Coroner's Finding: GW de-identified

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, family, friends, and others by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) I, Olivia McTaggart, Coroner, having investigated the death of GW Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is GW.

b) GW was born on 6 January 1951 in Launceston to H and KN. He was aged 68 years at the time of his death. In 1973 GW married his wife, PQ. There are four children of the marriage: O, T, U and V. GW had been employed in a variety of fields, including social work, butchery and as a kiosk operator. He retired in June

2019. Prior to his death, he was living with his wife and their youngest child in Lindisfarne.

GW was a heavy smoker and consumed alcohol in excessive quantities. In 2008 GW was noted by his doctor as suffering depression but there is no evidence that he sought treatment for any mental health condition after that time. In 2013 he was diagnosed with bowel cancer. After four years of treatment for this condition, GW entered remission. In the months leading up to GW’s death, his family noted that he had a serious and persistent cough with difficulties swallowing. He visited his doctor in February 2018 but was reluctant to return, likely due to a fear that he would be diagnosed with lung cancer.

GW was convicted for driving whilst exceeding the prescribed alcohol limit (‘drink-driving’) on four occasions. These occurred in 1991, 2004, 2012 and 2019.

He was disqualified from driving on each occasion but was granted a restricted driver’s licence by a magistrate in respect of each of the last three disqualification orders.

GW was the holder of a firearms licence for recreational hunting and vermin control. The firearms licence was first granted in 1997 and renewed by Firearms Services every five years - in 2002, 2007, 2012 and 2017. Additionally, GW was reassessed after his fourth and final drink driving conviction in 2019 as being a fit and proper person to continue to hold the licence. GW was authorised to possess, and did possess, several firearms pursuant to his licence.

On the morning of 10 December 2019, PQ and their youngest son went to work, leaving GW at home by himself. PQ returned home at 5.50pm and found GW lying on the ground in a room underneath the house. She observed that there was blood around his mouth and on the carpet around him. She tried to talk to GW but could not understand what he was saying. It was at this point she noticed a firearm lying approximately one metre away from his body. PQ called Ambulance Tasmania for assistance. At 6.18pm, officers of Tasmania Police were tasked to attend the property to assist Ambulance Tasmania paramedics who were unable to enter until the scene had been declared safe. Police officers arrived at 6.22pm and, after declaring the scene safe, the paramedics entered and attended to GW When asked by police whether he had shot himself, GW nodded.

GW was transferred to the Royal Hobart Hospital by ambulance. A CT scan showed that GW had severe facial injuries including a shattered maxilla, nasal septum, right intra-orbital bone and bullet fragments in the frontal lobe of the brain which had caused a large haemorrhage. He immediately underwent surgery, including a tracheostomy and insertion of a catheter to drain fluid from his brain.

After the surgery, he was transferred to the Intensive Care Unit of the hospital.

Between 11 December 2019 and 14 December 2019, medical assessments were conducted by specialist doctors at the hospital. GW was assessed as having a poor prognosis and future quality of life. On 15 December 2019, after consultation with treating doctors, GW’s family decided that his life support should be withdrawn. Following this, GW’s condition deteriorated rapidly and he was pronounced deceased later the same day.

An initial search of the scene by police located a handwritten note written by GW. The note indicated that GW intended to end his own life because of his depression, physical illness and fear of cancer. He stated that he had ‘often unlocked the gun cabinet’ with a view to suicide.

I am satisfied that GW deliberately shot himself with his own licenced firearm with the intention of ending his own life and that there was no other person involved nor any suspicious circumstances. Blood samples taken from him when he arrived in hospital identified a very high blood alcohol concentration (0.301g/100ml). It was later indicated by family members of GW that he had a significant amount of debt. It cannot be ascertained upon the evidence whether this fact contributed to GW’s mental state in the days leading up to his death.

c) GW’s cause of death was traumatic brain injury due to a gunshot wound to the head.

d) GW died on 15 December 2019 at Hobart, Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into GW’s death. The evidence includes:  Tasmania Police Report of Death;  Life extinct and identification affidavits;  Post mortem affidavit and toxicology report;  Medical records for GW from Bellerive Doctors, Ambulance Tasmania and Tasmanian Health Service;  Affidavits of PQ, wife of GW;  Affidavit of TV, son of GW;  Affidavits of five attending and investigating Tasmania Police officers, including photographs and body worn camera footage of the scene;  Physical evidence taken by police, including a handwritten note and firearm;  Tasmania Police and Firearms Services information;  Record of convictions for GW.

Comments GW’s firearms licence was last renewed by Firearms Services (part of Tasmania Police), on 14 June 2017. When GW made the application on that occasion, he did not disclose on his application form the fact that he had been convicted at that stage of three prior drink-driving offences. In any event, Firearms Services identified GW’s incorrect answer and also the extent of his previous offending through Tasmania Police screening processes. Firearms Services determined, nevertheless, that GW satisfied the criteria for the renewal of the licence, including that he was a fit and proper person.

