wayne likely stopped taking his medications earlier in time than only ‘last week’

• Dr Couper assessed Wayne as ‘overwhelmed’

• Dr Couper was worried about Wayne given her assessment and his serious mental health history

• There was no available option to refer Wayne back to Grafton Community Mental Health because he was not suicidal

• There was no available option to recommend Wayne attend the Emergency Department of the public hospital for treatment for his mental health because he was not suicidal

• There was no available option to refer Wayne to a private psychiatrist because there were no private psychiatrists in the Yamba, Grafton or Maclean regions and the psychiatrists in Lismore or Bangalow had a wait list of months

• Dr Couper did not have any information as to whether Wayne had access to firearms

• Dr Couper did not have any conversation with Wayne about going to any private hospital for treatment for his mental health

• The closest private mental health facility was Currumbin Clinic in Queensland

• Dr Couper asked her receptionist to schedule a next consultation sooner than the usual four weeks and told him he could come back earlier if needed

Date Information Noah’s Mother texts Wayne “what do you need to get Noah boat going”; Wayne 10 May 2023 responds “Gear box trying to find secondhand on hard to get or rebuild”; Noah’s Mother responds “Ok how much I can try and do more overtime” Wayne texts Noah’s Mother “Can you please help I am overwhelmed with NRMA stuff have emails for Mazda I think not sure what’s happening and where if cruise 12 May 2023 is at please help;” Noah’s Mother texts Wayne “It’s sorted”; Wayne says “Ok thank you I can’t thank you enough. Appreciate it so much” Noah’s Grandmother spoke with Wayne who told her that he could not cope with going back to work Mid May 2023 - Noah’s Grandmother said: “He just kept saying to me: ‘I don’t know how I’m going to get out of this deep hole’…I knew he was in a bad place but I still don’t think for one second that anything would happen” According to Noah’s Mother, she spoke with Wayne and he said he was again struggling with his mental health

• Noah’s Mother said: “Wayne also told me he had asked Noah to move in with me or his parents but Noah had refused. This was the last time I physically spoke with Wayne.” Mid May 2023 - Noah’s Mother said: “Over the following week I spoke with Noah several times via text and phone calls asking him to come and live with me or my parents to give Wayne a break, but he continued to refuse. In contrast, Noah constantly asked me to move back home with him and Wayne, but I told him I couldn’t do it.” (Noah’s Mother’s last conversation with Wayne) 16 May 2023 Wayne texts Noah’s Mother “Payed land rates” Wayne texts Noah “Noah nans ok been to bank no problem”; Noah replies “Ok” 19 May 2023 and “That’s good”.

Noah’s Mother texts Wayne “Road side paid and under land cruiser”; Wayne 21 May 2023 replies “Thanks”; Noah’s Mother says “Sorry missed your call yesterday.” Tom Commerford texts Wayne saying “Hi mate Just checking in on you. Hope 22 May 2023 you’re doing better today.” Gary Price (Wayne’s colleague) texts Wayne with details for Hunterlink EAP “Hey 22 May 2023 mate I really think getting in touch with EAP would be of benefit” 22 May 2023 Noah texts Wayne “how did you go today?” Wayne and Noah at Noah’s Grandmother’s house for dinner

• after dinner Noah didn’t want to go home and wanted to stay there

• Noah’s Grandmother said that Wayne needed his medication and needed to go home

• Wayne said he would go home and get his medication and come back but 22 May 2023 Noah refused

• Wayne and Noah went home to get Wayne’s medication

• Wayne and Noah stayed at Noah’s Grandmother’s house for 2 nights,

• Noah’s Grandmother thought Noah’s behaviour was unusual and they wouldn’t tell Noah’s Grandmother why Noah didn’t want to go home According to Noah’s Grandmother, whenever Noah would go to school he would message Wayne and check if he was okay and Wayne would usually say he was at Noah’s Grandmother’s house or that everything was okay According to Michael Read, he rang Wayne, wanted to pick him up and take him for a walk out to the Yamba break wall to get him out of the house, chatted for maybe 10 minutes but Wayne said he wasn’t up for it and “Wayne sounded pretty grim really” 23 May 2023 Noah texts Wayne “love you dad have a good day” Wayne contacted Olivia Simone at Hunterlink

• “Wayne has been struggling recently. He’s not eating properly, struggling to complete regular tasks – not functioning properly, can’t concentrate, having 23 May 2023 financial struggles, he mentioned that he can’t cope with looking after his son (aged 16)”

• “Wayne asked about being admitted, and I suggested that if he feels it’s needed to head to the hospital.”

