Finding into death of Luciano T

Rule 60(1)

FORM 37

REDACTED FINDING INTO DEATH WITH INQUEST

Court reference: 1893/07

Inquest into the Death of Delivered On:

Delivered At:

Hearing Dates: Findings of: Place of death:

Counsel Assisting the Coroner:

Section 67 of the Coroners Act 2008

LUCIANO T August 16, 2011

Coroners Court of Victoria Level 11, 222 Exhibition Street, Melbourne 3000

August 16, 2011

JUDGE JENNIFER COATE

Avondale Heights, Victoria 3034

Ms Jacqui Hawkins, Principal In-house Solicitor

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FORM 37 Rule 60(1)

REDACTED FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1893/07 In the Coroners Court of Victoria at Melbourne I, JUDGE JENNIFER COATE, State Coroner having investigated the death of:

Details of deceased:

Surname: T First name: LUCIANO Address: Avondale Heights, Victoria 3034

AND having held an inquest in relation to this death on August 16, 2011 at Melbourne

find that the identity of the deceased was LUCIANO T!6

and death occurred on 19th May, 2007

at Avondale Heights, Victoria 3034

from ta, GUNSHOT WOUND TO THE HEAD!7

in the following circumstances:

1, Mr Luciano T was born in Trieste, Italy on 11 February 1932. He was 75 at the time of his death and was one of four children. His father died when he was nine and he lived with his

mother,

2. Mr and Mrs T met and married in Trieste when Mrs T was 17 and a half and Mr T was 19 and a half, They immigrated to Australia in 1955.

3. Mr T worked as a fitter and turner, His wife described him as a hard worker, obtaining a job the second day after they arrived in Australia.!8 Within about 2 years of living and working in Melbourne, they were able to put a deposit on a family home. In 1959 their first son Anthony

was born. Andrew, his second son was born in 1966.

16 Statement of Identification by Claude Pellegrini, brother-in-law of Mr ‘l made on May 20 2007 '7 Autopsy report of Dr Noel Woodford Statement of Mrs ‘I’ 23 June 2007 (Inquest Brief)

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4, Mrs T described the early years of their life together in Melbourne as one of considerable enterprise wherein they shared the parenting of Anthony whilst they both worked and opened and operated a small business.

5. From 1968 to 1971 the family returned to live in Trieste, then returned to Melbourne where they remained living. During the time that the family was back in Trieste, Mr T assisted in placing his sister in a nursing home as she was suffering from advanced Alzheimer’s disease, Mr T’s mother also suffered from dementia.

6. In 1972 the family purchased the home in Avondale Heights. This remained the family home.

7. Mr T had quite a serious workplace accident in the 1970's. Indeed Mr T had a range of very significant health issues including non insulin dependent diabetes, left sided sciatica and neuropathy of the right thoracic chest.!9 He had been under the care of the Neurology Unit of the Alfred Hospital since 2002 and had had multiple admissions. It is noted that during Mr T’s first admission to The Alfred in 2002, he was admitted with the problem of pain and depression.29

8. By the age of 51, Mr T was no longer able to work. Mrs T stated that Mr T "was a proud

man and a hard worker and his illness took this away from him".

9. Mrs T’s statement, obtained after her husband’s death, and despite her considerable injury at his hands, was replete with considerable sympathy and understanding for her husband, describing how much pain he was in and how depressed he had become consequent upon his

various health problems.

10. For exatnple, in the 2 years leading up to his death, in December 2005 he was admitted to hospital with a diagnosis of diabctic neuropathy of the right thoracic chest wall and a secondary diagnosis of depression. Tis chest pain was described as "severe, burning, constant and worsening. He had been on opiates amongst a number of other therapies but had had no

improvement. "2!

11. In September 2006, he was again admitted to The Alfred hospital, after a three week history of fluctuating and varying neurological symptoms. He was diagnosed as suffering a

19 Mr T’s considerable complex medical and health history included the left sided sciatica which was diagnosed as a painful side effect of the diabetes. He also had a documented history of depression. His treating General Practitioner, Dr Rothbart, provided a statement in which he also noted a trans-urethral resection of prostate, renal calculi and varicose veins. He was being treated with a considerable array of medications for his various conditions.

