Coroner's Finding: LOCKWOOD Andrew James

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 8th day of September 2020 and the 28th day of May 2021, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Andrew James Lockwood.

The said Court finds that Andrew James Lockwood aged 49 years, late of 2 Rotary Avenue, Mount Gambier, South Australia died at Mount Gambier, South Australia on the 2nd day of April 2017 as a result of a shotgun wound to head. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Andrew James Lockwood was 49 years old when he died on 2 April 2017 at his home address at 2 Rotary Avenue, Mount Gambier.

1.2. On 3 April 2017 an autopsy was conducted in respect of Mr Lockwood’s body. It was conducted by Dr Cheryl Charlwood, a forensic pathologist at Forensic Science South Australia. Dr Charlwood’s post mortem report states that the cause of Mr Lockwood’s death was a ‘shotgun wound to the head’.1 I find that to have been the cause of his death. Toxicological analysis revealed a blood alcohol level of 0.19% which is a significant level consistent with intoxication. Sertraline (Zoloft), an antidepressant medication that had been prescribed for Mr Lockwood, was found in his blood in high but non-toxic concentrations.2 There is no evidence that this medication contributed to Mr Lockwood’s death.

1 Exhibit C2a 2 Exhibit C3a

1.3. A bottle of Scotch whisky which was approximately three-quarters full and a glass with remnants of a liquid in it were located by crime scene investigators in the kitchen of the premises in which Mr Lockwood was located.

2. Reason for inquest 2.1. Mr Lockwood’s death was by his own hand. Police had responded to a request for assistance at Mr Lockwood’s home address. They located him in possession of the shotgun. I infer that attending police were attempting to apprehend Mr Lockwood with a view to preventing him from taking his own life. However, Mr Lockwood shot himself and inflicted a non-survivable wound to his head. According to Dr Charlwood, death would have been almost instantaneous. Mr Lockwood’s death was a death in custody in respect of which an inquest was mandatory.

3. Background 3.1. Mr Lockwood was married in 1989. Mr Lockwood lived with his wife at 2 Rotary Avenue, Mount Gambier.

3.2. Since 2013 Mr Lockwood had worked as a prison guard at Mount Gambier Prison for the security company G4S. He had previously worked as an IT technician, repairing and maintaining computers.

3.3. In November 2014 Mrs Lockwood moved out of the family home and into a unit with two of their children. In her statement Mrs Lockwood describes years of physical, emotional and financial abuse by her husband.3 No reports were ever made to police.

A note from a consultation that Mr Lockwood had with his general medical practitioner on 10 November 2014 states that Mr Lockwood became angry in relation to personal issues with his wife. At times his anger was apparently alcohol induced.4

3.4. Mrs Lockwood states that the separation lasted about one month until Mr Lockwood threatened to take his own life if his family did not return. They subsequently did return.

3.5. In 2015 Mr and Mrs Lockwood received marriage counselling. They remained living together until November 2016 when they again separated. Mrs Lockwood and two of the children moved out of the family home.

3 Exhibit C6a 4 Exhibit C22

4. Deceased’s relevant medical history 4.1. Mrs Lockwood described her husband as ‘a heavy drinker’. However, after their separation he stopped drinking and would run three times per day. She says that he lost about 16 kilograms. He was taking antidepressant medication and medication for cholesterol issues.

4.2. Mrs Lockwood states that in the four months before her husband’s death he had said on more than one occasion that he would take his own life. He said, ‘you can call the police they will take my guns and I will lose my job’. However, he also said that this would not matter as he would use a piece of wire.5 Mr Lockwood had also once said that there was a noose in the shed. As I understand the evidence, no report was made to police regarding Mr Lockwood’s statements about taking his own life or his references to his firearms in that connection.

4.3. Mrs Lockwood describes an incident in December 2016 when she was at their house and where Mr Lockwood made some strong threats to harm himself. Without recalling exactly what had been said by Mr Lockwood, it was said in a manner that was more threatening than usual.