Date Information

• “Mr Smith was wanting to re-engage with Sharnie, because it had been a couple of months since Mr Smith had engaged with Sharnie I had asked him what had been happening recently and if anything had changed. This is when we discussed the topics outlined in my intake notes…because of the information Mr Smith disclosed I asked if he wanted to see another counsellor sooner, within the week. Mr Smith said that he would prefer to see Sharnie, because he had seen her previously and didn’t want to explain everything to someone else. I respected Mr Smith’s request and booked him in at the earliest time that was convenient for him and Sharnie’s schedule” Noah’s Mother texts Wayne saying “I will pick Noah up after school to get jumper if 24 May 2023 that’s ok”; Wayne replies “Yep.” Wayne attended consultation with Dr Couper

• “no improvement in mood”

• “not sleeping”

• “couldn’t cope with work so left yesterday”

• “things at home falling apart. Struggling to care for his son. He will not go to grandparents and mum will not come down to care for him”

• “long chat”

• “has engaged with a counsellor that he has spoken to before”

• “no thoughts of self harm or suicide or any past history of it”

• “for increase in mirtazapine”

• “short term some temazepam to help with sleep”

• “med cert for work”

• “review in 10 days or sooner” Prescription

• Mirtazapine 15 mg ceased

• Mirtazapine 30 mg added

• Temazepam 10 mg added Dr Couper said in her statement: 24 May 2023

• “Wayne told me there was no improvement in mood and he wasn’t sleeping, said he wasn’t coping at work so he had left work early as well, said things at home were falling apart and he was struggling to care for his son.”

• Consultation for about 16 minutes

• “Wayne spoke in detail about the boat he bought. Wayne spoke about Noah always wanting more”

• “Wayne spoke about the financial stress he was under and he couldn’t see a way out”

• Assessed “no thoughts of self-harm or suicide and no past history of it”

• Plan to issue new script for mirtazapine 30mg doubling the dose and short term script for temazepam to help him sleep, medical certificate to cover some time off work, spoke about reviewing in 10 days time

• “Wayne reassured me that he was having no thoughts of hurting himself because he was caring for his son Noah” Dr Couper said in oral evidence:

• “assessed no thoughts of self-harm or suicide and no past history of it” recorded in notes but this recorded Wayne’s answer when “questioned by Dr Couper.” 24 May 2023 Noah texts Wayne “clean kitchen please” Noah and Noah’s Mother send text messages: Noah “Mum can you move back for abit please”; Noah’s Mother “why”; Noah “because me and dad need help please” “just for a little bit” “please” “yes or no”; Noah’s Mother “no I can’t. I’ll help you other ways”; Noah “how”, “Mum I need you back bad”, “please” “you will have a 25 May 2023 spot for your car” “please” “can you answer”; Noah’s Mother “working with boss” “No I can’t” “what do you need”; Noah “please mum” “I’m going bad”; Noah’s Mother “you can stay with me”; Noah “Please come back just for a month”; Noah’s Mother “No I can’t”; Noah “can you transfer the money across dads very worried” “he’s been upset all day about it”; Noah’s Mother “how did you go at the doctors” Noah and Noah’s Mother send text messages: Noah “good” “ are you going to 26 May 2023 transfer the money please for dad he’s very stressful”; Noah’s Mother “you can’t

Date Information just transfer the money it’s in an investment fund”; Noah “so how do you do it”; Noah’s Mother “his mum offered him the money”; Noah “he won’t take it I’m pretty sure”; Noah’s Mother “He will have to”; Noah “Why can’t he get the other one”; Noah’s Mother “because it’s locked in”; Noah “how long for”; Noah’s Mother “they will have to sell the shares I think it’s not easy”; Noah “well can they”; Noah’s Mother “why you just pay the loan back”; Noah “but dad’s worried a lot about it because we are going backwards of all the bills we stopped eating out or spending money”; Noah’s Mother “then get from his mum she given his brother plenty”; Noah “he won’t take it”; Noah’s Mother “Last time I looked the shares had dropped I don’t want to lose money”; Noah “okay could you have a look please”; Noah’s Mother “when I get time Tell him to take the money from his mum”; Noah “he won’t take it”; Noah’s Mother “I confirmed Netflix, why you not at school” Noah’s Mother spoke to Noah, asking him to help Wayne with general household chores, this was the last time Noah’s Mother spoke to Noah, over the next couple 28 or 29 May 2023 of days they would text about school related activities and Noah’s Mother checking up on Noah Texts between Noah and Noah’s Mother: Noah’s Mother “Did you go boating with your friends”; Noah “Nah no today”; Noah’s Mother “You ready for school 28 May 2023 tomorrow”; Noah “yep” “all clothes ready computer charged”; Noah’s Mother “thanks for being good” “what you do today”; Noah “Nothing much just chilled with dad” Alan Jones goes around to Wayne’s house and it seemed so much better, Wayne 29 May 2023 was more energetic Texts between Noah and Noah’s Mother: Noah’s Mother “You ready for school”; Noah “yep on the bus”; Noah’s Mother “have a great day”; Noah “you to”; Noah’s 29 May 2023 Mother “you have a practice test for English to do before Wednesday can you do it and give me a look please”; Noah “ok” Text between Noah and Wayne: Noah “love you dad have a good day see you this afternoon”; Wayne replies “ok love u” Later text from Noah “how you going dad”; Wayne reply “at nans watching tv”; 29 May 2023 Noah “ok that’s good”. Later text from Noah “dad can I walk home please”; Wayne reply “no I wait for u”; Noah “I was gonna walk home” ”because I was gonna go get a footy with cooper I’m not getting one he is”; Wayne “okay see u at home”; Noah “unless you are already there because I’m still at Maclean”; Wayne “at car park” Texts between Noah and Wayne: Noah “Love you dad have a good day see you this afternoon”; Wayne “Ok”; Noah “are you gonna have breakfast”; Wayne “Yep”; 30 May 2023 Noah “good job” Later Noah “ How you feeling dad done maths test”; Wayne “went for a walk”; Noah “that’s good” Wayne and Noah went to Noah’s Grandmother’s house for dinner (which happened regularly) 31 May 2023 As at date of death – Wayne had firearms registered as follows:

