Finding into death of S K

IN THE CORONERS COURT Court Reference: COR 2022 000598

OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Deputy State Coroner Paresa Antoniadis Spanos Deceased: SK Date of birth: 12 April 1996 Date of death: 30 January 2022 Cause of death: 1(a) Gunshot injury to the head Place of death: Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria Key words: Unregistered firearm, inexperienced firearm user, misadventure, fatal gunshot injury

INTRODUCTION

1. On 30 January 2022, SK was 25 years old when he died from an accidental self-inflicted gunshot wound. At the time, Mr SK lived in Wollert with his girlfriend.

2. According to his mother, Mrs QF, he experienced difficulty in school due to attention-deficit/ hyperactivity disorder (ADHD) for which he was later prescribed Ritalin (methylphenidate).

3. At age 16 years, Mr SK began an apprenticeship in cabinet making in Thomastown. At this time, Mr SK moved in with his grandmother in Reservoir to be closer to work. He later moved Thornbury, Frankston, back to his parents’ house, and then to Wollert. According to his father, Mr WF, Mr SK was introduced to illicit drugs whilst living with his cousin.

Mr SK subsequently returned to live with his parents in Broadford.

4. In mid-2019, Mr SK began a relationship with Ms KL. A few months later, they moved in together, living first in Reservoir and then in Coolaroo.

5. Ms KL stated that her partner had struggled with drug use and mental health issues for a number of years, and she was aware that he used Xanax and cannabis and later ice. She noted that Mr SK was open about experiencing ADHD, borderline personality disorder, post-traumatic stress disorder (PTSD), and also experienced symptoms of depression and anxiety.

THE CORONIAL INVESTIGATION

6. Mr SK’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent, or result from accident or injury.

7. The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.

8. Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of

comments or recommendations in appropriate cases about any matter connected to the death under investigation.

9. The Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Mr SK’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.

10. This finding draws on the totality of the coronial investigation into Mr SK’s death, including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.1

MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Identity of the deceased

11. On 2 February 2022, SK, born 12 April 1996, was visually identified by father, Mr WF, who signed a formal Statement of Identification to this effect.

12. Identity is not in dispute and requires no further investigation.

Medical cause of death

13. Senior Forensic Pathologist, Dr Michael Burke, from the Victorian Institute of Forensic Medicine (VIFM), conducted an inspection on 31 January 2022, and provided a written report of his findings dated 3 February 2022.

14. The post-mortem CT scan showed a gunshot entrance injury to the right side of the head and gas in the right side of the heart.

15. The external examination was otherwise unremarkable.

1 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.

16. Routine toxicological analysis of post-mortem samples detected methylamphetamine and amphetamine,2 a metabolite of clonazolam,3 ketamine,4 citalopram,5 promethazine,6 and cannabis.7

17. Dr Burke provided an opinion that the medical cause of death was “1(a) Gunshot injury to the head”.

18. I accept Dr Burke’s opinion.

Background circumstances

19. In March 2021, Mr SK reported symptoms of anxiety to his general practitioner, Dr Muy Hak Lim at Coolaroo Clinic. Dr Lim prepared a Mental Health Care Plan and a referral to a psychiatrist through Glencairn Consulting Suites for treatment of ADHD. However, over the next two weeks, the referral was returned to Dr Lim as Mr SK could not be contacted.

20. In June, Dr Lim provided the contact details for Glencairn Consulting Suites to Mr SK so he could make direct contact with them. Mr SK later informed Dr Lim that he was seeing a psychiatrist to help with withdrawal from alprazolam.

21. In early June 2021, Mr SK attempted suicide following arguments with Ms KL and family members. According to Ms KL, her partner was acting erratically in the lead-up to this incident.