20 See Statement of Dr McDonald (Inquest Brief)

21 Statement of Dr McDonald Cnquest Brief)

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delirium suspected to be secondary to his medication regime on a background of early signs of dementia.22

Psychiatric History

12. Mr T also had a documented psychiatric history dating from 2002. According to his General Practitioner (GP), Dr Rothbart, due to his extreme anxiety and claustrophobia in the wake of an MRI procedure, Mr T was referred for psychiatric assessment and treatment, Dr Rothbart’s statement notes that Mr T was assessed as having some anxiety and depressive symptoms superimposed on some chronic paranoid personality traits. A psychiatrist from the Alfred Hospital recommended an Italian speaking psychiatrist be found to commence therapy with Mr T.

13. The psychiatrist that the T's apparently chose was Dr Leonardo Congui. Dr Congui first saw Mr T on June 13 2002. He noted that Mr T presented as an anxious and depressed man.?3 He was being medicated for anxiety (Oxazepam) and depression (Mirtazapine) and MS Contin

for his pain.

14, Dr Congui stated that he saw Mr T again in June 2002 after a recent hospital admission wherein Dr Congui noted that Mr T was extremely thin, having difficulties walking requiring him to use a four wheel frame and close to tears throughout the consultation.24 Dr Congui noted that part way through the consultation Mr T told him of his belicf that his wife had been unfaithful and that he believed that one of his children was not his. After some examination of Mr T, Dr Congui concluded that his presentation was typical of "Delusional Jealousy Syndrome". He commenced Mr T on an anti psychotic called Olanzapine, Dr Congui saw him several more times throughout 2002 and into early 2003 and noted that whilst Mr T’s mood and weight increased, Mr T avoided discussion about his wife’s unfaithfulness which Dr Congui assessed as evidence that Mr T had regained some insight.

15. Mr T was also seen on three occasions at The Alfred hospital for psychiatric consultation after having been referred for assessment for depression and confusion, On the first occasion in June 2002, he was diagnosed with depression and possibly showing carly signs of dementia. The psychiatric registrar had a discussion with Dr Congui about his findings.

16. In December 2005, during another in-patient stay at The Alfred hospital, a psychiatric registrar again assessed Mr T. He was still being diagnosed with depression (mild to moderate) although noted not to be suicidal. His anti depressant medication was increased and he agreed to recommence seeing his private psychiatrist. On 22 September 2006 he was again referred to a

22 Statement of Dr McDonald Cnquest Brief) Statement of Dr Congui (28.4.10) 24 Yhid

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psychiatrist during an in patient stay at The Alfred hospital, The registrar consulted with Mr T’s GP, made some adjustments to his medication and referred him to the MidWest Aged Persons Assessment team for follow up. However, contact was not made with this service.

Relevant Background

17. Mr and Mrs T were married for 53 years, Mr T had reported a troubled childhood to his wife, Nelly. He had confided in his wife that, as a boy, he had witnessed his mother doing "very bad things." Mrs T stated that in her opinion the events witnessed by Luciano involving his own mother caused Luciano to hold a position of deep mistrust of women and a firm belief that all women were promiscuous and unfaithful to their partners.

18, Mrs T noted that her husband had always been markedly jealous. This was so throughout their whole life together. She denied ever having been unfaithful to Mr T. It was Mrs T’s opinion that he had been scarred by his early life resulting in a bad opinion of women generally. Mrs T stated that this was so, even when they were young and very much in love. She stated that she did not think this would last her whole life with Mr T. Sadly, the accusations of infidelity persisted to the extent that the evidence leads me to conclude that this became part of family life in the household. But, for a reported period of about two weeks when Mrs T moved in with her brother to get some respite from this behaviour, she remained with Mr T.

