Coroner's Finding: NB

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Andrew McKee, Coroner, having investigated the death of NB.

Find, pursuant to Section 28(1) of the Coroners Act 1995, that: a) The identity of the deceased is NB; b) NB died in the circumstances set out below; c) The cause of death was a contact range gunshot wound to the forehead, an action taken by NB, acting alone, with the intention of ending his life; and d) NB died on 15 January 2018 at Launceston in Tasmania In making the above findings I have had regard to the evidence gained in the comprehensive investigation into the death of NB. That evidence is comprised of the following:  The Police Report of Death;  An opinion of the forensic pathologist who conducted the post-mortem examination;  Relevant police and witness affidavits;  Medical records and reports;  NB’s application to renew his firearms licence;  An affidavit from 1/C Constable Denholm, a ballistics expert; and  Forensic evidence.

NB was born in Launceston on 24 March 1985 and was aged 32 at the time of his death. He was the eldest of two children born to the marriage of AT and LB. He was raised in the Westbury area. His parents separated when he was 10 years of age. He then spent time with both his mother and father.

He attended the Meander Primary School and completed his secondary education at Prospect High School. After completing his secondary education he commenced an information technology course at TAFE. He then held employment at Frontline, an organisation involved in

sound and audio support for stage productions. From 2006 until 2012 NB was employed at an organisation known as Professional Computer Maintenance.

In 2005 he commenced a relationship with Ms KL. In June of 2009 the couple purchased a residence in the Launceston suburb of Mowbray.

In 2012 the couple relocated to the United Kingdom. After nine months in the United Kingdom the couple returned to Tasmania. From November 2012 until 2016 NB worked at Miztek, an organisation installing EFTPOS and TOTE machines in the northern area of Tasmania.

In late 2015 NB was diagnosed with Crohn’s disease. That condition, coupled with a preexisting condition of depression, led him to cease full-time employment. He then applied for, and was placed on, a sickness allowance through Centrelink. He briefly attended university in

2017. He was attempting to re-enter the workforce at the time of his death and had applied for a position with TasWater.

Medical History NB suffered from symptoms of depression for a significant period of time. In August 2009, he became a patient of the Longford Medical Practice. The consultation notes from his first attendance records that he gave a history of suffering from depression which commenced around 18 years of age. His general practitioner treated him for depression.

He was referred to appropriate social supports, referral to a psychologist and a psychiatrist.

NB’s depression fluctuated and at times he responded positively to the treatment he received.

In 2014 he was reviewed by Dr Hyde, a psychiatrist, who diagnosed him with mild-to-moderate Asperger’s Syndrome and major depression. Dr Hyde suggested psychological intervention and reviewed the current medication being prescribed to NB.

In 2016 NB attended two sessions with a psychologist, Mr David Morrison. NB voluntarily ceased that treatment.

Dr Hyde reviewed NB in 2016. He provided a written report to NB’s general practitioner, Dr Hamilton. After assessing NB, Dr Hyde noted in his report that NB had ongoing symptoms of major depression. He had an underlying diagnosis of an opiate addiction, which was most likely in remission. A number of recommendations were made by Dr Hyde regarding NB attempting to obtain employment or to consider undertaking study. The medications prescribed to him were reviewed.

I am satisfied that the treatment received by NB by all medical practitioners who treated him was appropriate.

Circumstances Surrounding the Death NB’s relationship with Ms KL began to deteriorate in 2017. On 15 January 2018 NB spoke with his mother and advised her that the relationship had come to an end. Arrangements were made for him to relocate to his mother’s residence a few days later.

On the morning of 15 January 2018, Ms KL left the residence to attend work. During the day she had contact with NB via text message.

When she finished work she travelled to her sister’s home, arriving back at the home she shared with NB around 9.50pm. She located NB deceased.

I am satisfied based on the post mortem report prepared by Forensic Pathologist, Dr Christopher Lawrence, and the affidavit of 1/C Constable Denholm, that NB, acting alone, utilised a .223 Rem. Calibre TIKKA bolt action repeating rifle to take his own life. I am satisfied, based on the investigations of officers of Tasmania Police, that there are no suspicious circumstances surrounding NB’s death.

Sadly it appears that NB’s mental state was such that he decided to take his own life. I am satisfied that there was no action that could reasonably have been taken by any person to prevent him from taking that course of action.

Firearms Licence NB was granted a firearms licence on 28 March 2011. The application completed by him is unable to be produced by Firearms Services. I assume that he answered ‘yes’ to the following question on the approved application form for a firearm: “Health

12. Have you ever needed treatment for or are you being treated for?

Mental/emotional problems Yes Specify below No”

I make this assumption because contained in his medical records maintained by his then general practitioner is the following entry: “History Needs paperwork/form for Tas Police re firearms application. Form completed.

Poses no significant risk. Well managed.” At the date of his death whilst NB was attending the same medical practice he was seeing a different general practitioner.

In accordance with the Firearms Act 1996, NB was required to renew his firearms licence. A renewal form was sent to him which he completed and his firearms licence was subsequently renewed in March of 2016.

The following question appeared on the renewal form: “3. History Since being issued with your firearms licence have you: Circle Answer a) Been convicted of an offence in Tasmania or elsewhere? YES/NO Details: ……………………………………………………… b) Suffered from any mental or physical disability? YES/NO If you answered YES to this question you must obtain a medical report from a doctor who treated you for, or is familiar with, your condition(s).” I have the completed renewal form before me. NB circled ‘no’ to question 3(b).

I am satisfied that NB’s then general practitioner was unaware that he was applying to renew his firearms license.

My first observation is that there is different terminology used in applying for a firearms licence and applying to renew a firearms licence when regard is had to mental health.

An application for a firearms licence enquires of an applicant if they “have ever needed treatment for or are you being treated for mental/emotional problems.” This appears to be a

low threshold test designed to trigger further enquiries if the question is answered in the affirmative.

The renewal form enquires of the applicant if since the granting of a firearms licence he or she has “suffered from any mental or physical disability”.

This appears to be a higher threshold test to trigger enquiries. The reference to treatment is deleted. The reference to emotional problems has been deleted. No definition of mental disability is provided to the applicant.

For no apparent reason a different test is applied to the granting of an initial firearms licence and the renewal of a firearms licence in the context of mental health.

It is trite to observe that the nature of mental health conditions fluctuate. I see no reason why a different test is utilised when an individual applies for the renewal of a firearms licence than that applied to the granting of a firearms licence in the context of mental health.

In my view, consideration should be given to the implementation of consistent wording in the application for and the renewal of a firearms licence in the context of mental health.

I also note that in an application for a firearms licence a precondition to answering ‘yes’ to question 12 is that the applicant has undergone treatment. In my view, whilst the question regarding treatment should be maintained, it should be expanded upon by asking if the applicant has suffered from mental/emotional problems. This issue could be dealt with by the implementation of a standard question for both applications and renewals.

The next observation I wish to make is that the form is totally reliant upon self-reporting. The evidence before me discloses that NB has suffered from mental health issues since 18 years of age. To obtain a firearms licence he was required to obtain materials from his general practitioner in relation to his mental health.

His claim in his renewal form that he did not suffer from any mental disability (even though that term is undefined) is incorrect. The reports from Dr Hyde and a consideration of his medical records maintained by his general practitioner clearly demonstrate he had ongoing mental health issues.

I am of the view that once an individual identifies themselves as suffering from a mental condition or emotional issues in an application for or renewal of a firearms licence, and that mental condition or emotional issue requires ongoing treatment or monitoring, that the applicant or licence holder should be required to provide a report from a qualified medical

practitioner that the mental condition or emotional issue is being properly managed and the condition would not disqualify them from holding a firearms licence. The frequency that such a review should take place is best left to the discretion of the Commissioner of Police.

This will assist to prevent the situation that arose in relation to NB where he simply answered ‘no’ to question 3(b) on the renewal form.

I have given consideration as to whether imposing such a strict requirement in relation to mental health would result in individuals failing to report mental health issues in application or renewal forms. Given the current system relies on self-reporting, I am of the view that such a system should be implemented.

I also note the provisions of section 148 of the Firearms Act 1996. I comment that it would be appropriate for the Commissioner of Police to embark on an education program to remind general practitioners of their obligation under that section, and to encourage them to accurately identify in their patients’ records that a patient is the holder of a firearms licence so that the medical practitioner can give consideration to his or her objection under section 148.

In this case, I note that NB’s general practitioner was unaware of the fact that he was applying for a renewal of his firearms licence or that he was in fact a firearms licence holder.

Comments and Recommendations I make the following recommendations:

1. That Firearms Services give consideration to using consistent language in questions relating to mental health in applications for and renewals of firearms licences.

2. That once an individual has self-identified as suffering from, or requiring treatment for, a mental condition or emotional issues in an application or renewal of a firearms licence, and that mental condition or emotional issue requires ongoing treatment or monitoring, that the applicant or licence holder be required to provide a report from a qualified medical practitioner that the mental condition or emotional issue is being properly managed and would not disqualify the applicant or licence holder from holding a firearms licence.

I convey my sincere condolences to NB’s family and loved ones.

Dated: 12 May 2021 at Hobart in the State of Tasmania.

Andrew McKee Coroner