Finding into death of AS

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2014 004172

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, ROSEMARY CARLIN, Coroner having investigated the death of AS

without holding an inquest:

find that the identity of the deceased was AS born 1946

and the death occurred on 15 August 2014

at residential premises

from:

l(a) | GUNSHOT INJURIES TO THE ABDOMEN

Pursuant to section 67(1) of the Coroners Act 2008 there is a public interest to be served in making findings with respect to the following circumstances:

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AS was born 1946. He was 68 years old when he took his own life. Mr AS lived alone in

Victoria. He is survived by his family including his children.

2. Victoria Police prepared a brief for the Coroner that included statements from Mr AS’s brother, treating clinicians and police. I obtained further material regarding Mr AS’s involvement with mental health services and the firearm licensing process. I have drawn on this material as to the factual matters in this finding.

Medical history

3. In 1988 Mr AS was diagnosed with bipolar affective mood disorder. He also had a long

history of excessive alcohol consumption. Mr AS received treatment from psychiatrist Dr Dennis Maginn for many years. When Dr Maginn retired, Mr AS was reluctant to see another psychiatrist and thereafter his mental health was managed by his general

practitioners.

4. Dr Daryl Smith was Mr AS’s general practitioner from 2008 until his death. He reported that Mr AS’s bipolar disorder was well controlled for many years by a combination of lithium and citalopram, however in 2012 his mental health deteriorated. He became more depressed and drank excessively. He declined referral to another psychiatrist. His

medication was adjusted with some effect.

5. In May 2014 Mr AS presented to Dr Smith complaining that his depression had become worse. Dr Smith referred Mr AS to Latrobe Regional Hospital where he received treatment from mental health services, including psychiatrist Dr Nader Yakoub. Dr Yakoub assessed him on three occasions and noted that his mood improved on the second occasion. Mr AS’s medication was changed from olanzapine to quetiapine. His lithium dose was also reduced

within a therapeutic range.

6. On 22 July 2014, Dr Yakoub conducted a final review of Mr AS. He reported that Mr AS had ‘occasional thoughts of self-harm but denied any intention to act on them’ and that his family were his protective factor. Mr AS was provided contact telephone numbers of Bairnsdale Community Mental Health Service (BCMHS) to contact for post-discharge assistance. He was assigned a case manager and was given the after-hours Mental Health Triage telephone number. In the event that number is unmanned callers are advised by

recorded message to telephone ‘000’ if it is an emergency and otherwise to leave a message.

Gun ownership and registration

7. At the time of his death Mr AS held a current firearms licence, The licence was first issued in 2002 and renewed in 2006. In August 2011, his firearm licence lapsed. He submitted a new application in March 2012 which was approved and a new licence was issued in April 2012 with an expiry of 3 April 2017. In all three applications Mr AS indicated he required

the licence for hunting vermin on his rural property.

8. On 24 October 2006 Mr AS obtained a permit to acquire the rifle which he subsequently used to kill himself,

9. In Mr AS’s first licence application in 2002 he ticked ‘yes’ to having been treated in the past 5 years for ‘psychiatric, depression, stress or emotional problems’, In his renewal application in 2006, he also ticked ‘yes’ to having been treated in the past 5 years for ‘psychiatric or psychological conditions’. In each case he provided a medical report from his treating medical practitioner supporting his application. The medical report in 2006

referred to his bipolar disorder as being well controlled by medication for 22 years.

any

13,

In his licence application in 2012, Mr AS ticked ‘no’ to the same question of whether he had been treated for any medical condition in the past 5 years, including ‘psychiatric, depression, stress or emotional problems’, This was false as he continued to see Dr Smith throughout

that time and was prescribed medication for his bipolar condition.

. Further, in all three licence applications Mr AS either ticked ‘no’, or left blank, the answer

to the question of whether he had any alcohol or drug dependence problems in the last 5 years, despite the fact he was known by his medical practitioners to have a history of alcohol

eXcess.