19. As Anthony was preparing to marry at the age of 40, Mr T stated in front of his son’s intended wife that he did not believe Anthony was his son. Mr T could not be dissuaded from this belief and, as a result, Mrs T, Anthony and Mr T underwent paternity testing. This revealed Mr T was indeed Anthony’s father. Mrs T stated that Mr T did not understand how hurtful his obsession was to the family and, in the wake of having the results confirmed, he accused Mrs T

of having paid the nurse to "fix" the results,

20. Anthony T also made a statement to police in the wake of his father’s death. He described

his father as “obsessively jealous" of his mother.

21. He stated that, although there was little physical violence associated with this oft-stated belief, he constantly accused Mrs T of being unfaithful. He also noted that his father would wake

at night with some confusion and observed signs of some dementia.

22, Andrew T also stated that his father was obsessively jealous of his mother and that was a big problem in their marriage. Andrew recalled that his mother had left his father twice as a result, He stated that his father had intermittently stated in recent years that he was "sick of it all and he wanted to finish it all" and had threatened to kill his wife before dying himself. Andrew did not believe these threats had ever been intended to be carried out by his father. Andrew was

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not living at the home but he stated that he had been staying quite a lot at his parent’s home.?5 He described "bad days" for his father where he would get up during the night and not know where he was and then be coherent again in the morning.

Mr T’s last day

23, The morning of Saturday May 19 2007, was such a morning according to Andrew. Mr and Mrs T and their younger son Andrew were at their home, Andrew having stayed overnight.

According to Mrs T, Mr T had been faccally incontinent in the past couple of days and he had been distressed by that associating it with his sister’s dementia.

24. That afternoon, whilst extended family were present in the house, Mrs T asked Mr T to stop making disparaging remarks about a mutual friend. Mr T became angry and aroused by his wife’s comments and accused his wife of having scx with numbers of men and removed his pants and commenced mimicking a sexual act he believed had happened between his wife and another man. This caused considerable distress to Mr T’s wife, his son Andrew and Andrew’s uncle and godfather who were present when this happened.

25. Andrew described his reaction to this scene in his statement as not "being able to take if anymore", He described a scene of considerable distress and upset amongst the family members wherein he spoke to his father in very strong and loud language berating him for his conduct towards his mother, and slapping his father. Andrew stated he had never hit his father before,

26, Andrew stated that by about 6.00pm that evening the household had returned to calm and he left. He observed his father lying quietly on the couch half asleep and seeming to be finc.

27. Mrs T stated that, after Andrew and the other visitors had left, she and Mr T did some routine things around the home and then she observed Mr T come into the kitchen with a gun in his hand and start questioning her about the men she had been with stating various names. Mrs T described him as speaking in a calm and normal voice. She denicd the infidelities and stated that he called her a "fucking Har" in a mixture of English and Italian and then pointed the gun at her head and shot her in the side of her face. The bullet entered her right lower jaw. Mrs T described Mr T’s tone as "as cold as anything".

28. Mrs T ran from the house after having been shot. As she was fleeing she felt another

bullet pass her right arm.

29, Mrs T ran to elderly neighbours Mr and Mrs Darmanin across the road and knocked on

25 Statement of Andrew (Inquest Brief)

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their door,26 Upon seeing their neighbour with bloodied face and in obvious pain and distress on their doorstep, they immediately took her in and commenced assisting her and dialed 000. Mrs T had told them that her husband had shot her.

30. According to the statement provided by Mr Darmanin, Mr T arrived in the house a couple of minutes after his wife, as the front door had been left open in the confusion. Mr Darmanin described Mr T, armed with the gun and moving through his house looking for Mrs T.

31. Mr Darmanin, in what can only be described as an extraordinary act of courage, followed Mr T who found his wife sitting petrified in the bathroom. Mr Darmanin observed Mr T "fiddling" with the gun, When Mr Darmanin asked Mr T why he was doing this and what had his wife done to deserve this, Mr Darmanin stated that Mr T "just waved him away" and said nothing. Mr Darmanin stated that Mr T was trying to get the gun to work but could not and he then walked out of their home and returned to his own.

The police response

32. The call made by Mrs Darmanin was received at ESTA at 6.50 pm. At 6.51 pm Victoria Police dispatched a police vehicle designated Avondale Heights 303 (containing S/C Sadler and Constable Sengul) to the scene. A canine unit nominated itself as a back-up unit. The Beacon Principles warning was given reminding members to exercise the 10 safety principles for such a scene, which had the discharge of a firearm with the whereabouts of the offender as unknown as

they approached the scene.

33. At 6.51pm another unit in the Avondale Heights region carrying Senior Sergeant Buchhorn and S/C Budd and Constable Kerry also heard the incident being reported as did the supervising sergeant, Acting Sergeant Paulli,

34, At 6.53pm the supervising Sergeant Paulli issued two directives to members attending the scene, The first was to attend a nominated rendezvous point for a briefing and the second was to

don ballistic vests.

35. By 6.56pm after information being provided by attending ambulance officers, the police were being advised that it was likely that Mr T had returned into his home.

36. By 6.59pm Acting Sergeant Paulli called for the Critical Incident Response team of Victoria Police to attend the scene to give assistance.

26 Mr Darmanin was 82 and his wife 79 at the time of this incident. They had lived in their home for 47 years and knew the T’s to say hello to and have a neighbourly chat.

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37, A large number of police units were in the area by 7.09pm at which time Senior Sergeant Buchhorn made a request through police communications for the attendance of the Special Operations Group.

38. The investigating member Detective Sergeant Allan Birch of the Homicide Squad provided a list of the police members who attended this scene this night. They totaled 41 police members in attendance that night.

39, Many members were engaged to set up an inner perimeter and an outer perimeter cordon in accordance with police policy and a "cordon and contain” operational plan was adopted.

40. By 7.20pm, four police members attended at the Darmanin’s home and thereafter gave the ambulance officers the "all clear" to come in to attend to Mrs T.

41, Anthony had received a call from Mrs Darmanin just after 7.00pm advising him of the shooting. Together with his wife he travelled immediately to his parents’ home.

42, He states that when he arrived at the house he saw his father on the balcony of their house. He asked his father where his mother was and his father told him she was across the road, Anthony stated he thought his father was "pretty calm" when he told him this.27 Anthony went on to describe further exchanges with his father where his father asked him if his mother was still alive and Anthony told him he did not know, Anthony then describes his father as appearing to place one of his hands beside his head in a manner as if he was placing a gun at his head.

Anthony statcs he could not see if it actually was a gun. Several times Anthony asked his father to put the gun down and come downstairs but stated that his father was not answering his

questions, only asking if his wife was alive or dead.

43, Anthony stated that after a short time the police moved them up the street. From where he stood, Anthony saw his father move in and out a number of times from the balcony. Anthony stated he was only threatening to kill himself and not anybody else.

44, Anthony stated that he remained where he was with his wife until the police told him his father had taken his own life.

45. Anthony stated he had no knowledge of his father having a firearm.

46, Andrew stated that he got a call from his brother at about 7.00pm telling him what had

happened. He too set out for his parent’s home immediately. He stated he got there 15 or 20 minutes later, He stated he continually tried to call his father at the house and on about the 6th

27 Statement of Anthony T..

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attempt he spoke to his father. He asked his father what had happened and he stated that his father said to him "in his calmest voice” "I’ve just killed your mum’... and now I’m going to kill myself” and then he said “and it’s your fault... and if you come to the house I’m going to kill you as well..."°8 The police had this information relayed to them by Andrew. At this time they were endeavouring to negotiate with Mr T to surrender himself.

47. Andrew agreed with Anthony, that Anthony would stay in the vicinity of their parent's house and he would go to the hospital with their mother.

48, By about 11.06pm, after not having heard or seen Mr T for several hours, and having endeavoured to make contact with Mr T in a number of different ways, including via a Public Address system, the Special Operations Group forced an entry into the home and found Mr T in his bedroom lying motionless on the bed with a pistol in his right hand. An ambulance was called and attended confirming that Mr T was deceased.