• 2 x Category A and 1 x Category B firearms registered to Wayne

• 22LRcalibre LITHGOW Model 12 bolt action rifle (serial number 2065) (NSW Registration 706891327)

• .303 calibre UNKNOWN Model unknown bolt action rifle (serial number C5370) (NSW Registration 706891343

• 12-gauge HARRIGTON & RICHARDSON Model unknown single barrel shotgun (serial number 682637) (NSW Registry 730386734) Wayne goes to his mother’s house and Noah goes to school

• Noah’s Grandmother and Wayne have breakfast and later lunch

• Wayne went on a walk and Noah’s Grandmother remembers thinking how good it was that he went on a big walk, felt like she was seeing positive things for Wayne, Noah’s Grandmother packed something for dinner

Date Information Noah text Wayne “Hi dad have a good day love you”; Wayne “thanks see u after 7:33 – 8:11 school”; Noah “sounds good” “are you going to nans for breakfast?”; Wayne “yep”; Noah “Ok that’s good”.

8:22 CCTV at family home: Wayne leaves in vehicle Noah texts Wayne “how was breakfast”; Wayne “eggs on toast”; 8:44-9:39 Noah “that’s good, just have a chill day today” ”can you please reply”; Wayne “at nans all good”; Noah “sweet” Noah’s Mother text to Noah “what happened in English yesterday”; Noah “nothing”; Noah’s Mother “why you got to do English at lunchtime”; Noah “not sure”; Noah’s Mother “I got an email from your teacher” Email from ICAC with letter outlining decision to not investigate Wayne’s 9:10 allegations against BSO and, instead, to refer the matter to Transport for NSW 13:01 CCTV at family home: Wayne returns in vehicle 16:15 CCTV at family home: Wayne leaves in vehicle CCTV at family home: Wayne and Noah return in vehicle, Noah in school uniform, 16:33 Noah says something like “Now I know that you are getting better and better every day” Wayne calls Thomas Commerford, said he would come around with Noah and 16:38 have a cup of tea, CCTV at family home: Wayne and Noah leave in vehicle, Noah has changed out 16:55 of school uniform Wayne and Noah go to Tom Commerford’s house at 45 The Halyard Yamba:

• both seemed fine, Noah his usual self and Wayne the happiest he had seen 17:00 him in weeks, Wayne said he was going home to cook rissoles and veggies – approximately the first time he had cooked in months, as they left Wayne said “I will see you tomorrow”, Tom said “my door is always open mate” CCTV at family home: Wayne and Noah return in vehicle and enter house through 17:34 the front door CCTV at family home: Lights inside house (or at least inside the kitchen and lounge room) turned off (Thomas Commerford says it wasn’t unusual for Wayne 18:39 and Noah to watch a movie together in Wayne’s bedroom on the king sized bed and sleep in there together, easier after Noah’s accident) Vincent (Noah’s maternal grandfather) rang Wayne, Noah’s grandparents had driven to Sydney that day and Vincent rang Wayne to say they had arrived safely, Between Vincent could tell Wayne was down, didn’t sound like himself (for last few weeks), 20:00-21:00 handed the phone to Noah which was unusual because normally everyone would speak on speakerphone, spoke to Noah for 5 minutes, nothing really stands out from the phone call apart from Wayne handing the phone to Noah 1 June 2023 00:32 CCTV at family home: Light in lounge room/kitchen on CCTV at family home: Second light appears to be turned on momentarily before both lights turned off 00:34 - SC Porou is of the view that Wayne turned the lights on in order to walk to the garage, open the gun safe, retrieve the firearm and walk back into the bedroom 00:35 CCTV at family home: Light in kitchen turned on and remains on CCTV at family home: Sound of first gunshot on CCTV 00:41