Due to Mr AS’s false answer (or answers) in his 2012 application it appears Mr AS’s bipolar disorder was not considered at that time. According to Paul Connor, Sergeant of Police at the Licensing and Regulation Division, there was nothing in Mr AS’s 2012

application of concern and it was therefore approved.

Mr AS’s brother, AT was ‘surprised that he got a gun licence, with his history of Bipolar’.

Circumstances leading to death

AT maintained regular contact with his brother. According to AT, his brother had ‘hinted at suicide’ in the past, but maintained his mental health by treatment and keeping busy. In the two months prior to his death, AT thought his brother was ‘down’ and arrangements were

made for ‘psych nurses to go out and see him’.

.On Thursday 14 August 2014, AT and his daughter visited Mr AS at his home. AT

described his brother as ‘a bit down’. Also that day, Mr AS telephoned BCMHS and spoke to the receptionist. According to Cayte Hoppner, Director of Mental Health at Latrobe Regional Hospital, Mr AS asked to speak with his case manager, but did not indicate any urgency. A message was left for his case worker to return his call, but she did not receive

this message until she returned to work the following Monday,

Later that day, Mr AS telephoned Dr Smith. According to Dr Smith, Mr AS was ‘quite agitated’ and cited issues with his medication. Mr AS told Dr Smith he had been trying to make contact with Psychiatric Services throughout the day without success. Dr Smith noted that Mr AS did not express suicidal ideation. Dr Smith offered advice regarding medication and arranged a follow up appointment. Following this call, Mr AS spoke to his brother and

“seemed more settled’.

On Friday 15 August 2015 at approximately 8.57 a.m. Mr AS telephoned ‘000’. He advised the call taker he intended to commit suicide using his gun and he wanted to report it. He

told the call operator ‘I’m Bipolar and there’s lots of things going on’ and explained he was

“down and out’. The call taker notified police and transferred the call to a Sergeant, but Mr

AS did not respond.

. At approximately 9 a.m., police were notified to attend Mr AS’s address. They carefully

coordinated their approach to Mr AS’s property due to the inherent danger of the situation: a mentally unstable person with a firearm. At approximately 9.40 a.m. they started to search his property but could not find him. At approximately 3 p.m., they again searched the property and found Mr AS seated in the lounge room of his house. He was deceased and there was a visible gunshot wound on his body. Mr AS’s rifle was positioned between his

legs.

Post mortem investigation

19. Dr Paul Bedford, Forensic Pathologist with the Victorian Institute of Forensic Medicine,

inspected Mr AS’s body. The examination was consistent with circumstances of death.

Toxicological analysis of post mortem blood samples revealed therapeutic quantities of the anti-depressant citalopram (0.Smg/L), anti-psychotic quetiapine (0.1mg/L) and verapamil!

(0.3mg/L). Dr Bedford reported the cause of death as 1(a) Gunshot injuries to the abdomen.

Finding

20. Iam satisfied having considered the evidence that further investigation is not required. I am

Bly

satisfied there were no suspicious circumstances and that Mr AS intentionally ended his life.

I find that AS died on 15 August 2014 from self-inflicted gunshot injuries to the abdomen.

COMMENTS

Pursuant to section 67(3) of the Coroners Act 2008, 1 make the following comments connected

with the death:

In his 2012 firearm licence application, Mr AS did not admit to having a recent history of psychiatric or related problems. Specifically, he ticked ‘no’ to receiving treatment for any ‘psychiatric, depression, stress or emotional problems’. This was inconsistent with his answer to the equivalent question in his two previous applications. The discrepancy was

either not detected or not investigated.

There is no evidence as to whether Dr Smith would have provided a favourable report if he had been asked, however he did note Mr AS’s worsening depression and increased alcohol

consumption in 2012.

' Used to treat high blood pressure, angina and irregular heartbeat.