49. Dr Noel Woodford, head of Forensic Pathology at the Victorian Institute of Forensic Medicine performed an autopsy and found that Mr T had died from a single gunshot wound to his head.

50. _ A firearms expert S/C Glaser from Victoria Police attended the scene and was given the bullet removed from Mr T, He provided his opinion that the bullet retrieved from Mr T was fired from the handgun Mr T had been holding at the time of his death, Andrew and Anthony both stated that they had never known their father to have a firearm beyond an air-rifle many years earlier. The investigation was not able to discover where or how Mr T obtained the firearm he used to shoot his wife and then take his own life.

51. Ethical Standards were notified given the death occurred in police presence and the investigation was conducted by the Homicide Squad.

52, In the circumstances contained in the Brief of Evidence provided, I find no issues raised with respect to the response of Victoria Police to the situation they were confronted with on this evening. It was both a complex and confronting situation for the police members involved, given that there was a person seriously injured and another still armed and at Icast initially apparently at large in a residential area. Proper instructions appear to have been given incorporating the Beacon warnings as well as instructions to members to wear ballistic vests, and create a cordon and containment plan orchestrated from a rendezvous point. Despite the sad outcome in that Mr T lost his life, there is no evidence to suggest that this was a result of anything that the Victoria Police members who responded to this incident could have done differently.

28 Statement of Andrew T CUnquest Brief).

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Family Violence Review

53. Given the background and circumstances of the shooting of Mrs T and the death of Mr T, this coronial investigation has been assisted by the Coroners Prevention Unit, a specialist team who are engaged in conducting the Victorian Systemic Review of Family Violence. The purpose of this review is to examine family violence-related deaths to inform future interventions aimed at protecting both children and adults from family violence.29

54. To pursue this aspect of the Coronial Investigation, an expert opinion was sought from consultant forensic psychiatrist Dr Danny Sullivan. This report was obtained and has been tendered into evidence. (8 January 2011),

55. In that report, Dr Sullivan describes delusional jealousy and its frequency in this way » Jealousy is a normal human emotion... in some people jealousy is persistent, pervasive and is part of an abnormal personality structure. Some mental disorders are specifically associated with pathological or morbid jealousy, including depression, alcohol and other substance use disorders, psychotic illnesses and organic brain disorder. The nomenclature is confusing but delusional jealousy is considered a subset of pathological or morbid jealousy. A small number of jealous people have delusional jealousy. This is at the extreme end of the continuum and is based upon the presence of fixed, unchangeable beliefs held with absolute conviction, that the other party is unfaithful. There may be psychotic elaboration, drawing inferences from incidental Phenomena that confirm the delusional belief: in some cases hallucinatory phenomena confirm the underlying delustonal belief. The prevalence of delusional jealousy is unknown, It iy considered elevated in substance abusers and particularly on those dependent on alcohol, It is

56. In the body of his report, Dr Sullivan also addressed the risks associated with a diagnosis of delusional jealousy. He stated as follows: .. "Morbid jealousy is a condition which is known to be associated with an increased risk of assaults and murder, The predominant factors associated with violence are overt psychotic symptoms (command hallucinations and paranoid delusions), intoxication, and previous violence, especially domestic violence to the partner perceived as unfaithful. Suicidal ideation is also accompanied by increased risk of homicide in these cases. In Mr T’s case intermittent suicidal statements had not apparently been accompanied by plans or attempts, and were no doubt taken as expressions of distress and hopelessness but not as premonitory statements of intent His jealousy had been present for the life of the relationship, over 50 years, but he had not by all accounts engaged in any significant violence or threats of violence, He was not known to have a firearm in recent years. He had no other history of

29 ‘The Victorian Systemic review of family violence deaths was established in 2009 to assist coroners with their investigation of family violence related deaths, to contribute to the development of a better understanding of and potential making of recommendations aimed at reducing family violence generally and family violence related death in particular,