22. Two or three days later, he attended the Northern Hospital Emergency Department expressing self-harm ideation and was referred to the Hume Acute Community Intervention Service for 2 Amphetamines is a collective word to describe central nervous system (CNS) stimulants structurally related to dexamphetamine. One of these, methamphetamine, is often known as speed or ice. Amphetamines can be administered both orally and intravenously. Amphetamine is also a metabolite of methamphetamine, benzfetamine and selegiline. One of the main effects sought by amphetamine users is euphoria, the high experienced with the amphetamine rush in the body. This high is associated with an elevation of mood and increased alertness. Increased confidence and increased mental and physical strength become part of this effect. This high may last for several hours. Amphetamines stimulate the CNS causing persons to become hyperactive and more aroused. Blood pressure and heart rate are also increased. This stimulation lasts as long as the drug is present in a person’s body, with larger effects more intense soon after administration. Amphetamine users often develop a psychosis, particularly paranoid psychosis. This can often lead to irrational and violent behaviour and is a frequent factor in serious assault caused by amphetamine usage.

3 Clonazolam has been sold as a falsified benzodiazepine, commonly as diazepam and alprazolam. Clonazolam produces sedation, muscle relaxation, loss of motor control, amnesia and respiratory depression, and does not appear to induce cross-tolerance with other benzodiazepines.

4 Ketamine is an anaesthetic normally used for short and medium duration operations as an induction agent.

5 Citalopram is indicated for major depression and panic disorders. Escitalopram is indicated for the treatment of major depression, social anxiety disorders, panic disorder, generalised anxiety disorder, and obsessive-compulsive disorder.

6 Promethazine is an antihistamine.

7 Delta-9-tetrahydrocannabinol (THC) is the active form of cannabis (marijuana). Persons under the influence of cannabis will experience impaired cognition (reasoning and thought), poor vigilance, and impaired reaction times and coordination.

follow-up. He was subsequently assessed on 12 June 2021 at which time he provided further detail about the suicide attempt including that it had occurred during a drug binge.

23. According to Sharon Peters, registered mental health nurse, Mr SK said he was committed to engaging with mental health services and drug and alcohol services. Regarding drug use, he disclosed daily cannabis use, frequent use of alprazolam, weekend use of MDMA, and intermittent use of speed, ice, and magic mushrooms. He also reported using his mother’s Ritalin medication. Regarding mental health, Mr SK described experiencing anxiety since childhood. Mr SK was assessed as being at chronic medium to high risk of self-harm when substance affected. A safety plan was completed and a psychiatric review with Dr Lokesh Sekharan, psychiatrist, was scheduled for 16 June 2021.

24. Dr Sekharan explained that Mr SK was diagnosed with social anxiety, dysthymia, polysubstance dependence, and cluster B personality (borderline personality) traits. He was prescribed diazepam to assist with symptoms of withdrawal and commenced on escitalopram (an antidepressant medication). He was also provided education about relaxation techniques and encouraged to see a psychologist.

25. After these initial assessments, Mr SK was discharged from the service for further management by his general practitioner, with recommendations that he be referred to a private psychiatrist and psychologist. Mr SK was considered to be at low risk of self-harm when not intoxicated.

26. On 18 June 2021, Mr SK consulted Dr Lim about further experience of anxiety. He told Dr Lim that he had seen a psychiatrist as outlined above and had been prescribed escitalopram and diazepam. Dr Lim later also prescribed escitalopram but did not see Mr SK after midNovember 2021.

27. During this period, Mr SK was also referred to STAR (Substance Treatment and Recovery) service to assist with his substance abuse issues. On 6 July 2021, he underwent a comprehensive alcohol and other drug (AOD) assessment and was placed on a waitlist for Complex AOD Counselling, which involved 12 sessions over a maximum of six months. He was also placed on the waitlist for Care and Recovery Coordination, which consists of 15 hours of case management support over a maximum of 18 weeks.

28. During his engagement with STAR, Mr SK disclosed he had access to weapons, being a ‘licensed’ crossbow and knives. STAR staff reported this information to the Broadmeadows Police station and his mental health treating team. The STAR records note police as advising

that a person could not have a license for a crossbow, and that they would send the report to the appropriate team to investigate what action could be taken. At some point during this period, Mr SK’s family took away his crossbow and knives.