Upon review of the documentation from Firearms Services, it is also apparent that for each past renewal application, GW falsely or incorrectly answered ‘no’ to the question of whether he had been convicted of any offence. At the time of each incorrect answer, he had in fact been convicted of one or more drink-driving offences. It cannot be ascertained from the documentation whether Firearms Services knew that his answers in this regard were incorrect. It is also arguable, despite the manner in which the question was phrased in the form, that GW falsely or incorrectly answered ‘no’ to the question of whether he suffered from any physical or mental disability.1 In particular, he had been treated for depression 2008 and it appears that this condition continued until his death albeit without treatment. It would appear that, on the strength of his answers, Firearms Services did not seek records or a report from his doctor.

On 16 April 2019, 12 days after GW’s conviction for his fourth offence involving driving whilst exceeding the prescribed alcohol limit, Firearms Services reviewed whether GW continued to be a fit and proper person to hold his firearms licence.2 The manager of Firearms Services assessed GW to be a fit and proper person. In doing so, he took into account various matters specified by the Firearms Act 1996. These included:  Whether there was any likelihood of GW using firearms to harm himself or others;  The mental and physical condition of GW;  The criminal activity of GW; and  The ability of GW to exercise reasonable and responsible control over a firearm.

The manager of Firearms Services reported that, in assessing these matters, he took into account GW’s recorded offences and penalties. He specifically relied upon the fact that GW’s offending was ‘non-violent’, that the court had issued him with a restricted licence in respect of his last offence and that there was seven years between his previous two drinkdriving offences. He also noted the lack of any other evidence to indicate that GW was likely to use a firearm to harm himself or others. A medical report regarding his mental or physical health was not sought by Firearms Services at that time as the manager reported that there were no indications of concerns that GW was unfit to continue to hold firearms. I make the point that GW’s lack of disclosure may have contributed to this decision.

1 In the finding of Nicholas Mulvhill Johnson, 21May 2021, Coroner McKee noted the potential difficulties arising from inconsistent wording of the relevant question between the original application form and renewal applications, and recommended that consistent wording be used.

2 Section 29 of the Firearms Act 1996 requires, inter alia, an applicant to be a fit and proper person to hold a licence.

I accept that there was no reason at the time of this assessment for Firearms Services to consider that GW suffered depression with suicidal ideation and had likely planned suicide using his firearms on past occasions. Even if Firearms Services had made enquiries with his doctor, useful information may not have been forthcoming as GW had not sought treatment in recent years before his death nor had he apparently disclosed his current mental health issues in consultations.

I do have some concerns, however, with the assessment of GW as a fit and proper person to continue to hold a firearms licence in respect of his drink-driving offences.

Despite the granting of a restricted driver’s licence to GW, his final offence was considered serious enough for the presiding magistrate to impose a prison sentence (albeit wholly suspended on conditions of good behaviour). Although the evidence in this investigation did not delve into the processes of Firearms Services decision-making, I comment that the imposition of a criminal conviction with an order of imprisonment in such circumstances might well have disentitled GW to his firearms licence.

Further, he had accumulated four convictions for drink-driving offences when he was assessed. It is reasonable to assume that such repetitive offending is, prima facie, indicative of an issue with excessive consumption of alcohol, potentially over many years in the case of GW. It is well-established that alcohol intoxication and addiction are associated with loss of judgement and inhibition, poor decision-making and decreased intellectual performance - all factors that impede the ability to exercise reasonable control over a firearm. It does not appear that Firearms Services sufficiently considered or investigated GW’s alcohol consumption.

A final and related issue is whether Firearms Services should have initiated action to cancel GW’s licence pursuant to its power under the Firearms Act3 because of his failure in 2017, and on each prior application form, to disclose his drink-driving offences. GW’s preparedness to provide incorrect answers to this question should have caused concern about whether other unverified information provided by him could be relied upon in granting him the privilege and great responsibility of holding firearms.

As a coroner always has the benefit of hindsight, I recognise that caution is required in criticising particular decisions made prior to the death of a deceased. However, in this case it is appropriate for the above reasons to question whether GW was a person who should have had control over and ready access to firearms. It is established that access to means of suicide increases the chance of its occurrence.

3 Section 51 of the Act.

Recommendation I recommend that Firearms Services considers reviewing its decision-making policies and processes in respect of the granting of firearms licences in cases where an applicant has been convicted of multiple drink-driving offences or other alcohol-related offences.

I recommend that Firearms Services considers reviewing its decision-making policies and processes in respect of the cancellation of a firearms licence where the holder knowingly supplies false or misleading information in connection with the application.

I extend my appreciation to investigating officer Sergeant Loretta Ashwood for her investigation and report.

I convey my sincere condolences to the family and loved ones of GW.

Dated: 25 November 2022 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner