Demographics
44y, male
Coroner
Coroner John Olle
Date of death
2017-10
Finding date
2020-09-11
Cause of death
compression of the neck consequent upon hanging
AI-generated summary
A 44-year-old man with a 42-year history of intimate partner violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessions. He reported suicidal ideation and lowered mood but did not seek mental health support despite encouragement from friends. Post-mortem alcohol was detected (0.16 g/100mL). The coroner's extensive investigation examined 2,554 Victorian suicides (2009-2015) of men aged 35-74, identifying patterns in anger/aggressive behaviours, substance use, relationship breakdown, and mood disorders. Key clinical lessons: anger and aggressive behaviours, particularly when new or uncharacteristic, may indicate emerging mental illness or distress requiring early intervention; behaviour change programs need formal suicide risk assessment and mental health monitoring; general practitioners are crucial contact points for men in crisis who rarely access specialist mental health services; substance use assessment and treatment must be integrated into violence prevention programs; and primary care providers need education on recognising distress expressed as anger in men.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT OF VICTORIA AT MELBOURNE Court Reference: COR 2017 5305
FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: MR JOHN OLLE, CORONER Deceased: MR A* Date of birth: Date of death: Cause of death: COMPRESSION OF THE NECK
CONSEQUENT UPON HANGING Place of death: Catch words: FAMILY VIOLENCE; SUICIDE; MENTAL
HEALTH; SUBSTANCE USE; BEHAVIOUR CHANGE PROGRAM *The published version of this finding has been de-identified to preserve the privacy of the deceased’s family.
TABLE OF CONTENTS Circumstances in which the death occurred pursuant to section 67(1)(c) of the Coroners Act 2008 ... 4
Mr A had three children with his wife of 44 years, Mrs A, however, the couple had recently separated. He was a carpenter by trade, but had been unemployed for two years after injuring his Achilles tendon. He experienced ongoing disability and pain related to the injury.
From the available medical records, it appeared Mr A had no formal or documented psychiatric condition or diagnosis.1
Mr A’s death constituted a ‘reportable death’ under the Coroners Act 2008 (Vic), as his death occurred in Victoria, and was both unexpected and unnatural.2
The jurisdiction of the Coroners Court of Victoria is inquisitorial3. The purpose of a coronial investigation is independently to investigate a reportable death to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which death occurred.
It is not the role of the coroner to lay or apportion blame, but to establish the facts.4 It is not the coroner’s role to determine criminal or civil liability arising from the death under investigation, or to determine disciplinary matters.
The “cause of death” refers to the medical cause of death, incorporating where possible, the mode or mechanism of death.
For coronial purposes, the circumstances in which death occurred refers to the context or background and surrounding circumstances of the death. Rather than being a consideration of all circumstances which might form part of a narrative culminating in the death, it is 1 Seaport Medical Centre and statement by general practitioner (GP) Dr Jesse Das. The focus was medical issues, most related to his January 2016 Achilles injury of which the care appears appropriate. His last consultation was with Dr Abraham Stephanson on 14 July 2017. Mr A was also referred to and assessed by an Epworth senior physiotherapist who recommended vocational rehabilitation and a return to work. Coronial brief of evidence, pages 15 – 27.
2 Section 4, definition of ‘Reportable death’, Coroners Act 2008.
3 Section 89(4) Coroners Act 2008.
4 Keown v Khan (1999) 1 VR 69.
confined to those circumstances which are sufficiently proximate and causally relevant to the death.
(a) to report to the Attorney-General on a death;
(b) to comment on any matter connected with the death they have investigated, including matters of public health or safety and the administration of justice; and
(c) to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice. These powers are the vehicles by which the prevention role may be advanced.
MATTERS IN WHICH THE CORONER MUST, IF POSSIBLE, MAKE A FINDING Identity of the Deceased pursuant to section 67(1)(a) of the Coroners Act 2008
Medical cause of death pursuant to section 67(1)(b) of the Coroners Act 2008
the neck consequent upon hanging”. I accept Dr Parsons’ opinion in relation to the cause of death.
Circumstances in which the death occurred pursuant to section 67(1)(c) of the Coroners Act 2008
My investigation revealed Mr A’s death occurred in the context of psychosocial stressors, the consequences of perpetrating family violence, substance dependence, a possible emerging mental illness for which he did not seek help, and engagement with behaviour change services.
At the time of his death, Mr A and Mrs A had been separated for approximately five months.
Mrs A noted a history of family violence with Mr A, and described her husband as “a little bit volatile”. She stated he could be “physical” towards her, but only in private, and usually when consuming alcohol. Mrs A said she left the family home after an altercation in which Mr A told her to leave and had been physically aggressive.
Mr A struggled with the prospect of Mrs A not returning to the relationship and had voluntarily enrolled in a men’s behaviour change program run by Brophy Family and Youth Services (BFYS) in Warrnambool. The program lasted 18 weeks and Mr A had completed 17 of 18 sessions at the time of his death. The last session was scheduled for 18 October 2017, however, he did not attend.
During the program, Mr A had admitted to using violence after five years of being in the relationship.6 A Family Violence Intervention Order was in place at the time of Mr A’s death, although Mr A had stated he was unaware of the conditions of any order because he had torn it up when he was at Court.7
Mr A’s friend, Mr B, engaged him as a casual labourer, and they had a standing catch-up every Thursday and often on Sundays for coffee. Mr B described Mr A as upset “for the past few months” following his separation from Mrs A, and said he had encouraged Mr A to see a counsellor.
6 Submission of Brophy Family and Youth Services assessment page 5.
7 Submission of Brophy Family and Youth Services assessment page 5. Details of any order were not obtained.
Mrs A said Mr A was feeling down, was more withdrawn and that he often fluctuated in how he presented. Her last contact with him was via text message on 15 October 2017 while she was in Brisbane visiting their daughter.
On Monday 16 October 2017, Mr B said Mr A seemed “bloody good”, but later in the day and after alcohol, Mr A had become tearful and upset about the loss of his relationship.
On the evening of Tuesday 17 October 2017, Mr A spoke with each of his three adult children and described future plans.
Mr B tried to contact Mr A by phone during the early evening on 18 October 2017, but received no response. According to Mr B, at about 7:00am on 19 October 2017, he attended Mr A’s home as usual, and located Mr A hanging in the back yard.
Emergency services were contacted but Mr A was declared deceased at the scene. Mr A left suicide notes to five people. The note to Mrs A was bitter and accusatory and this information was included in his note to their son . Notes written to friends and family were positive.
Review of Brophy Family and Youth Services
Ms Donna Wynters, Manager of Family and Individual Support Programs at BFYS provided a statement, attaching a copy of Mr A’s participation forms in the behaviour change program. Ms Wynters described the behaviour change program as accessible, flexible and individualised in its response to assisting men who use violence against women, while maintaining the safety of women and children as paramount. In addition, Ms Wynter provided details of the evidence base for the model of service which included contact and voluntary participation by a partner. Mr A’s attendance at the program was voluntary, whereas many participants, even if compelled, only attend the assessment appointment.
Mr A told group facilitators he drank alcohol most days of the week. He said he was angry about Mrs A telling friends they had volunteered for the Commonwealth Games and detailed the verbal and physical interaction that led to Mrs A leaving the family home. He expressed regret and shame at his behaviours and explained he was participating because his behaviours were not healthy for others and himself. However, Mr A’s presentation within the group fluctuated, as did his level of engagement as opposed to attendance.
Mr A self-reported recent suicidal thoughts, and acknowledged an attempt 10 years prior.
When this was explored, Mr A did not have current suicidal thoughts and was planning on taking the caravan and going away.
Mr A was expecting and hoping Mrs A would return to the marriage; that his participation in the behaviour change program was evidence of his commitment. However, he continued to blame Mrs A for his predicament – that she was not responding to his text messages as he wished. He believed he would lose everything in the event of a formal separation.
In June 2017, it was noted that Mr A was not coping with the separation and the idea of his abusive behaviours; that he had shut down within himself, and had suicidal thinking which staff would monitor.
In July 2017, Mr A was angry, felt sorry for himself, but was willing to look at his past behaviours in his relationship. At the end of July 2017, he had contacted his children, left voice messages for Mrs A and she had responded.
Around this time, Mrs A realised Mr A had controlled her throughout their relationship. In September 2017, it was noted Mr A expressed experiencing guilt and shame in the group, and that he should not be pushed any further.
There was no formal assessment or monitoring of Mr A’s mood or suicidal thinking as a participant in the program. His program safety plan was focused on steps to take to avoid behaving violently.8 Internal review
BFYS completed an internal review and identified that the safety of participants in the context of the risks associated with ongoing and personally reflective programs, required a more formal response. Consequently, BFYS implemented the following:
(a) All new program referrals have a weekly clinical review;
(b) Participants with a past or current history of suicidal thinking at referral, have a suicide risk assessment commenced and documented in their file; 8 Brophy Family and Youth Services participation notes from the program include the agreed action plan, assessment, individual briefing sheet, safety plan (focused on not behaving violently), records of in-house family violence meetings group records, participant agreement and a case note. The safety plan comprised the time-out/walk away strategy of which CPU advised there is limited evidence of effectiveness without other supports.
(c) Weekly clinical meetings to specifically include the identification of any participants with current risk indicators; and
(d) Participants with current risk indicators to have an alert noted on file.
Conclusion
Coroners Prevention Unit review
As part of my investigation into Gary’s death, and in order to identify any prevention opportunities, I requested the Coroners Prevention Unit (CPU)9 Mental Health Team, conduct a comprehensive review of the cohort of suicides into which Gary’s death fell. I requested CPU review the Victorian Suicide Register (VSR) for those aged 35 to 74, with a focus on males who had known anger and angry behaviours. I also sought submissions from organisations who provide services to these men.
The report was reviewed by the CPU Mental Health Investigators, CPU Family Violence Team, and CPU Manager Research and Data.
Trends identified by CPU
(a) All Relevant Deaths Cohort: 2,554 people (1,932 males and 622 females) aged 35 to 74 years who suicided in Victoria between 2009 and 2015.
(b) Anger/Angry Behaviours Cohort: 667 people (570 males and 97 females) among the 2,554 Victorian suicides, where there was explicit evidence they displayed anger and/or angry behaviours prior to death.
9 The CPU assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the Coroner and is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
(c) Duration of anger/angry behaviours cohort: 229 people (205 males and 24 females) among the 667 suicides in the anger/angry behaviours cohort, where there was sufficient evidence available to establish the duration of the behaviours for more detailed analysis.
(a) A high tolerance for anger/angry behaviours within a family(s) – for example: “It was the only time he was physical with me; during 18 years he’d only ever been insulting and verbally aggressive; It was always something that I did that he said made him hit me; When he started to tell my son again and again that it was his fault he had kicked or threatened me, I knew I needed to get out; I could tell when he was building up, when he was likely to explode, we all learned the signs.”
(b) That many of the family relationships were complex – for example: “His Ex, the kids, his father and his work wanted him as much as me and I’m his fiancé and it was exhausting.”
(c) That formal partner separation while sharing the same accommodation adds additional stressors – for example: “We couldn’t afford the mortgage and rent for a second place plus needing more childcare so we just tried to stay apart under the same roof.”
(d) Intergenerational trauma – for example: “An alcohol fuelled violent childhood; He was sexually abused by his brother for years;” and
(e) That the presence of alcohol was a constant.
(a) All Relevant Deaths Cohort
29.3%). This suggested an association between sex and partner stressors prior to suicide.
Partner violence (perpetrator and/or victim) was identified in 16.2% of all deaths (males 15.7% versus females 17.7%).
A higher proportion of females than males experienced family stressors (60.1% versus 50.9%) which included family death, family conflict, and family health issues. This was similarly seen in the non-family stressors (females 49.7% versus males 43.2%) which included non-family death, non-family conflict, and non-family health issues. This suggested an association between sex and family stressors prior to suicide.
Of the 2,554 deceased, 85.1% experienced one or more contextual stressor during their life including work, finance, legal, sexual, isolation, bullying, abuse10 and substance use, with little difference between females and males.
Of the deceased who suicided, 57.4% had a documented mental disorder diagnosis, (females 71.7% versus males 52.8%) of which 47.7% were mood disorders. Of the 1,467 deceased with a documented mental health disorder, 83% had a mood disorder (females 85.6% versus males 81.9%). This suggested an association between sex and a mood disorder prior to suicide. The second frequent diagnosis was non-psychotic/mood which includes anxiety and stress related disorders at 20.2% (females 28.9% versus males 17.4%). Of these 517 deceased with a documented non-psychotic/mood mental health disorder, females had a higher proportion at 46.3% versus males 33%.
Of the 2,554 deceased who suicided, 64.1% had contact with at least one health service for a mental health related issue within the 12 months prior to their death (females 77.5% versus males 59.8%). Of the 1,637 deceased who had contact, 73.1% were with a general practitioner (females 74.6% versus males 72.5%), 49.4% with a psychiatrist (females 57.2% versus males 46.1%) and 37.1% with a mental health practitioner (females 40.6% versus males 35.6%). There was a higher proportion of females than males across contacts with psychiatrists, psychologists, mental health practitioners, emergency departments and crisis assessment and treatment teams. Of note, across all deaths, the frequency and proportion of contacts with addiction (substance use) services was small.
10 Bullying and abuse included experience as perpetrator and/or victim.
(b) Anger/Angry Behaviours Cohort
combined with evidence of orders or other activities related to aggression and violence.
(a) 463 (males 74.7% and females 25.3%) case narratives from family, friends, neighbours, practitioners etc. were considered as insufficient to assess presence or absence of anger/angry behaviours.
(b) 1,424 (68%) of 2,091 remaining case narratives did not contain stated anger/angry behaviours associated with the deceased (males 71% and females 29%).
(c) In 667 cases (32%), the case narratives contained explicit evidence of anger/angry behaviours associated with the deceased; 570 (85%) of the cases were deceased males and 97 (15%) were deceased females.
(d) Across both males and females, the greater proportion of stated anger/angry behaviours occurred in the 35 to 44 and 45 to 54 age groups.
Among all the 667 deceased, 84.7% had at least one partner stressor (females 77% versus males 86%). A higher proportion of males than females experienced partner separation (57.2% versus 47.4%) and partner conflict (70.2% versus 53.6%). Partner violence (perpetrator and/or victim) was identified in 35.5% of the deaths (males 36% versus females 33%). Among the 565 deceased with at least one partner stressor, partner conflict was the higher proportion 80% (males 81.6% versus females 69.3%) and partner separation 65.8% (males 66.5% and females 61%).
A higher proportion of females than males experienced family stressors (79.4% versus 64%). Among the 442 deceased with at least one family stressor, family conflict had the
higher proportion at 66.9% (females 68.8% versus males 66.5%) and family death at 42.9% (males 41.6% and females 49.3%).
A higher proportion of females than males experienced non-family stressors (64.9% versus 56.7%). Among the 386 deceased with at least one non-family stressor, non-family conflict had a high proportion at 40.9% (females 49.2% versus males 39.3%).
Across both the All Deaths Cohort (35.2%) and all Anger/Angry Behaviours Cohort (40.8%), the higher proportion of non-family stressor among those with at least one nonfamily stressor was ‘other’ at 70.4% (females 69.8% versus males 70.5%). ‘Other’ included a specific identified interpersonal stressor not related to partner or family, for example, a one-off aggressive or violent incident.
Of the 667 deceased, 94.9% experienced one or more contextual stressors during their life, which is a higher proportion than the All Deaths Cohort (85.1%).
Of the 667 deceased, 53.4% had a documented mental disorder diagnosis, (females 74.2% versus males 49.8%) of which 45% were mood disorders. Of the 356 deceased with a documented mental health disorder, 84.2% had a mood disorder (females 83.3% versus males 84.5%). The second frequent diagnosis was non-psychotic/mood at 32.5% (females 30.5% versus males 33%). Of the 356 deceased, 23.8% had a substance use disorder (females 20.8% versus males 24.6%), which is higher than the proportion of the 1,467 All Deaths Cohort deceased with a mental health disorder diagnosis at 19.6% (females 16.3% versus males 21%).
Of the 667 deceased, 47.2% had contact with at least one health service for a mental health related issue within the 12 months prior to their death (females 69.1% versus males 43.5%), a lower proportion than the 64.1% of the All Deaths Cohort. Of the 315 deceased who had contact, 66% were with a general practitioner (females 67.1% versus males 65.7%), 37.1% with a psychiatrist (females 35.8% versus males 37.5%) and 27.3% with a mental health practitioner (females 28.3% versus males 27%). There was a higher proportion of females than males across contacts with mental health practitioners, crisis assessment and treatment services and general practitioners. There was a higher proportion of males than females for contact across psychiatrists, psychologists, emergency departments and addictions services.
Of the 326 deceased males who had experienced intimate partner separation, 151 narratives contained sufficient information to code for proximity of separation, proximity of conflict, proximate conflict with IVO where the deceased was the respondent, and any event which
could be reasonably considered as finalizing, including property settlement, refusal by partner to “try again”, custody of children agreements, partner formalizing separation/divorce, and IVO initiation.
(c) Duration of Anger/Angry Behaviours Cohort
Of the 667 case narratives that contained stated anger/angry behaviours associated with the deceased, 229 (34.3%) contained enough evidence and information to code for the duration of anger/angry behaviours, of which 205 (89.5%) were males and 24 (10.5%) were females.
Further analysis focused on the male deaths in line with the scope of my request. From the 205 narratives associated with the deceased males, two groups emerged:
(a) the deceased who had longstanding anger/angry behaviours – 119 (58%); and
(b) those who had developed anger/angry behaviours in the months/year preceding their death – 86 (42%).
These are referred to as the Longstanding Group and the Recent Group respectively.
Submissions from service providers
(a) whether men access current mental health services;
(b) whether the services are accessible to men;
(c) whether there are any gaps or barriers; and
(d) any recommendations about how to increase the engagement of men in such circumstances, with a focus on the prevention of suicide.
(a) Relationships Australia – Victoria (RAV);
(b) No to Violence (NTV), Simone Tassone;
(c) Australian Psychological Society (APS), Dr Lyn O’Grady; and
(d) Royal Australian College of General Practitioners (RACGP), Dr Cameron Loy.
Of note was the high quality of submissions which were all referenced, evidence based and contained comprehensive critical analysis.
(a) Men and mental health service help-seeking
(a) the attitudes and behaviours contributing to the perpetration of family violence;
(b) the likely mental states of men using family violence upon presentation for assessment and throughout the program;
(c) factors that contribute to self-imposed isolation, family isolation, reduction in help seeking and sustained refusal to access social supports; and
(d) the strong correlation between family violence, suicide and homicide involving victims of the men using family violence.
RAV’s submission was detailed and supported by references and clear analysis. RAV’s submission included information regarding the likely mental states of men who participate in family violence group interventions, and highlighted that relationship separation is a dangerous time (for violence and perpetrator suicide). RAV also discussed perpetrator dangerous thinking and thought stacking.11
RAV also noted the use of the threat of suicide as a control strategy that is embedded in the man’s coercive control pattern, both in the relationship and at the point of separation. RAV submitted that, when this is used in the post separation context as a threat, the separation 11 A thinking pattern preceding an angry outburst most often has a build-up phase characterized by thought stacking. Following an initial trigger, the person becomes increasingly angry as they in quick succession dwell on one hostile thought then another that results in a chain of negative assumptions which can initially justify abusive behaviour and if substances are involved, excuse the behaviour on the basis of being substance affected.
violence escalates, and the coercive control pattern then changes to increased dangerous thinking. This then becomes a vulnerable context for the man where his thinking processes have narrowed down his options to carry out the threat as part of the control pattern. RAV noted that in the context of family violence this is significant because, where depression is a clinical presentation along with the attitudes of resentment, obsessive jealousy and the presence of alcohol use or substance use, it is likely that the man will be using a particularly dangerous and vulnerable pattern of thoughts that can lead to either impulsive or compulsive actions.
NTV’s Ms Tassone noted that men are consistently less likely to help-seek for emotional distress, that men’s ill-health may both exacerbate the frequency and severity of violence perpetrated against family members, and that such conditions may also create barriers for men in accessing available treatments. Ms Tassone detailed the Man Box Project which found: “The less respondents endorsed rules of the Man Box,12 the more likely they were to seek help for feelings of sadness and depression from a wide variety of sources including romantic partners, male friends, female friends, and psychologists. Positively, over three quarters of participants disagreed with the Man Box rules of hypersexuality, rigid household roles, and men should use violence.”
NTV provided extensive references of when and how men access and use health services and identified early intervention strategies as important. Ms Tassone also noted that men who sought help for mental health reasons tended to do so late in any illness, and once engaged in a service and/or treatment, that any masculine norms related to self-sufficiency could interfere with treatment processes. Ms Tassone stated that a client must believe that they cannot fix their problem alone as fundamental to treatment for men, however, ideals of invulnerability present particular challenges and threats to identity and self-concept.
APS’s Dr O’Grady listed specific lifespan development stressors for men 35+ years, including a conflicting sense of identity, relationship difficulties (including social isolation), increased family demands, homelessness, bereavement because of suicide and pressures related to finances and employment. There is further detail specific to psychologists, their training and professional guidelines including the APS 2014 Ethical Guidelines relating to clients at risk of suicide and 2017 Ethical Guidelines for psychological practice with men 12 The Man Box is a set of beliefs within and across society that place pressure on men to be a certain way – to be tough; not to show any emotions; to be the breadwinner, to always be in control, use violence to solve problems; and to have many sexual partners.
and boys which highlight how gender role socialisation can sometimes negatively impact on the psychological health of men and boys. Dr O’Grady noted that men’s access to service has increased over the past decade and provided supporting evidence from 2011-2012.
(b) Service accessibility for men
“What we now know in men’s behaviour change work is that family violence in the context of separation is a risk factor for increased vulnerability to bitter thought processes; resentful beliefs and ideas that can lead to obsessive behaviours that isolate men from addressing their accountability.”
RAV identified the barriers in change behaviour programs as: “The opportunity for self insight, self responsibility and increased ability to contemplate expansive ideas of seeing his life beyond separation is lost when this mental state is informed by a strong sense of male privilege, and the need to control (toxic masculinity) commonly associated with perpetrating family violence. These then act as immutable and emotive barriers to more positive perceptions of their circumstances that can then lead to long term acceptance of relationships ending where suicide is not a considered option.”
NTV Ms Tassone believes that a lack of help-seeking amongst men is a contributor to mental illness and maladaptive coping, including the use of substances and violent crimes, and that regardless of the health concern, they are less likely to seek help, and that masculine norms increase the risks to men’s overall health outcomes: “Awareness of these risk factors is critical to services’ engagement of men in treatment or program interventions and informs suicide prevention strategies more broadly. As outlined above, particular attention must be paid to understanding that due to gender socialisation, men may be more reluctant to reveal internalising disorders, and may more readily report gender normative avoidance strategies such as substance abuse.”
APS identified traditional masculine norms that have to be overcome by many men before accessing services, including self-stigma, discomfort and negative beliefs about helpseeking, and even when services are accessed, sustaining engagement is challenging.
Dr Loy noted general practitioners are equitably and easily accessible and without a referral.
General practitioners can refer consumers to specialist practitioners such as psychologists using the general practitioner Mental Health Treatment Medicare items that provide a structured framework for early intervention, assessment and management of patients with a mental illness, including referral to specialist services. An example is the Access to Allied Psychological Services federal funding program (ATAPS). Dr Loy noted that in 2015-2016, almost 72,500 consumers used the Medicare items of which 94.6% were referred by general practitioners.
(c) Gaps and barriers
RAV highlighted the need for further research at the intersection of suicide and men perpetrating family violence, and the link between the presence of depression in men and family violence outcomes, identifying this group of men as vulnerable.
According to Ms Tassone, there is some evidence that the lack of knowledge about the specific points, places, and contexts in which opportunities to engage might exist for men who are at risk of using family violence impacts on them not help-seeking. In addition, a proportion of men are willing to access professional help, but how such help is presented to men is important.
APS’s Dr O’Grady raised how the assessment of suicide risk is gender informed and that current ways of assessing risk in men may result in lower rates of detection and intervention.
Dr O’Grady noted that further detail about the signs of current suicidality in men are not always clear, with men’s distress not always immediately recognised and consequently mental health difficulties and suicide risk remain undetected. Dr O’Grady stated: “Stoicism associated with avoidant, isolative coping strategies, including affective or substance abuse issues, are more prevalent among men. Accordingly, warning signs can take on more gender-specific forms, such as increased aggression and substance abuse, and may not be seen as warning signs related to suicide risk.”
Dr O’Grady suggested mental health practitioners need to be sensitive to diverse masculinities, to detect and respond appropriately to distress, and noted that service provision for men needs to be provided differently in order for men to trust service providers and for interventions to be effective in meeting their needs.
Dr Loy noted the many psychobiological and cultural realities for men in Australian society that are necessary to understand men at risk of suicide. Dr Loy noted as most significant to men 35+ years are: unemployment, relationship breakdown, alcohol and substance use, rural locations, a diagnosis of major depression and sexuality. Dr Loy also identified gaps and barriers that apply across the population including: stigma and discrimination; fragmented state/federal funding systems; lack of community emotional literacy; rural and remote locations; lack of preventative strategies for vulnerable population groups; socioeconomic disadvantage; inadequate family and carer support; lack of integration of primary care and mental health providers; and general practitioner remuneration.
Discussion
(a) Mood disorders
While all submissions noted mood disorders such as depression as potentially having an impact on the decision of a man in these circumstances to suicide, there is limited reliable evidence defining the relationship between them. However, in light of the VSR data, it required consideration.
Mental disorder diagnoses were present in over 50% of all male deaths aged 35 to 74 who suicided between 2009 and 2015, with 43.3% mood disorders. This increased slightly to 45% in the Anger/Angry Behaviours Cohort, 44.5% in the Longstanding Group, however, decreased to 38.4% in the Recent Group.
The narratives also supported that family and friends suspected some of the deceased had a type of mood disorder – for example: “Everything started to overwhelm him; He was grumpy and flat; Very down a lot; Marked deterioration in his outlook, he was depressed; Stopped enjoying everything; He would hibernate away for days regularly then he’d be OK with me going round and getting him up; Always sleeping, lost interest in work, just didn’t care; Distant, uncommunicative, couldn’t finish a day’s work, negative and withdrawn; Low selfesteem, just not happy; Depressed after his partner’s death; Became intense and moody; Lack of motivation; He had been depressed for years and now he couldn’t hide it anymore; Never seen him like this before; His personality changed; I believed he would just snap out of it and be himself; His mind wasn’t straight; Tired and out of character; On edge; and Mood swings.”
In addition, the narratives referred to a deceased’s poor sleep and the use of alcohol – for example: “He didn’t sleep; He drank more to get to sleep; Said he needed it to stop his brain from running overtime; He moved onto the couch when he couldn’t sleep and drank; Was so worried he couldn’t sleep; He would just be exhausted and irritable and he saw his doctor about not sleeping but it didn’t help and just said he had to stop drinking.”
Of the 240 (84.5%) deceased in the Anger/Angry Behaviours Cohort with a formal mood disorder diagnosis: 141 (58.7%) had been prescribed an antidepressant proximate to their death, 25 (17.7%) were having a non-pharmacological therapy with either a psychiatrist, psychologist, general practitioner or other health discipline, and 46 (32.6%) had counselling from other counselling and social services.
Of the 53 (82.8%) deceased in the Longstanding Group with a formal mood disorder diagnosis: 35 (66%) had been prescribed an antidepressant proximate to their death, 4 (7.5%) had non-pharmacological therapy with either a psychiatrist, psychologist, general
practitioner or other health discipline proximate to death, and 13 (37.1%) had counselling from other counselling and social services proximate to death.
Of the 33 (66%) deceased in the Recent Group with a formal mood disorder diagnosis: 24 (72.7%) had been prescribed an antidepressant proximate to their death, 2 (6%) had nonpharmacological therapy with either a psychiatrist, psychologist, general practitioner or other health discipline proximate to death, and 5 (15.1%) had counselling from other counselling and social services proximate to death.
This raised questions about the knowledge of the clinical guidelines for the treatment of depression, including first and second line treatments,13 whether referrals were offered to the deceased for non-pharmacological therapies and counselling and refused, were made and the deceased did not follow-up, or whether access to and wait times for appointments impacted on engagement. It also suggested that the deceased were more likely to engage with social services and counselling providers than health disciplines. This may be because access was more straightforward, faster, cheaper or it was the more appealing option to these men.
(b) Substances use
The VSR substance use data included a documented diagnosis, however, it was also coded as a contextual stressor which allowed for further analysis. Coding required positive evidence that substance use was a stressor for the deceased.
In the Anger/Angry Behaviours Cohort, substance use was identified as a stressor in 62.8% of deaths (males 63.7%) which increased to 77.3% in the Longstanding Group and was 61.6% across the Recent Group. Of the 363 males in the Anger/Angry Behaviours Cohort, 17.6% had a documented diagnosis of a substance disorder; of the 92 males in the Longstanding Group, 19.5% had a documented diagnosis of a substance disorder, compared to 13.2 % of the 53 males in the Recent Group.
Notable was the low proportion of deceased males with a substance use diagnosis who had contact with an addiction service, including the Anger/Angry Behaviours Cohort at 5.2%, Longstanding Group at 6.5%, and 3.7% of the Recent Group. The All Deaths Cohort also had a low proportion of contact by males with addiction services across the treating practitioner contacts (5.1%).
13 Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Mood Disorders; Australian and New Zealand Journal of Psychiatry 2015; 49 (12):1087-1206; Your Health In Mind – RANZCP – Depression. www.yourhealthinmind.org/mental-illnessesdisorders/depression; Therapeutic guidelines – Psychotropic – 2015. Principles for the Treatment of depression.
There is an increased rate of suicidal behaviour as well as completed suicide among individuals with an alcohol use disorder. The VSR data shows that alcohol is consistently detected during post-mortem examination in between 25% and 35% of all Victorian suicides each year. The association between alcohol consumption and self-harm/suicide is not entirely clear, however, substance misuse predisposes suicide by disinhibiting or providing “courage” to overcome resistance in carrying through the act, clouding one’s ability to see alternatives, and worsening of mood disorders. Theoretically, consumption of alcohol may influence self-harm/suicide due to the depressant influence of the substance itself, or acute alcohol intoxication contributes to disinhibited and/or impulsive behaviours or alternatively, self-medicating with alcohol may prevent the individual from developing more functional coping strategies.
The submissions also supported that substance use plays a role in intimate partner violence (IPV), family and non-family violence. RAV noted: “In this particular death, the use of alcohol whilst not considered causation relevant to family violence, unaddressed intoxication and addiction is considered a ‘key risk indicator’ that contributes to high risk family violence behaviours underpinned by attitudes and beliefs that gives the man ‘attitudinal permission’ for violence to occur and to act in this way as an acceptable response to perceived or real losses of control (impending separation, ongoing non resolution of addressing his accountability, poor or no help seeking, etc).”
The narratives further supported that alcohol also played a role in the escalation of violence and aggression – for example: “He was always drunk after work and would go on about work and then have a go at me; He was consuming large amounts of alcohol and would get agitated; Drinking issues and would lash out; and Violent when he was drinking.”
Post-mortem toxicology showed that, of the 469 deceased males with a substance detected post-mortem in the Anger/Angry Behaviours Cohort, 82.3% had substances detected, of which, 57.3% detected alcohol, 24.5% illicit substances and 71.2% prescription medicines.
Post-mortem alcohol was detected in a greater proportion across the Recent Group at 74 (63.5%), compared with the Longstanding Group at 101 (49.5%), and both groups had a similar proportion of prescribed medicines (Recent Group 71.6% versus Longstanding Group 70.2%), but the Longstanding Group had a greater proportion of illicit substances (37.6% versus 20.2%).
Combined with the pervasive reference to alcohol use, in particular, by family, friends, and employers throughout the narratives, the VSR data supported minimal use of addiction services across all groups. This may be impacted by a view that alcohol consumption is a cultural norm and/or that an overuse of it is reasonable, for example, to obtain sleep and reduce stress, and therefore is not a problem to be addressed. Low access to or use of addiction services may also reflect a lack of knowledge of these services and how to access them and/or a reluctance by the deceased to engage. There is also an implication that practitioners do not recognise addiction services as specialised, or that the treatment of substance use when it is at the point of causing distress to a man may require more than the management of withdrawal, that substance use in combination with mood, sleep and anxiety disorders and/or contextual stressors will be controlled or contained when the underlying disorder or stressor is addressed, and that in the absence of positive change, there is a lack of willingness to advise and promote referral to addiction services.
Consequently, in the context of the association between violence and suicide in this group of deceased, a more proactive approach to the assessment, impact and treatment of substance use provides an opportunity for prevention.
(c) Contact with services and help-seeking
59.8% of all males aged 35 to 74 years who suicided between 2009 and 2015 had contacted a service that provides mental health care and for a mental health reason within 12 months of death. This decreased across the Anger/Angry Behaviours Cohort (43.5%), but increased in the Longstanding Group (48.7%) which had contact across most service types, and decreased in the Recent Group (39.5%). General practitioners were the most frequently contacted service for all male deaths and across all cohorts and groups.
Across the Recent Group, 60% did not have any contact, but when it occurred, 73.5% contacted general practitioners, which supported Dr Loy’s submission. It also suggested that early intervention opportunities for men who have recently developed anger and angry behaviours might rest with general practitioners if contact was made.
Of note, 13.7% of the All Deaths Cohort had contact with psychologists; this decreased to 9.1% for the Anger/Angry Behaviours Cohort. Of the 248 deceased males in the Anger/Angry Behaviours Cohort who did make contact with a service, 20.9% had contact with a psychologist, this increased to 24.1% across the Longstanding Group, compared to 17.6% of the Recent Group. As stated by Dr Loy, the ATAPS program offers funded
sessions for therapies with private psychologists and general practitioners refer patients frequently. What is not known is the effectiveness and outcomes of such referrals, whether the deceased were referred but did not follow-up, how many sessions they attended if they did engage, and what was the outcome of attending sessions for these men.
It is unclear what interventions practitioners offer to men who do engage, and in particular, if these interventions are informed by a contemporary understanding of the evidence base for anger/angry behaviours and their association with increased risks of violence, homicide and suicide.
All submissions identified health seeking by men as low, that it may not happen until associated distress is high, and that retention is a challenge for men in this age group, and not just those with anger/angry behaviours. The narratives suggested many of the deceased males who were encouraged to seek help did not do so – for example: “I offered to go with him to see the doctor; He made a couple of appointments but didn’t go; Said he would but I know he never got any help; I just wanted my husband back, he had changed and I knew something was wrong; I would say go see a doctor but he’d get so furious and tell me to mind my own business; and Mum pushed him to see a doctor and even made an appointment but he didn’t.”
The VSR data revealed that, across the Anger/Angry Behaviours Cohort and Longstanding Group, nearly half the deceased males did have contact with health services about a mental health related issue. While this is less than the 59.8% of the All Deaths Cohort, it is perhaps higher than expected given the apparent barriers to access and engagement for these men.
It supported the submissions regarding the apparent lack of knowledge and service systems, where to find the information, what they offer and how to access them. APS noted: “The researchers concluded that public health campaigns that promote service use among vulnerable groups at times of crisis might usefully be targeted at those likely to be experiencing financial and relationship issues.”
The VSR data also supported that general practitioners are most often the initial helpseeking contact for men in similar circumstances to those like Mr A. Dr Loy commented that a streamlined mental health approach that addresses all the social determinants of health, and includes the integration of mental, medical, substance use and social care would increase the engagement of men in help-services.
Consequently, this revealed some prevention opportunities including:
(a) public education for men to what services are available, what they offer and how to access them;
(b) changing the services offered to men to improve retention and outcomes; and
(c) education for practitioners about contemporary thinking for interventions for men who have anger and angry behaviours.
(d) Exploration of anger as an indicator of illness
APS’s Dr O’Grady suggested men’s distress may not always be recognised, and consequently, mental health difficulties and warning signs such as substance use and change in behaviours related to suicide risk are not identified. NTV also noted the point regarding practitioner stereotyping – that men externalise emotional distress, for example as anger, which could explain some under-recognition of internalising disorders such as depression.
This was particularly relevant to the Recent Group, whose stories from their family and friends suggested that anger/angry behaviours prior to their death were unusual – for example: “It came out of nowhere; I was terrified when he just up and threw things around the lounge; He’s never even yelled before, it was completely out of character; Never ever been violent but started about two months ago; Uncharacteristic aggression; Following his accident he started to criticise me and the children; Never seen him this angry before; and Following his workplace injury he got angry about everything.”
It is reasonable to consider that this type of unusual behaviour may be associated with increased use of substances, but also the result of feeling overwhelmed, of losing any sense of control from the impact of psychosocial and interpersonal stressors. This is supported by 43% of the deceased experiencing three or more stressors across the domains of work, finance, legal, sexuality, isolation, education, substance abuse/use, combined with poor distress tolerance and emotional regulation, and are attempts to regain control by controlling others.
Nonetheless, it would be short sighted not to consider that for some, the changes may be associated with an emerging mental disorder. Anger and aggression are often central to practitioner risk assessments, but with a focus more often on the prevention of harm to
others. Accepting that behaviours can be new, it raises the question for services and practitioners whether routine exploration of a man’s angry behaviours as being recent or longstanding patterns of behaviour, might improve the individuality of approach to each man’s needs. This type of focus on the behaviour may also offer opportunities for practitioners to engage directly with men about anger and angry behaviours, to reinforce the unacceptability of aggression and violent behaviours, the potential consequences of their use, options for early intervention for help to manage anger and to treat any emerging mental disorders and/or substance use.
(e) Conflict, separation and relationships
All of the deceased males in the Anger/Angry Behaviours Cohort had experience with partner violence, and 92.3% of the Longstanding Group and 94.1% of the Recent Group had conflict across all three domains of partner, family and non-family, suggesting the behaviours were not always discriminatory.
Separation was identified in the submissions as a high-risk time for men and their partners and children, and the narratives supported the deceased’s difficulties in coming to terms with the relationship breakdown, loss of relationship or separation, and a reluctance to participate in options to repair a relationship if it was a possibility – for example: “I wanted him to get help to manage his anger, then we’d see; He would not accept the end of our marriage; It didn’t sink in, no matter what I said; I wanted to work to fix our relationship but he refused any counselling; I said I had no intention of staying separated, I was just desperate for him to stop his drinking and I never thought our marriage was over, I just wanted him to stop hurting us.”
The VSR data showed that 44.9% of males in the All Deaths Cohort were separated, compared to 57.2% of the Anger/Angry Behaviours Cohort. Further analysis of the 93 cases of the Longstanding Group and 58 cases of the Recent Groups who were separated showed proportions of proximate partner conflict above 97% in both groups. 61.5% of the Longstanding Group and 44.6% in the Recent Group were respondents in an intervention order. The most notable difference between the two groups was whether the separation was within weeks/months/year before death or longer (remote). The Longstanding Group separations were nearly all remote, while the Recent Group were nearly all within the year prior to death.
Although the sample was comparatively small (151), the narratives suggested the risk of suicide increased when associated with what the CPU referred to as ‘finalising events’.
These were events that could be interpreted by the deceased as decisive, of removing further choice and/or control which included property settlement, refusal by a partner to “try again” when asked, custody of children arrangements, partner formalizing separation/divorce, and IVO initiation. Finalising events were associated with 46.2% of the Longstanding Group and 36.2% of the Recent Group deaths of males who had separated.
(f) Intergenerational trauma
Intergenerational trauma was evident in the stories of family, friends and in the documented medical records of the deceased – for example: “Our father was a violent alcoholic; Beaten up by his brother for years; Violent upbringing; Traumatic childhood; Abusive mother, Childhood was frightening; Violent father; Alcoholic father; Physical and emotionally abusive parents; and Raised in a violent setting.”
NTV noted suicide rates are higher for individuals who have experienced or witnessed abuse as a child. While acknowledging this intergenerational trauma was not further explored, and with respect to the evidence base for family violence and men’s health services, it is unclear if there is any conflict between a focus on shame as a pathway to change and reparation, and that of the evidence-base for the treatment of the effects of developmental trauma such as trauma-informed practice. NTV stated: “Trauma-informed services do no harm i.e. they do not re-traumatise or blame victims for their efforts to manage their traumatic reactions, and they embrace a message of hope and optimism that recovery is possible. In trauma-informed services, trauma survivors are seen as unique individuals who have experienced extremely abnormal situations and have managed as best they could.”
It is unclear if the two are balanced by behaviour change services and if, within a group environment, that an expectation of such a balance is possible or even reasonable.
Nonetheless, it is appropriate that behaviour change services are confident the content of the programs do not re-traumatise, and that the assessment of participants includes the
identification of their history of trauma and this is considered in the program they are offered.
As stated by RAV, behaviour change programs move men through a group process aimed at accountability, self-responsibility, self-insight and self-reflection which can result in a man actively changing how he thinks while he recognises he has choices over his own perceptions which can result in him making better choices about interpersonal relationships and himself. RAV, NTV and APS provided comprehensive references for the evidence bases supporting this approach, however, it is unclear how much of the focus is on the learning of new ways to self-regulate their emotional responses and what are more appropriate behaviours.
The group behaviour change programs run for many weeks however, the ability of participants to embed lifetime positive change to thinking and resultant behaviours is unclear, for example, are new behaviours and strategies resistive to the effects of substance use. The VSR Longstanding Group data supported that the anger/angry behaviours for many of the deceased had been repeated over many years and may often have been learned while young and/or during exposure to developmental or other trauma. RAV and NTV noted referral to post-program supports if needed, but this was not explored further.
(g) Lack of insight into the effects of anger/angry behaviours on children
Men who use anger/angry behaviours often lack insight into the impacts of their behaviours on their children, and the trauma it can cause. According to the stories of the deceased’s family, friends and their medical records, many did not accept there was a link between their use of anger/angry behaviours and their relationships with their children, especially older children, who described their own reasons for not having a relationship with their father included their experience of anger and angry behaviours – for example: “My dad texted me that he loved me, wanted to see me but really I was too scared of him; Kept saying he loved his kids but they were older now and wanted nothing to do with him; He blamed me for his son not talking to him. He always hit him and bullied him and seemed to enjoy it; Stopped work so he didn’t have to pay for the kids then tell ’em it was their mother’s fault; and He would yell at me and say he was my father and I had to see him when he said.”
There were also stories that the deceased missed their children and vice versa, and of isolation from family and friends, which, as noted in the submissions, was often selfimposed – for example: “He was a great Dad, always taking me to footy and netball; The kids are devastated; I don’t understand why he left us, he should’ve got help; Since he had to leave it was all about getting custody of the kids and he was worried he wouldn’t get to be with them; He was fighting for custody but he wouldn’t see the kids. He could have; I know Dad got angry at Mum, but I really miss him; When he moved in with us, all he thought about was the kids and I worried too because they’re my grandkids and I saw them all the time, but not now, not at all; At work he just went on and on about the kids, like how much he missed them, if they were alright, how he reckon’d he’d let them down. I couldn’t help him; and He used to take the kids boating when we all stayed at the park every Christmas since we were at uni, but when they spilt up he wouldn’t come at all, wouldn’t bring the kids.”
(h) Contingent suicidality
(i) Death of family and non-family as a stressor
The VSR data showed that across all deaths (2,554) in the All Deaths Cohort, 27.1% (524) of males had a family death as a stressor. Of the 983 deceased males who had at least one identified family stressor, 53.3% (524) had a family death as a stressor. Across all deaths (667) in the Anger/Angry Behaviours Cohort, 26.7% (152) of males had a family death as a stressor. Of the 365 deceased males in this cohort who had at least one identified family stressor, 41.6% (152) had a family death as a stressor.
Across all deaths (2,554) in the All Deaths Cohort, 5% (97) males had a non-family death as a stressor. Of the 835 deceased males who had at least one identified non-family stressor, 11.6% (97) had a non-family death as a stressor. Across all deaths (667) in the Anger/Angry Behaviours Cohort, 6.5% (37) males had a non-family death as a stressor. Of the 323 deceased males who had at least one identified non-family stressor, 11.4% (37) had a nonfamily death as a stressor.
This was not explored in depth, however, suggested grief, loss and the importance of friendships outside of and especially within families have an impact on the risk of suicides in men.
(j) Physical health stressors
Submission recommendations
RAV, NTV, RACGP and APS were invited to suggest recommendations with a focus on the prevention of suicide deaths in males aged 35 to 74 years. Their recommendations shared similar themes including: how services are delivered to men; practitioner knowledge including assessing risk of suicide for men and evidence-based interventions; public campaigns that promote help-seeking amongst men; and the need for further research. Their recommendations were valuable and were based on their experiences and knowledge of the organisations and practitioners who provide services to these men.
RAV’s Ms Tassone, and Ms Wynters of Brophy Family and Youth Services provided the evidence base, purpose and goals for behaviour change programs. The behaviour change program elements of thought stacking and dangerous thinking are logical and relatable, and provide a framework to challenge thinking and promote recognition by a man that what he thinks is a normal thinking pattern, is not.
However, although information on thought stacking and tips for controlling anger are available, it is not overt. In the experiences of the submitting organisations and the Court, this information is not readily understood or utilised by many of the practitioners and services who are often the initial contacts for men in this age group. This is particularly so for those men whose behaviours are new and out of character, when early intervention is likely to be most effective. To identify these men would require a deliberate discussion about his behaviours with an emphasis on anger and angry behaviours, but it is not clear this would occur routinely when a man seeks help from primary care or other practitioners, and, if this did occur, what an appropriate intervention would be.
Notwithstanding, aggression and violence were factors identified in the stories from family, friends and others, and evident in the VSR data and in the circumstances of Mr A’s death.
Consequently, prevention opportunities associated with the VSR cohorts discussed above would ideally start before the development of sustained and patterned angry behaviours and violence.
Mr A had a 42-year-history of intimate partner violence including verbal and physical aggression to his wife, which was often associated with his consuming alcohol. He reported some suicidal ideation and a lowered mood when asked, and that he was concerned he was at risk of losing everything if Mrs A did not return home. The realisation that his hope of Mrs A returning to the marriage and his status quo, mixed with periods of insight documented as guilt and shame, potentially impacted his mental state. Notes he left for his wife and family suggested that any insight into the nexus of his aggressive and angry behaviours experienced during the behaviour change program was fleeting, or was not forefront in his mind when affected by alcohol. He did not seek help for his lowered mood, for the grief he experienced at the loss of the relationship with Mrs A, or suicidal thinking, despite the encouragement of his friend Mr B to seek counselling.
The coronial experience as illustrated by Mr A’s death bears out NTV’s conclusion that: “If men are left alone, they pose a risk both to themselves and their families as they are more likely to be living with untreated mental illness, be coping through the use of drugs and alcohol, and are more likely to externalise their symptoms by blaming their partners, families, or society more broadly.”
There is some suggestion that focus on men who are angry should begin especially early after the act of IPV, however, the VSR data suggested there may be opportunities to intervene still earlier, and the ability to intervene lies not with specialist behaviour change services or specialist family violence services, but with primary care services.
The Department of Health and Human Services has comprehensive family violence workforce development plans which rightly focus on the victims of family violence. There also exists however, missed opportunities to focus on the prevention of violence perpetrated by men who are angry/exhibit angry behaviours, and the prevention of their suicide deaths.
The VSR data supported a high proportion of mood disorders across the deceased males, but little is known about the relationship with the anger/angry behaviours of the deceased, or if it was an indicator of increased risk.
These men are more likely to access a social service or general practitioner in the first instance, and the development of skills in working with these men would be appropriate.
This should include information for primary healthcare providers and other associated services about what services are available for men who require specialist input for any current or escalating anger and associated behaviours that may or may not be associated with a mental disorder or current interpersonal or contextual stressors.
Violence and aggression were factors associated with Mr A’s death, and this reflects the experience of many partners, families and friends, in similar circumstances – there is distress and trauma before and after the death. What was reassuring from the submissions provided, was that these organisations have identified strategies and options to reduce both the violence and aggression, but also the suicide of these men. Nonetheless, the VSR data revealed there are further opportunities to enhance the prevention of suicide in such cases.
I wish to acknowledge the significant efforts of the CPU Mental Health Team in conducting the considered research and data analysis for this investigation. Their findings, coupled with the firsthand knowledge and experience offered by the submitting organisations, have greatly assisted my ability to identify prevention opportunities and frame my recommendations.
Having investigated the death of Mr A, and having considered all of the available evidence, I am satisfied that no further investigation is required.
On the basis of the available evidence, I am satisfied to the requisite standard that Mr A intentionally ended his own life.
I make the following findings, pursuant to section 67(1) of the Coroners Act 2008:
(a) that the identity of the deceased was Mr A, born ;
(b) that Mr A died between , at , from compression of the neck consequent upon hanging; and
(c) that the death occurred in the circumstances described in the paragraphs above.
(a) It is not within the scope of the Coroner to recommend service delivery pathways and innovations, however, encouragement is given to funding bodies, organisations, practitioners and social services that concerted consultation and involvement of men as service providers and service users, is undertaken as part of the design and development of such pathways and service innovations.
(a) Family Safety Victoria work with the Blue Knot Foundation to review the behaviour change program for opportunities to embed trauma-informed principles and practices;
(b) To improve the safety of the men who engage in family violence behaviour change programs, the Family Safety Victoria Minimum Standards should include:
i. Active and explicit discussion about suicidal thinking in the program interventions and material; ii. Assessment for suicide risk at entry and regular review throughout the program; iii. Use of a screening tool for a mood disorder as part of assessment; and iv. Include as part of the program, a mental and physical health focus with connection to a participant’s local general practitioner.
Department of Health and Human Services
(a) To reduce the suicide of men through the promotion of help-seeking, develop public awareness raising strategies that: i. Are inclusive of all men and promote early help-seeking as normal and appropriate; ii. Target times in a man’s life when he is likely more vulnerable, including relationship breakdowns, and advice of what services are available and how to access them; iii. Explore the problems associated with a reliance on alcohol to manage distress and such things as sadness, poor sleep and increased stress; and iv. Promote addiction services to men as an accessible and appropriate option in circumstances when substance use is contributing to anger, aggression and violence.
(b) To increase the engagement of men with social services and practitioners, develop advice for the community of ways to increase both the appeal of, and engagement with services by men.
Department of Health and Human Services and Family Safety Victoria
(a) The Department of Health and Human Services and Family Safety Victoria work together with organisations who provide behaviour change programs for men, professional bodies, social services, mental health services, and with particular emphasis on involvement of general practitioners and addiction services, develop practical information about the relationship between angry behaviours, violence and
associated suicide risk. The information should focus on practical interventions and strategies for men who have anger and/or with angry behaviours, and include when and where to seek specialist advice.
(a) Mr A’s family, senior next of kin;
(b) Investigating Member, Victoria Police; and
(c) Interested Parties: i. The Department of Health and Human Services; ii. Family Safety Victoria; iii. Dr Cameron Loy – Royal Australian College of General Practitioners; iv. Dr Lyn O’Grady – Australian Psychology Society; v. Simone Tassone – No to Violence; vi. Relationships Australia – Victoria; vii. Royal Commission on Mental Health Services in Victoria; viii. The Hon. Martin Foley MP, Minister for Mental Health; ix. The Hon. Jenny Mikakos, Minister for the Coordination of Health and Human Services; x. Chief Psychiatrist, Dr Neil Coventry, and Chief Mental Health Nurse, Ms Anna Love; xi. Blue Knot Foundation; and xii. National Health and Medical Research Council.
Signature: ______________________________________
MR JOHN OLLE CORONER Date: 11 September 2020
Attachment A: Victoria Suicide Register Data Tables
The search strategy used by the CPU was reliant on thorough and accurate coding in the VSR.
Therefore, it is possible that the CPU did not identify all relevant deaths. Further to this point, the amount of information contained in the VSR can vary significantly between deaths, depending on a range of factors including the thoroughness and focus of the coronial investigation, and the material that is available for coding into the VSR.
1.2 Relevant deaths - All Deaths Cohort The CPU identified 2554 relevant deaths for analysis as extracted from the VSR in January 2020.
Among the deceased, 1932 (75.6%) were males.
1.3 Data tables for suicides 2009 to 2015 with age between 35 and 74 Table 1: Frequency and proportion by sex of the All Sex Cohort for experience of partner stressors, Victoria 2009-2015 Male Female All Partner stressors*
N % N % N % Evidence of stressors 1146 59.3 359 57.7 1505 58.9 Partner death 71 3.7 50 8.0 121 4.7 Partner separation 867 44.9 238 38.3 1105 43.3 Partner conflict 685 35.5 182 29.3 867 33.9 Partner health issues 83 4.3 48 7.7 131 5.1 Partner FV 304 15.7 110 17.7 414 16.2 No evidence of stressors 786 40.7 263 42.3 1049 41.1 Total 1932 100.0 622 100.0 2554 100.0 *Please note a deceased may have experienced multiple partner stressors.
14 Data between 2009 and 2015 was extracted as these are the years for which enhanced data entry was complete in the VSR.
Table 2: Frequency and proportion by sex of the All Sex Cohort for experience of family stressors, Victoria 2009-2015.
Male Female All Family stressors
N % N % N % Evidence of stressors 983 50.9 374 60.1 1357 53.1 Family death 524 27.1 196 31.5 720 28.2 Family conflict 523 27.1 217 34.9 740 29.0 Family health issues 248 12.8 124 19.9 372 14.6 Family FV 213 11.0 97 15.6 310 12.1 No evidence of stressors 949 49.1 248 39.9 1197 46.9 Total 1932 100.0 622 100.0 2554 100.0 *Please note a deceased may have experienced multiple family stressors.
Table 3: Frequency and proportion by sex of the All Sex Cohort for experience of non-family stressors, Victoria 2009-2015.
Male Female All Non-family stressors
N % N % N % Evidence of stressors 835 43.2 309 49.7 1144 44.8 Non-family death 97 5.0 42 6.8 139 5.4 Non-family conflict 253 13.1 101 16.2 354 13.9 Non-family health 12 0.6 7 1.1 19 0.7 issues Fam-friends other 668 34.6 230 37.0 898 35.2 No evidence of stressors 1097 56.8 313 50.3 1410 55.2 Total 1932 100.0 622 100.0 2554 100.0 *Please note a deceased may have experienced multiple non-family stressors.
Table 4: Frequency and proportion by sex of the All Sex Cohort for experience of contextual stressors, Victoria 2009-2015.
Male Female All Contextual Stressors*
N % N % N % Evidence of stressors 1670 86.4 504 81.0 2174 85.1 Work 796 41.2 186 29.9 982 38.4 Financial 762 39.4 203 32.6 965 37.8 Legal 556 28.8 123 19.8 679 26.6 Sexuality 58 3.0 14 2.3 72 2.8 Isolation 308 15.9 134 21.5 442 17.3 Abuse** 584 30.2 233 37.5 817 32.0 Education 55 2.8 21 3.4 76 3.0 Bullying** 206 10.7 77 12.4 283 11.1 Substance abuse/use 941 48.7 247 39.7 1188 46.5 Other stressors 419 21.7 84 13.5 503 19.7 No evidence of stressors 262 13.6 118 19.0 380 14.9 Total 1932 100.0 622 100.0 2554 100.0 *Please note a deceased may have experienced multiple contextual stressors.
**Abuse and Bullying coding included experience as perpetrator and/or victim.
Table 5: Frequency and proportion by sex of the All Sex Cohort for a documented mental disorder diagnosis coded to ICD-10 Classification of Mental and Behavioural Disorders, Victoria 20092015.* Male Female All Mental disorders formal diagnosis**
N % N % N % Documented diagnosis*** 1,021 52.8 446 71.7 1,467 57.4 F01-F09 - Physiological 21 1.1 4 0.6 25 1.0 F10-F19 - Substances 215 11.1 73 11.7 288 11.3 F20-F29 - Non-mood psychotic 119 6.2 60 9.6 179 7.0 F30-F39 - Mood 837 43.3 382 61.4 1,219 47.7 F40-F49 - Non-psychotic/mood 337 17.4 180 28.9 517 20.2
F50-F59 - Physiological/physical 18 0.9 20 3.2 38 1.5 F60-F69 - Personality 83 4.3 83 13.3 166 6.5 F70-F79 - Intellectual disabilities 2 0.1 0 0.0 2 0.1 F80-F89 - Developmental 9 0.5 1 0.2 10 0.4 F90-F98 - Child/adolescent onset 12 0.6 3 0.5 15 0.6 F99-F99 - Unspecified 6 0.3 1 0.2 7 0.3 No documented diagnosis 912 47.2 176 28.3 1,088 42.6 Total 1,933 100.0 622 100.0 2,555* 100.0 *Data extracted 4 June 2020.
**The proximity of the formal diagnosis to the death was not explored for the purposes of this report.
***Deceased may have had multiple diagnoses.
Table 6: Frequency and proportion by sex and involved clinician of the All Sex Cohort for experience of contact with a treating practitioner for a mental health reason within 12 months of death, Victoria 2009-2015.
Treating Male Female All practitioner N % N % N % Treatment within 12 Months* 1155 59.8 482 77.5 1637 64.1 Psychiatrist 533 27.6 276 44.4 809 31.7 Psychologist 264 13.7 118 19.0 382 15.0 Mental Health Practitioner 412 21.3 196 31.5 608 23.8 General Practitioner 838 43.4 360 57.9 1198 46.9 Emergency Department 273 14.1 122 19.6 395 15.5 Clinician
CATT 170 8.8 94 15.1 264 10.3 Drug and Alcohol Clinician 99 5.1 23 3.7 122 4.8 No Treatment within 12 months 777 40.2 140 22.5 917 35.9 Total 1932 100.0 622 100.0 2554 100.0 *Please note a deceased may consulted more than one practitioner type/discipline.
Coding included use of variants of words used in narratives including angry, aggressive, threatening, intimidating, argumentative, abusive, all abuse including sexual, physical, psychological, constraints and restrictive practices, financial, legal, systemic/services, all types of neglect, passive such a sulking, shouting, bickering, criticism, bullying, fighting, throwing things around, property damage etc. combined with evidence of orders or other activities related to aggression and violence.
463 (males 74.7% and females 25.3%) case narratives from family, friends, neighbours, practitioners etc were considered as insufficient to assess presence or absence of anger/angry behaviours.
1424 (68%) of 2091 remaining case narratives did not contain stated anger/angry behaviours associated with the deceased (males 71% and females 29%).
2.1. Relevant deaths In 667 (32%) the case narratives contained explicit evidence of anger/angry behaviours associated with the deceased; 570 of the deceased (85%) were males and 97 (15%) were female.
Across both male and female deceased the greater proportion of stated anger/angry behaviours occurred in the 35 - 44 and 45 - 54 age groups 507 (76%).
2.2 Data tables for Anger/Angry Behaviour Cohort Table 7: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of partner stressors, Victoria 2009-2015.
Male Female All Partner stressors*
N % N % N % Evidence of stressors 490 86.0 75 77.3 565 84.7 Partner death 23 4.0 6 6.2 29 4.3 Partner separation 326 57.2 46 47.4 372 55.8 Partner conflict 400 70.2 52 53.6 452 67.8 Partner health issues 25 4.4 5 5.2 30 4.5 Partner FV 205 36.0 32 33.0 237 35.5 No evidence of stressors 80 14.0 22 22.7 102 15.3 Total 570 100.0 97 100.0 667 100.0 *Please note a deceased may have experienced multiple partner stressors.
15 Analysis included the use of variants of words including “angry”, “aggressive”, “threatening”, “intimidating”, “argumentative”, and “abusive”.
Table 8: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 7) with at least one partner stressor, Victoria 2009-2015.
Male Female All Partner stressors*
N % N % N % Partner stressors 490 100 75 100 565 100 Partner death 23 4.7 6 8.0 29 5.1 Partner separation 326 66.5 46 61.0 372 65.8 Partner conflict 400 81.6 52 69.3 452 80.0 Partner health issues 25 5.1 5 6.6 30 5.3 Partner FV 205 41.8 32 42.6 237 41.9 Total 490 100 75 100 565 100 *Please note a deceased may have experienced multiple partner stressors.
Table 9: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of family stressors, Victoria 2009-2015.
Male Female All Family stressors*
N % N % N % Evidence of stressors 365 64.0 77 79.4 442 66.3 Family death 152 26.7 38 39.2 190 28.5 Family conflict 243 42.6 53 54.6 296 44.4 Family health issues 69 12.1 20 20.6 89 13.3 Family FV 105 18.4 26 26.8 131 19.6 No evidence of stressors 205 36.0 20 20.6 225 33.7 Total 570 100.0 97 100.0 667 100.0 *Please note a deceased may have experienced multiple family stressors.
Table 10: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 9) with at least one family stressor, Victoria 2009-2015.
Male Female All Family stressors*
N % N % N % Family stressors 365 100.0 77 100.0 442 100.0 Family death 152 41.6 38 49.3 190 42.9 Family conflict 243 66.5 53 68.8 296 66.9 Family health issues 69 18.9 20 25.9 89 20.1 Family FV 105 28.7 26 33.7 131 29.6 Total 365 100.0 77 100.0 442 100.0 *Please note a deceased may have experienced multiple family stressors.
Table 11: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of non-family stressors, Victoria 2009-2015.
Male Female All Non-family stressors*
N % N % N % Evidence of stressors 323 56.7 63 64.9 386 57.9 Non-family death 37 6.5 9 9.3 46 6.9 Non-family conflict 127 22.3 31 32.0 158 23.7 Non-family health 2 0 2 issues 0.4 0.0 0.3 Fam-friends other** 228 40.0 44 45.4 272 40.8 No evidence of stressors 247 43.3 34 35.1 281 42.1 Total 570 100.0 97 100.0 667 100.0 *Please note a deceased may have experienced multiple non-family stressors.