4.4. Mrs Lockwood states that her husband was obsessive in his desire for him and his wife to re-unite. She states that he would repeatedly contact her and would do so on a daily basis.

4.5. Mr Lockwood sought medical assistance for depression. On 10 November 2014 he and his wife attended an appointment with Dr Ronan Mackle. He said that he thought that he had been suffering from depression for twelve years.6 It was noted that he was suffering acute stressors due to his wife moving out of the marital home the previous weekend. He stated that he became angry, had motivation difficulties and had debts.

Although he reported fleeting ideas of self-harm he was not considered to be actively suicidal. Dr Mackle referred Mr Lockwood for a mental health treatment plan and to a mental health clinician, Daniel Wakefield. He also considered a diagnosis of a personality disorder.

5 Exhibit C6a 6 Exhibit C22

4.6. An alcohol use assessment was conducted during this consult and it was noted that there was a strong indication that Mr Lockwood had an alcohol dependency problem.

4.7. Mr Lockwood and his wife attended counselling appointments with Mr Wakefield on 19 November 2014, 4 December 2014, and 16 December 2014.7 Mr Wakefield states that following the appointment on 16 December 2014, he tried calling and sent a letter to arrange a follow up appointment but did not hear back. He subsequently sent a report to Dr Mackle advising of the outcome of the counselling sessions.

4.8. On 5 December 2016 Mr Lockwood attended an appointment with a general practitioner, Dr Scott Milan. Dr Milan also diagnosed depression.8 Mr Lockwood stated that his wife had again moved out of the marital home. He said that he had been experiencing low mood for some time. He denied suicidal thoughts and said that he had no suicidal intent or plan. A scoring tool9 was used to evaluate Mr Lockwood’s mental state. The results suggested extremely severe stress levels, severe anxiety and severe depression. Dr Milan’s overall assessment was that Mr Lockwood was suffering from major depression which was likely longstanding in duration. Mr Lockwood was counselled. He was prescribed sertraline and was referred for psychological intervention. Dr Milan noted that Mr Lockwood was at a ‘low acute’ level of risk with his daughter at home being a protective factor.

4.9. On 23 December 2016 Mr Lockwood again saw Dr Milan. Mr Lockwood stated that he was not actively suicidal but he admitted to fleeting suicidal ideation. He stated that he had no intention to commit suicide. Dr Milan asked whether Mr Lockwood had made an appointment for psychological intervention. He replied that he had not yet made an appointment but would ‘wait and see how the meds go’. On examination he was reactive, settled, attentive and he exhibited good self-care. His management plan included continuing the medication at the current dose.

5. Andrew Lockwood’s state of mind in the months prior to his death 5.1. Mr Lockwood’s daughter’s statement asserts that when her mother moved out of the family home with her siblings it greatly upset her father. She states that he stopped eating to the point that he lost 10 to 15 kilograms. He would walk a lot and would 7 Exhibit C24 8 Exhibit C22 9 CAGE questionnaire

otherwise just sleep or lie on the lounge. She describes her father at this time as ‘broken’ and that ‘he was always trying to get mum back, she was his focus in life’.10

5.2. Ms Lockwood states that her father was upset that he was not involved in the planning of his wife’s 50th birthday party. She explains that he was invited to the party but he was not happy as he always thought that they would celebrate their birthdays together and it was being planned without his input. On the other hand, Mr Lockwood’s son in his statement asserts that his father was involved in the planning and was helping out.

He states that he ‘seemed really happy about this’.11

5.3. Mr Lockwood’s son describes his father in the months before his death, as ‘a bit up and down in his moods’ but not as depressed as he had been. Mr Lockwood would often pick him up from school and they would do things together including surfing.

5.4. Mr Lockwood’s mother recalls a conversation with her son in which he asked if there had been a family history of depression. He said that he had been prescribed some tablets but that he did not really like taking them and did not want to be on them. On another occasion about two weeks before his death Mr Lockwood was in his shed upset and crying. Mr Lockwood’s mother states that ‘looking back and I can see that he wasn’t coping that well’.