30 See Report of Dr Danny Sullivan P.6

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violence, overt personality disorder or substance abuse. He did not show evidence of clear psychotic symptoms or gross preoccupation with his beliefs in his wife’s infidelities. Compared to others with pathological jealousy, Mr T. would not have been considered to be at escalated risk of violence or suicide. The main factor which would have downgraded the risk was the longstanding persistent symptoms without escalation or significant elaboration... The significant difference on the day of his attempt to kill his wife and then suicide, was that he had been criticised in front of other others in a manner likely to have caused great humiliation to him and occurred on a recent background of concern that he was dementing, and the longer background of ill-health and chronic pain, I do not consider that anyone would have foreseen that this altercation would have had such a profound impact on Mr T.... ."

57. Whilst I do not take issue with Dr Sullivan’s expertise or opinion about the catalyst for Mr T’s behaviour on the day, it does not explain nor address the fact that Mr T had clearly set about to obtain a firearm before this episode and apparently in contemplation of the actions which ultimately ended his life and left his wife seriously injured,

58. Dr Sullivan was also asked to comment upon the treatment and management of Mr T’s condition, in particular throughout the years from 2002 onwards.

the main issue rather than a secondary concern, it would have been appropriate to advise Mrs T about potential risk to her. Antipsychotic and antidepressant medication are appropriate treatments for delusional jealousy, There is no guidance as to how long these should continue but it would be accepted practice that if morbid jealousy persisted, treatment should be maintained.

Patients may however not disclose jealous beliefs.”

60. Importantly, Dr Sullivan went on to state that he found no information suggesting "that Mr T. would have warranted involuntary treatment at that time."

61, Dr Sullivan also noted that the persistence of Mr T’s beliefs "without escalation or indication of violence risk may have persuaded treating doctors to regard this as low-risk,"

that his pathological jealousy was a current issue at any stage, except perhaps when paternity testing took place. Unless this was the presenting complaint of Mr T, or his wife, or there were threats or actual violence, it is likely that his Jealousy would have been considered due to personality or cultural background without clear indication that it warranted treatment. Given the long-standing nature of his symptoms in the absence of risk indicators such as actual violence or overt threats to his wife, it appears that the attempted murder of Mrs T and the suicide of Mr T were highly unlikely to have been foreseen. Even if he had been under treatment with antipsychotic medication, the events are unlikely to have been prevented..."

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Conclusion

63. Given all of the above, I find that Mr T intentionally took his own life by shooting himself in the head with an unlicensed unregistered firearm he had obtained in unknown

circumstances,

64, The death of Mr T occurred in the context of a range of complex medical conditions and associated mental health difficulties, most notably being depressed and having a diagnosis of delusional jealousy syndrome, The genesis of Mr T’s attempt to kill his wife and of his subsequent suicide were most likely to have related to his pathological jealousy. The evidence is that the other elements, which may have contributed to Mr T’s actions, included depression, chronic pain, a fear of developing dementia and possible carly dementia.

COMMENTS: Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments:

To assist in the raising of awareness and development of understanding of the increased risk of harm within intimate personal relationships of pathological jealousy, I direct the distribution of this finding to the following organisations and entities for their information only:

The Office of the Chief Psychiatrist, Department of Health, Victoria The Royal Australian and New Zealand College of Psychiatrists The Australian Psychological Society

The Royal Australian College of Gencral Practitioners

PFeYeNPR

Talso direct that a copy of this Finding be provided to :

• Mr Andrew T (the son of Mr Luciano T)

• Investigating Member, Detective Senior Sergeant Allan Birch

• Dr Danny Sullivan, Consultant Forensic Psychiatrist

~ Dr Congui

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• Dr Rothbart GP

• Medical Director The Alfred Hospital

• Associate Professor Steven Ellen

For the purpose of general publication pursuant to s 73 Coroners Act 2008, I direct that the family name of the deceased be removed and that the family name be referred to by the initial T.

ge Jennifer Coate tate Coroner 29th August, 2011

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