**Family-Friends – Other includes a specific identified stressor, for example, a one-off aggressive or violent incident (king-hit in a bar or verbal abuse from a passenger on a train).
Table 12: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 11) with at least one non-family stressor, Victoria 2009-2015.
Male Female All Non-family stressors*
N % N % N % Non-family stressors 323 100.0 63 100.0 386 100.0 Non-family death 37 11.4 9 14.2 46 11.9 Non-family conflict 127 39.3 31 49.2 158 40.9 Non-family health 2 0.6 0 0 2 0.5 issues Fam-friends other** 228 70.5 44 69.8 272 70.4 Total 323 100.0 63 100.0 386 100.0 *Please note a deceased may have experienced multiple non-family stressors.
**Family-Friends – Other includes a specific identified stressor, for example, a one-off aggressive or violent incident (king-hit in a bar or verbal abuse from a passenger on a train).
Table 13: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of contextual stressors, Victoria 2009-2015.
Male Female All Contextual Stressors*
N % N % N % Evidence of stressors 544 95.4 89 91.8 633 94.9 Work 265 46.5 25 25.8 290 43.5 Financial 260 45.6 33 34.0 293 43.9 Legal 218 38.2 37 38.1 255 38.2 Sexuality 10 1.8 2 2.1 12 1.8 Isolation 67 11.8 23 23.7 90 13.5 Abuse** 292 51.2 61 62.9 355 53.2 Education 18 3.2 3 3.1 21 3.1 Bullying** 120 21.1 18 18.6 138 20.7 Substance abuse/use 363 63.7 56 57.7 419 62.8 Other stressors 140 24.6 19 19.6 159 23.8 No evidence of stressors 26 4.6 8 8.2 34 5.1 Total 570 100.0 97 100.0 667 100.0 *Please note a deceased may have experienced multiple contextual stressors.
**Abuse and Bullying coding included experience as perpetrator and/or victim.
Unemployment as a stressor across all deaths was 208 (31.1%).
Isolation as a stressor was most frequent for males 67 (70.1%) in the 34 – 44 and 45 – 54 age groups and most frequent for females 23 (73.9%) in 45 – 54 and 55 – 64 age groups.
Table 14: Frequency and proportion by sex and involved clinician of the Anger/angry Behaviour Cohort for experience of contact with a treating practitioner for a mental health reason within 12 months of death, Victoria 2009-2015.
Treating Male Female All Practitioner* N % N % N % Treatment within 12 Months 248 43.5 67 69.1 315 47.2 Psychiatrist 93 16.3 24 24.7 117 17.5 Psychologist 52 9.1 6 6.2 58 8.7 Mental Health Practitioner 67 11.8 19 19.6 86 12.9 General Practitioner 163 28.6 45 46.4 208 31.2 Emergency Department 53 13 66 Clinician 9.3 13.4 9.9
CATT 23 4.0 9 9.3 32 4.8 Drug and Alcohol Clinician 20 3.5 4 4.1 24 3.6 No Treatment within 12 months 322 56.5 30 30.9 352 52.8 Total 570 100.0 97 100.0 667 100.0 *Please note that a deceased person may have been treated by multiple practitioners within 12 months prior to their death.
Table 15: Frequency and proportion by sex and involved clinician of the Anger/angry Behaviour Cohort (Table 14) with at least one contact with a treating practitioner for a mental health reason within 12 months of death, Victoria 2009-2015.
Treating Male Female All Practitioner* N % N % N % Treatment within 12 Months 248 100.0 67 100.0 315 100.0 Psychiatrist 93 37.5 24 35.8 117 37.1 Psychologist 52 20.9 6 8.9 58 18.4 Mental Health Practitioner 67 27.0 19 28.3 86 27.3 General Practitioner 163 65.7 45 67.1 208 66.0 Emergency Department 53 21.3 13 19.4 66 20.9 Clinician
CATT 23 9.2 9 13.4 32 10.1 Drug and Alcohol Clinician 20 8.0 4 5.9 24 7.6 Total 248 100.0 67 100.0 315 100.0 *Please note that a deceased person may have been treated by multiple practitioners within 12 months prior to their death.
Table 16: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for evidence of a documented mental disorder diagnosis coded to ICD-10 Classification of Mental and Behavioural Disorders, Victoria 2009-2015.
Mental disorders Male Female All Formal Diagnosis* N % N % N % Documented diagnosis** 284 49.8 72 74.2 356 53.4 F01-F09 - Physiological 7 1.2 1 1.0 8 1.2 F10-F19 - Substances 70 12.3 15 15.5 85 12.7 F20-F29 - Non-mood psychotic 19 3.3 9 9.3 28 4.2 F30-F39 - Mood 240 42.1 60 61.9 300 45.0 F40-F49 - Non-psychotic/mood 94 16.5 22 22.7 116 17.4
F50-F59 - 3 0 3 Physiological/physical 0.5 0.0 0.4 F60-F69 – Personality 32 5.6 18 18.6 50 7.5 F70-F79 - Intellectual 0 0 0 disabilities 0.0 0.0 0.0 F80-F89 - Developmental 1 0.2 1 1.0 2 0.3 F90-F98 - Child/adolescent 4 1 5 onset 0.7 1.0 0.7 F99-F99 - Unspecified 4 0.7 0 0.0 4 0.6 No documented diagnosis 286 50.2 25 25.8 311 46.6 Total 570 100.0 97 100.0 667 100.0 *The proximity of the diagnosis to the death was not explored for the purposes of this report.
**Deceased may have had multiple diagnoses.
Table 17: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 16) with a documented mental disorder diagnosis coded to ICD-10 Classification of Mental and Behavioural Disorders, Victoria 2009-2015.
Mental disorders Male Female All Formal Diagnosis* N % N % N % Documented diagnosis** 284 100.0 72 100.0 356 100.0 F01-F09 - Physiological 7 2.4 1 1.3 8 2.1 F10-F19 - Substances 70 24.6 15 20.8 85 23.8 F20-F29 - Non-mood psychotic 19 6.6 9 12.5 28 7.8 F30-F39 - Mood 240 84.5 60 83.3 300 84.2 F40-F49 - Non-psychotic/mood 94 33 22 30.5 116 32.5
F50-F59 - 3 1.0 0 0.0 3 0.8 Physiological/physical F60-F69 – Personality 32 11.2 18 25.0 50 14.0 F70-F79 - Intellectual 0 0.0 0 0.0 0 0.0 disabilities F80-F89 - Developmental 1 0.3 1 1.3 2 0.5 F90-F98 - Child/adolescent 4 1.4 1 1.3 5 1.4 onset F99-F99 - Unspecified 4 1.4 0 0.0 4 1.4 Total 284 100.0 72 100.0 356 100.0 *The proximity of the diagnosis to the death was not explored for the purposes of this report.
**Deceased may have had multiple diagnoses.
Table 18: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of physical illness, physical injury and/or pain present proximate to death, Victoria 2009-2015.
Male Female All Physical health stressors*
N % N % N % Evidence of stressors 262 46.0 48 49.5 310 46.5 Physical illness 163 28.6 39 40.2 202 30.3 Physical injury 109 19.1 9 9.3 118 17.7 Pain 118 20.7 24 24.7 142 21.3 No evidence of stressor 308 54.0 49 50.5 357 53.5 Total 570 100.0 97 100.0 667 100.0 *Deceased may have experienced multiple physical health stressors.
Table 19: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 18) with a documented physical illness, physical injury and/or pain present proximate to death, Victoria 20092015.
Male Female All Physical health related
N % N % N % Physical health 262 100.00 48 100.00 310 100.0 stressors* Physical illness 163 62.2 39 81.2 202 65.1 Physical injury 109 41.6 9 18.7 118 38.0 Pain 118 45.0 24 50 142 45.8 Total 262 100.00 48 100.00 310 100.0 *Deceased may have experienced multiple physical health stressors.
Table 20: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for experience of substance use as a stressor and/or a formal substance use diagnosis and/or evidence of specialist addiction service contact Victoria 2009-2015.
Male Female All Substance related stressor*
N % N % N % Evidence of stressor 363 63.7 56 57.7 419 62.8 Formal diagnosis 64 11.2 15 15.5 79 11.8 Addiction service 19 4 23 contact 3.3 4.1 3.4 No evidence of stressor 207 36.3 41 42.3 248 37.2 Total 570 100.0 97 100.0 667 100.0 *Substance use requires evidence of impact of the substance use as a stressor.
Table 21: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 20) with a substance use stressor for formal substance use diagnosis and/or evidence of specialist addiction service contact Victoria 2009-2015.
Male Female All Substance related
N % N % N % Substance related 363 100.00 56 100.00 419 100.0 stressor* Formal diagnosis 64 17.6 15 26.7 79 18.8 Addiction service 19 5.2 4 7.1 23 5.4 contact Total 363 100.00 56 100.00 419 100.0 *Substance use requires evidence of impact of the substance use as a stressor.
Table 22: Frequency and proportion by sex of the Anger/angry Behaviour Cohort for evidence of substances detected by type in post-mortem toxicology Victoria 2009-2015.
Male Female All Post-mortem toxicology
N % N % N % Toxicology 570 100.0 97 100.0 667 100.0 Substance detected 469 82.3 81 83.5 550 82.5 Alcohol 269 47.2 34 35.1 303 45.4 Illicit drugs 115 20.2 14 14.4 129 19.3 Prescription medicines 334 58.6 76 78.4 410 61.5 Nil detected 101 17.7 16 16.5 117 17.5 Total 570 100.0 97 100.0 667 100.0 Table 23: Frequency and proportion by sex of the Anger/angry Behaviour Cohort (Table 22) with detected substances by type in post-mortem toxicology Victoria 2009-2015.
Male Female All Post-mortem toxicology
N % N % N % Substance detected 469 100.00 81 100.00 550 100.0 Alcohol 269 57.3 34 41.9 303 55.0 Illicit drugs 115 24.5 14 17.2 129 23.4 Prescription medicines 334 71.2 76 93.8 410 74.5 Total 469 100.00 81 100.00 550 100.0
Further analysis focused on the male deaths in line with the scope of the Coroner’s request.
From the 205 narratives associated with the deceased males, two groups emerged, a) the deceased who had longstanding anger/angry behaviours 119 (58%) and b) those who had developed anger/angry behaviours in the months/year preceding their death 86 (42%). These are referred to as Longstanding Group and Recent Group respectively, refer tables 24 - 34.