• SC Porou is of the view that this is the first gunshot that killed Noah CCTV at family home: Sound of second gunshot on CCTV 00:45 - SC Porou is of the view that this is the second gunshot that Wayne inflicted on himself 06:59 Text from Noah’s Mother to Noah “How was school yesterday” Wayne receives a text message reminding him of his EAP session on 2 June 10:07 2023

Date Information Wayne didn’t come for breakfast with Noah’s Grandmother

• she thought he might have confused dates for medical appointments for him and Noah, (they had appointments for the Friday and Noah’s Grandmother thought maybe there had been a mix up with dates) 12:30 - she tried to call him but he didn’t call back which was unusual

• she thought “my goodness he hasn’t come in for breakfast and he hasn’t come in for lunch, what’s going on?”

• she left a note on her front door saying “Wayne I’m going out to your house if you come here wait I’ll be right back” Noah’s Grandmother drives to Wayne’s house, no answer to knock on door but his vehicle out the front Noah’s Grandmother walked around right hand side of house and saw side gate open, screen sliding door open but glass sliding door closed, walked inside Noah’s Grandmother found both Wayne and Noah lying on the bed in master bedroom.

Noah’s Grandmother ran outside to the front of the house, in shock and saw Paul Hope, Dr Hope’s son 13:09 Paul Hope called Yamba Police station (which diverted to Grafton Police station) Police attend 23 Kookaburra Court, Yamba:

• run check on rifle located on bed, Lithgow Slazenger 12 rimfire .222 calibre long rifle 13:15

• Two other firearms in garage, 303 rifle and another shotgun

• No suicide note located

• Firearm safe in garage was open with nil evidence of forced entry SC Porou arrived at 23 Kookaburra Court, Yamba

• Noah’s Grandmother outside next to the car at front of house

• 2 other officers had already attended the scene: SC Jeffcoat and SC Carroll

• Located Wayne and Noah in bedroom, deceased (with firearm held by Wayne and resting across his chest)

• SC Porou’s initial impression: “It looked to me that Wayne had killed Noah, either by gunshot wound or some other method before Wayne shot himself in 13:50 the head”

• SC Porou (and other officers) inspected the house and spoke with Noah’s Grandmother (and Noah’s Grandmother gave him the details of Noah’s Mother)

• SC Porou arranged for forensic analysis and crime scene officers to attend the scene

• Once crime scene processed, Wayne and Noah were taken to Maclean Hospital Identification Statements for Noah and Wayne completed by Noah’s Grandmother:

• Wayne was 58 years old

• Noah was 15 years old SC Porou and other officers attended the scene in the morning and conducted an investigative search of the house SC Porou located the following medication on Wayne’s bedside table:

• Temazepam tablets (10mg, prescribed by Dr Fiona Couper 24 May 2023)

• Mirtazapine tablets (15mg, prescribed by Dr Fiona Couper 10 May 2023) 2 June 2023

• Prescription for Mirtazapine tablets (not filled) (30mg, prescribed by Dr Fiona Couper on 24 May 2023)

• Diazepam tablets (5 mgs, prescribed by on 15 May 2020)

• Candesartan tablets x 2 packets (16 mgs, prescribed by Dr Fiona Couper on 14 June 2022 and 10 May 2023, with repeat script) 2 June 2023 Sharnie from Hunterlink rings Wayne for scheduled appointment Verification of death of Wayne and Noah 2 June 2023

• Dr Daniel Henalla completed Verification of Death forms for Noah and Wayne Dr Couper made entry in Yamba Private Clinic notes 2 June 2023

• “Wayne unfortunately shot his son and then shot himself yesterday”

Date Information

• “during the last two consults with Wayne he mentioned significant financial stress with several boat engines breaking down and the purchase of a new boat that needed work”

• “recent time off work due to Noah’s orthopaedic surgery”

• “he mentioned that he was under pressure to get the boat finished and into the water and wasn’t sure how he was going to get it done” Autopsy performed on Noah

• Cause of death: gunshot wound to the head (back right side of head, single penetrating gunshot injury)

• Toxicology: none 6 June 2023 Autopsy performed on Wayne

• Cause of death: gunshot wound to the head (left temple, single penetrating gunshot injury, close contact entrance gunshot wound)

• Toxicology: diazepam (0.006mg/L); mirtazapine (0.17mg/L); temazepam (0.06mg/L); nordiazepam (0.02mg/L); oxazepam (0.01mg/L) According to Vincent (Noah’s paternal grandfather), Noah due for follow up appointment at John Hunter Hospital, Wayne was worried a lot about taking Noah June 2023 to these appointments, he had some car problems and for the last two appointments Vincent drove them both to Newcastle and back, the June appointment was weighing on Wayne’s mind