3. The Coroners Court has previously considered the issue of the firearm licensing regime and its reliance on the individual applicant declaring any potentially disqualifying conditions such as mental illness. The process depends not only on the honesty of the applicant, but also on the ability of the applicant to make that assessment. It is difficult to imagine many

people forming the view that they have an alcohol problem.

4. Coroner Spooner in her finding into the death of Peter Quin-Conroy* recommended that Victoria Police, Department of Health, the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists convene to resolve issues identified in the firearm licensing regime. She suggested a number of possible actions including a requirement that all applicants for a firearm licence provide a medical report from a medical practitioner in a position to comment on that person’s

medical history.

5. In response to this recommendation the firearm licensing regime was reviewed by a working group of the interested parties named by Coroner Spooner. This led to the development of a “Quick Guide: The role of health professionals in the firearm licensing process’ which was published by Victoria Police in February 2016. The Quick Guide is available online bya

search of the internet.

6. The Quick Guide is a helpful reference to health professionals and provides advice as to the circumstances in which they should consider making an ‘own motion’ report to Victoria Police of concerns in relation to a patient holding, or applying for, a firearms licence.

However, the fundamental position remains that the individual applicant must self-report his or her mental health, or other medical condition, before Victoria Police will seek a report from a health professional as to that person’s suitability to hold a firearms licence. Even then, the Quick Guide makes it clear that seeking a medical report is discretionary. Further the own motion reporting by health professionals can only occur if they know or suspect the

patient has, or is about to apply for, a firearms licence.

7. Arguments against requiring all applicants for a firearms licence to provide a supporting medical report include that it may provide a disincentive for patients to receive appropriate medical treatment and that it would be unduly onerous, As to the former, it is difficult to see how this would occur in practice. In any case medical professionals always retain the ability, if not obligation, to report relevant concerns to Victoria Police, as is made clear by the Quick Guide. It is not suggested that patients are not seeking treatment out of fear this

may occur.

2 COR 2010 3294.

—

As to the latter, evidence given in the Inquest into the death of Peter Quin-Conroy indicated that there were approximately 11,000 licence applications and 30,000 to 40,000 licence renewals each year. Of these only 50 to 60 were subject to an internal re-assessment process as a result of a self-declared medical condition. These figures show there are a large number

of applications being processed each year, but only few that require further consideration.

A requirement that all applications (including renewals) be accompanied by a medical report would increase the time taken to process applications at the initial phase, to some degree.

More significantly, it would likely increase the number of applications requiring further assessment as under-reporting of medical conditions by applicants can be assumed.

However, such an outcome is desirable, not undesirable.

The real burden of such a requirement would fall on the applicants as they would need to obtain and submit the medical report. This is a small price to pay for the privilege of

holding a firearms licence.

. Any added burden on health professionals is unlikely to be great as it could be anticipated

that any individual health professional would only occasionally be asked to provide a report

and if there were no concerns his or her report would be short.

. A requirement that all applications for licences or renewals be accompanied by a medical

report would serve the dual purpose of reducing under reporting by applicants and alerting health professionals to the fact a patient holds a firearms licence, a significant piece of

information in the treatment of the mentally unwell.

RECOMMENDATIONS

Pursuant to section 72(2) of the Coroners Act 2008, 1 make the following recommendations

connected with the death:

1,

That the Licensing and Regulation Division of Victoria Police implement a system whereby answers to relevant questions on firearms licence applications are compared to the same

answers on previous applications.

That the Licensing and Regulation Division of Victoria Police give further consideration to amending its firearm licence application process to require all applicants to submit a report

from a treating health professional as to their fitness to hold a firearms licence.

I direct a copy of this finding be provided to the following: The family of AS; Licensing and Regulation Division, Victoria Police; Royal Australian College of General Practitioners; Royal Australian and New Zealand College of Psychiatrists; Interested parties; and

Coroner’s Investigator, Victoria Police.

Signature:

ROSEMARY CARLIN CORONER Date: 11 March 2016