3.2 Data tables for the Duration of Anger/angry Behaviours Cohort Table 24: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort for experience of contextual stressors, Victoria 2009-2015.
Longstanding Recent All Contextual Stressors*
N % N % N % Evidence of Stressors 119 100.0 86 100.0 205 100.0 Work 48 40.3 42 48.8 90 43.9 Financial 59 49.6 44 51.2 103 50.2 Legal 78 65.5 38 44.2 116 56.6 Sexuality 2 1.7 1 1.2 3 1.5 Isolation 14 11.8 6 7.0 20 9.8 Abuse** 107 89.9 76 88.4 183 89.3 Education 5 4.2 2 2.3 7 3.4 Bullying** 55 46.2 25 29.1 80 39.0 Substance abuse/use 92 77.3 53 61.6 145 70.7 Other stressors 32 26.9 20 23.3 52 25.4 No evidence of stressors 0 0.0 0 0.0 0 0.0 Total 119 100.0 86 100.0 205 100.0 *Deceased may have experienced multiple stressors.
**Abuse and Bullying coding included experience as perpetrator and/or victim.
Table 25: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort for evidence of experience of physical illness, physical injury and/or pain present proximate to death, Victoria 2009-2015.
Longstanding Recent All Physical health stressors*
N % N % N % Evidence of stressors** 57 47.9 33 38.4 90 43.9 Physical illness 32 26.9 24 27.9 56 27.3 Physical injury 23 19.3 14 16.3 37 18.0 Pain 21 17.6 13 15.1 34 16.6 No evidence of stressor 62 52.1 53 61.6 115 56.1 Total 119 100.0 86 100.0 205 100.0 *Deceased may have experienced multiple physical health stressors.
**Coding required the illness, injury or pain evidence of impact of it as a stressor.
Table 26: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort (Table 25) with a documented physical illness, physical injury and/or pain present proximate to death, Victoria 2009-2015.
Longstanding Recent All Physical health*
N % N % N % Physical health 57 100.00 33 100.00 90 100.0 stressors** Physical illness 32 56.1 24 72.7 56 62.2 Physical injury 23 40.3 14 42.4 37 41.1 Pain 21 36.8 13 39.3 34 37.7 Total 57 100.00 33 100.00 90 100.0 *Deceased may have experienced multiple physical health stressors.
**Coding required the illness, injury or pain evidence of impact of it as a stressor.
Table 27: Frequency and proportion and involved clinician by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort for evidence of contact with a treating practitioner for a mental health reason within 12 months of death, Victoria 2009-2015.
Treating Longstanding Recent All Practitioner* N % N % N % Treatment within 12 Months 58 48.7 34 39.5 92 44.9 Psychiatrist 19 16.0 10 11.6 29 14.1 Psychologist 14 11.8 6 7.0 20 9.8 Mental Health Practitioner 13 10.9 8 9.3 21 10.2 General Practitioner 40 33.6 25 29.1 65 31.7 Emergency Department 13 3 16 Clinician 10.9 3.5 7.8
CATT 8 6.7 2 2.3 10 4.9 Drug and Alcohol Clinician 6 5.0 2 2.3 8 3.9 No Treatment within 12 61 52 113 months 51.3 60.5 55.1 Total 119 100.0 86 100.0 205 100.0 *Please note that a deceased person may have been treated by multiple practitioners within 12 months prior to their death.
Table 28: Frequency and proportion and involved clinician by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort (Table 27) with at least one contact with a treating practitioner for a mental health reason within 12 months of death Victoria 2009-2015.
Treating Longstanding Recent All Practitioner* N % N % N % Treatment within 12 Months 58 100.0 34 100.0 92 100 Psychiatrist 19 32.7 10 29.4 29 31.5 Psychologist 14 24.1 6 17.6 20 21.7 Mental Health Practitioner 13 22.4 8 23.5 21 22.8 General Practitioner 40 68.9 25 73.5 65 70.6 Emergency Department 13 22.4 3 8.8 16 17.3 Clinician
CATT 8 13.7 2 5.8 10 10.8 Drug and Alcohol Clinician 6 10.3 2 5.8 8 8.6 Total 58 100.0 34 100.0 92 100 *Please note that a deceased person may have been treated by multiple practitioners within 12 months prior to their death.
Table 29: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort for evidence of a documented mental disorder diagnosis coded to ICD-10 Classification of Mental and Behavioural Disorders.
Mental disorders Longstanding Recent All Diagnosis* N % N % N % Documented diagnosis** 64 53.8 50 58.1 114 55.6 F01-F09 - Physiological 1 0.8 2 2.3 3 1.5 F10-F19 - Substances 18 15.1 7 8.1 25 12.2 F20-F29 - Non-mood psychotic 5 4.2 0 0.0 5 2.4 F30-F39 - Mood 53 44.5 33 38.4 86 42.0 F40-F49 - Non-psychotic/mood 25 21.0 12 14.0 37 18.0
F50-F59 - 1 0 1 Physiological/physical 0.8 0.0 0.5 F60-F69 – Personality 10 8.4 4 4.7 14 6.8 F70-F79 - Intellectual 0 0 0 disabilities 0.0 0.0 0.0 F80-F89 - Developmental 0 0.0 0 0.0 0 0.0 F90-F98 - Child/adolescent 2 0 2 onset 1.7 0.0 1.0 F99-F99 - Unspecified 1 0.8 1 1.2 2 1.0 No Formal diagnosis 55 46.2 36 41.9 91 44.4 Total 119 100.0 86 100.0 205 100.0 *The proximity of the formal diagnosis to the death was not explored for the purposes of this report.
**Deceased may have had multiple diagnoses.
Table 30: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort (Table 29) with a documented mental disorder diagnosis coded to ICD-10 Classification of Mental and Behavioural Disorders.
Mental disorders Longstanding Recent All Diagnosis* N % N % N % Documented diagnosis** 64 100.0 50 100.0 114 100 F01-F09 - Physiological 1 1.5 2 4.0 3 2.6 F10-F19 - Substances 18 28.1 7 14.0 25 21.9 F20-F29 - Non-mood psychotic 5 7.8 0 0.0 5 4.3 F30-F39 - Mood 53 82.8 33 66.0 86 75.4 F40-F49 - Non-psychotic/mood 25 39.0 12 24.0 37 32.4
F50-F59 - 1 1.5 0 0.0 1 0.8 Physiological/physical F60-F69 – Personality 10 15.6 4 8.0 14 12.2 F70-F79 - Intellectual 0 0.0 0 0.0 0 0.0 disabilities F80-F89 - Developmental 0 0.0 0 0.0 0 0.0 F90-F98 - Child/adolescent 2 3.1 0 0.0 2 1.7 onset F99-F99 - Unspecified 1 1.5 1 2.0 2 1.7 Total 64 100.0 50 100.0 114 100 *The proximity of the formal diagnosis to the death was not explored for the purposes of this report.
**Deceased may have had multiple diagnoses.
Table 31: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort for evidence of a substance use stressor and/or a formal substance use diagnosis and/or evidence of specialist addiction service contact Victoria 2009-2015.
Longstanding Recent All Substance related stressors*
N % N % N % Evidence of stressor 92 77.3 53 61.6 145 70.7 Formal diagnosis 18 15.1 7 8.1 25 12.2 Addiction service 6 2 8 contact 5.0 2.3 3.9 No evidence of stressor 27 22.7 33 38.4 60 29.3 Total 119 100.00 86 100.00 205 100.0 *Substance use requires evidence of impact of the substance use as a stressor.
Table 32: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort (Table 31) with a substance use stressor and with a formal substance use diagnosis and/or evidence of specialist addiction service contact Victoria 2009-2015.
Longstanding Recent All Substance related
N % N % N % Substance related 92 100.00 53 100.00 145 100.00 stressor* Formal diagnosis 18 19.5 7 13.2 25 17.2 Addiction service 6 6.5 2 3.7 8 5.5 contact Total 92 100.00 53 100.00 145 100.0 *Substance use requires evidence of impact of the substance use as a stressor.
Table 33: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort with evidence of substances in post-mortem toxicology Victoria 2009-2015.
Longstanding Recent All Post-mortem toxicology
N % N % N % Toxicology 119 100.0 86 100.0 205 100.0 Substance detected 101 84.9 74 86.0 175 85.4 Alcohol 50 42.0 47 54.7 97 47.3 Illicit drugs 38 31.9 15 17.4 53 25.9 Prescription medicines 71 59.7 53 61.6 124 60.5 Nil detected 18 15.1 12 14.0 30 14.6 Total 119 100.0 86 100.0 205 100.0
Table 34: Frequency and proportion by Longstanding and Recent groups of the Duration of Anger/angry Behaviours Cohort (Table 33) with a substance detected in post-mortem toxicology Victoria 2009-2015.
Longstanding Recent All Post-mortem toxicology
N % N % N % Substance detected 101 100.00 74 100.00 175 100.0 Alcohol 50 49.5 47 63.5 97 55.4 Illicit drugs 38 37.6 15 20.2 53 30.2 Prescription medicines 71 70.2 53 71.6 124 70.8 Total 101 100.00 74 100.00 175 100.0 Of the 326 deceased males of the Anger/angry Behaviour Cohort who had experienced intimidate partner separation, refer table 7, 151 narratives contained enough information to code for proximity of separation, proximity of conflict, proximate conflict with IVO where the deceased was the respondent and any event which could be reasonably considered as finalizing, including property settlement, refusal by partner to “try again”, custody of children arrangements, partner formalizing separation/divorce, and IVO initiation.
Table 35: Frequency and proportion by Longstanding and Recent groups who experienced partner separation for proximity of separation, proximity of conflict, proximate conflict with IVO where the deceased was the respondent and any final event, Victoria 2009-2015.
Longstanding Recent All Partner stressor
N % N % N % Evidence of separation 93 100.0 58 100.0 151 100.0 Proximate separation* 2 2.2 56 96.6 58 38.4 Remote separation** 91 97.8 2 3.4 93 61.6 Proximate conflict*** 91 97.8 56 96.6 147 97.4 …Proximate conflict + 56 (91) 61.5 25 (56) 44.6 81 (147) 55.1
IVO Finalizing event 43 46.2 21 36.2 64 42.4 Total 93 100.0 58 100.0 151 100.0 *Separation occurred within a year/months/weeks before death.
**Separation occurred greater than one year before death.
***Conflict with partner/ex-partner.
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