5.5. On 28 March 2017 Mrs Lockwood and their son had dinner with Mr Lockwood at the Rotary Avenue premises. They left the family dog with him for companionship.

Mr Lockwood had previously mentioned that the dog was unwell. The following day he took the dog to the vet. The dog died on the 30 March 2017. Mr Lockwood’s daughter states that her father was very close to the dog and was upset about his death.

5.6. Mrs Lockwood states that her husband’s behaviour was very strange on the night of the dog’s death and also on the following day being 31 March 2017. When he was burying the dog he was heard to say, ‘I’ll see you tomorrow little buddy’ or ‘I’ll see you tomorrow mate’. Mr Lockwood’s daughter thought her father meant that he intended to visit his grave. At 1:03am that morning Mrs Lockwood received a text message from her husband indicating that he had spent time with the dog with a blanket because he was cold. He wrote that he was ‘broken’.

10 Exhibit C17 11 Exhibit C18

5.7. Saturday 1 April 2017 was the day before Mr Lockwood’s death. Mrs Lockwood was celebrating her 50th birthday with a party at 28 Kurrajong Street, Mount Gambier.

Mr Lockwood left the party at about 11pm. Mrs Lockwood states that her husband approached her and told her that the music was too loud. She told him that it was not and he knocked a drink from her hand. He then left the party.12 On the evidence this occurred sometime between 11pm and 1am.

5.8. Between 12:50am and 1:51am Mr Lockwood conducted a text message conversation with his daughter during which he told her not to come over.13

5.9. Mrs Lockwood received a text message from Mr Lockwood at 12:47am but did not read it until 2am. The message attached a photograph of a suicide note14 and included the words, ‘I’m in the back yard, do not let the kids be the first to find me. Let a normal person look at your SMS’.15

5.10. Other handwritten notes considered to have been made by Mr Lockwood, but which were not sent to his wife, would be found at his home address. The notes include the details of his daily movements, emotions and attempts to reconcile with his wife. The notes also include the details of possible ways to commit suicide.

5.11. At 2:01am Mrs Lockwood phoned the police line 131 444 and reported that she had been sent a text message with a suicide note and that her husband was in his back yard and did not want the children to find him.16

5.12. At 2:05am Mrs Lockwood received what she describes as a ‘hang up message’ from Mr Lockwood’s mobile phone number. He did not leave a message.

5.13. At 2:06am Senior Constables Angela Leigh and Simon Flett of Mount Gambier Operations arrived at the Rotary Avenue premises. Their attendance was within six minutes of the call for assistance. Police found the front door open but the screen door shut. They checked through the front door and in the shed on the side of the property and then began walking up the driveway. The officers then walked along the side of the house using their torches. As they were walking up the driveway of the house Senior Constable Flett heard over his police radio that the person they were 12 Exhibit C6a 13 Exhibit C17 14 Exhibit C46j 15 Exhibit C6a, page 3 16 Exhibit C46f

looking for had firearms registered to him. They then saw Mr Lockwood sitting on a chair in the rear yard with a shotgun leaning against his right leg.

5.14. Senior Constable Flett drew his firearm and levelled it. He instructed Mr Lockwood, ‘You need to stand up and step away from the firearm’. Senior Constable Flett thought that he could see a glass object in Mr Lockwood’s left hand. He thought it was a drink.

It was in fact a mobile telephone. This would later be confirmed by a crime scene investigator.

5.15. Senior Constable Flett described Mr Lockwood as sounding ‘drunken’. Mr Lockwood responded with, ‘Who is this’ and was squinting into the torchlight. Senior Constable Leigh then took hold of Senior Constable Flett and pulled him back to a position of cover. While that occurred Senior Constable Flett said ‘It’s the police’. Senior Constable Flett states that as he said that Mr Lockwood ‘reached over…grabbed hold of the barrel of the firearm…with his right hand’. Senior Constable Flett recalls that he transferred the weapon to his left hand. At one point Mr Lockwood had both hands on the barrel but then placed his mouth over the muzzle of the firearm.

5.16. Senior Constable Flett states that once he and Senior Constable Leigh were in a position that provided some cover he called out again, ‘Stand up and step away from the firearm’. Mr Lockwood then said words to the effect of ‘yeah, I’m doing it now’.

Senior Constables Leigh and Flett then heard one gunshot. They observed that Mr Lockwood had discharged the firearm in the vicinity of his mouth. Mr Lockwood was obviously deceased.

6. The firearm 6.1. At the time of his death Mr Lockwood had a current firearms licence. He held 14 registered firearms which included a Winchester 410 ‘Cooey’ model single barrel shotgun which was the weapon he used to end his life. The firearms were lawfully possessed by him.

6.2. At the time of Mr Lockwood’s death the Firearms Act 1977 was in operation. This legislation has since been repealed and replaced. Section 27A(1) of the repealed Act imposed certain obligations on persons to report unsafe situations associated with firearms. This provision stipulated that a medical practitioner who had reasonable cause to suspect in relation to a person whom he or she had seen in his or her

professional capacity that the person was suffering from a physical or mental illness or condition, or that other circumstances existed, such that there was a threat to the person’s own safety or the safety of another associated with the person’s possession or use of a firearm, and that the person had, or might be intending to acquire, a firearm, must report those circumstances to the Registrar of firearms. In effect, the obligation was to report to the police.17

6.3. The investigation report of Inspector James Downs states as follows: 'The investigation found that whilst the medical practitioners who consulted the deceased prior to his death had diagnosed the deceased with depression, the medical practitioners were of the view that, in the absence of any suicidal ideations, there was nothing to suggest the deceased was a threat to his own or the safety of others and thus no notification was made to the Registrar of Firearms.' 18

6.4. I agree with that assessment. Mr Lockwood was never considered actively suicidal.

Any documented thoughts of self-harm or suicidal ideation were ‘fleeting’ or ‘brief’ and with nil intent. At no time was he considered by the medical practitioners to constitute a risk to himself or to others. I have carefully assessed the evidence of the clinicians who were involved in Mr Lockwood’s care. I do not believe that the obligations set out in section 27A(1) of the Firearms Act were enlivened. There is no evidence that Mr Lockwood was actively suicidal or that if he was, the clinicians involved in his care were aware that there was a threat to Mr Lockwood’s safety associated with his possession of a firearm.

7. Death in custody 7.1. Police attended Mr Lockwood’s address in response to a call by his wife. The attendance was described initially as a ‘check on welfare’ in response to Mr Lockwood sending his wife a photograph of a suicide note. When police were confronted with the circumstances that prevailed upon their arrival at Mr Lockwood’s premises, the officers would at least have been lawfully authorised to apprehend Mr Lockwood pursuant to the Mental Health Act 2009. I find that police actions were at all times lawful and appropriate. It was evident that at all times Mr Lockwood was intent on ending his own life with the firearm. I do not believe that there can be any suggestion that anything done or not done by the two officers contributed to that decision. It is abundantly 17 The obligation is now contained within Regulation 96 of the Firearms Regulation 2017 18 Exhibit C46

evident that Mr Lockwood had made the decision to end his own life at a time before the police arrived. I do not believe that police could have done anything to prevent his death.

8. Conclusions 8.1. Consistent with the conclusions of the Inspector James Downs,19 I find that Mr Lockwood died as a result of a single self-inflicted gunshot wound to the head.

Police who attended his address did not contribute to the death. Mr Lockwood’s treating doctors, although treating him for depression, did not identify any active suicidal ideation and there were no reports made to authorities that Mr Lockwood had made attempts or threats to commit suicide or self-harm. There was no evidence to suggest that Mr Lockwood was not a suitable person to hold a firearms licence and possess registered firearms.

8.2. I have no recommendations to make in this matter.

Key Words: Death in Custody; Suicide; Firearm; Police In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 28th day of May, 2021.

Deputy State Coroner Inquest Number 75/2020 (0586/2017) 19 Exhibit C46