29. In early August, Mr SK commenced Care and Recovery Coordination, which included a referral to a general practitioner with AOD knowledge and understanding, to refer him to a psychiatrist for an assessment, and mindfulness meditation resources. He was subsequently discharged from the program in October as he was not seeking AOD supports beyond AOD counselling.

30. Mr SK commenced AOD Complex Counselling in August 2021. He attended and engaged in a total of four counselling sessions. This referral was also closed in October due to Mr SK missing two sessions without notice.

31. In August 2021, the couple moved to Wollert. By this stage, Mr SK had retrieved his crossbow from his parents’ house. Ms KL described things as “going really well” at this time – they were both employed and felt comfortable in their new home. His mother, Mrs QF, also described her son as very happy at this time.

32. However, in November 2021, Mr SK’s beloved dog passed away. Ms KL noted that her partner’s wellbeing and behaviour deteriorated thereafter. He stopped working; his mental health declined; and his use of Xanax and Rikodeine (cough suppressant) increased, in addition to his usual daily cannabis use.

33. According to Ms KL, at about this time, Mr SK began selling Xanax and Rikodeine and started carrying a firearm for protection. He had traded his crossbow for a shotgun in December 2021 and later traded the shotgun for a revolver. Ms KL explained that Mr SK usually left two chambers empty when he carried the revolver in his pants as it did not have a ‘safety’ mechanism to prevent accidental misfire.

34. Mr SK’s father stated that his son had no previous training or experience with firearms, and it was unlikely he knew how to operate one safely. He had shown the gun to his mother in the lead up to his death. Mrs QF noted, “the way SK was handling the gun, he looked just like an amature [sic]”. Both parents had pleaded with Mr SK to get rid of the firearm.

Circumstances leading to death

35. On 30 January 2022, Mr SK and Ms KL returned home with their friend, Ms RH, at about 6.00pm. Mr SK had used amphetamines, cannabis, Xanax (alprazolam), and Rikodeine that day and was happy as he had made some money selling Xanax.

36. According to Ms RH, everyone was in a good mood, dancing around the house. At some point, the two women sat on the couch in the living room. Both described Mr SK holding his revolver in his hands, dancing around and singing along to music.

37. Neither woman saw Mr SK point the revolver at his head but they both heard the gunshot being fired at about 7.15pm. Following which, Mr SK immediately fell to the floor and was unresponsive. They observed a gunshot wound to the head, with the entry point at the right temple and exit point on the left forehead.

38. Ms KL immediately telephoned emergency services and began administering cardiopulmonary resuscitation as instructed by the call-taker.

39. Ambulance Victoria paramedics responded to the scene and provided initial treatment at the scene before transporting Mr SK to the Royal Melbourne Hospital (RMH).

40. Upon arrival at RMH, Mr SK was in cardiac arrest. Investigations by clinical staff indicated he had sustained a traumatic brain injury that was considered unsurvivable. Cardiopulmonary resuscitation was ceased at 9.57pm and Mr SK was verified deceased.

41. Victoria Police members also attended the scene locating a revolver on the living room floor.

The revolver was examined and found to contain four rounds in the chambers – one spent round and three live rounds. The remaining two chambers were unloaded.

42. Attending police members also found drug paraphernalia and multiple open alcohol containers throughout the kitchen and living area, as well as several imitation firearms and several hunting/combat knives at the premises.

43. Sergeant Shane Leggatt, Coroner’s Investigator, noted that Ms KL and Ms RH both provided sworn statements that provided a consistent version of events –relevantly that Mr SK had been in possession of the firearm and discharged it himself, causing the fatal injury. There was no evidence to suggest a struggle or disturbance at the

Wollert address and no evidence of suspicious circumstances connected with Mr SK’s death.

44. Examination of Mr SK’s mobile phone revealed that he had been engaged in drugtrafficking, mostly of Xanax tablets.

45. Sergeant Leggatt considered that Mr SK’s death was a result of misadventure. He noted contributing factors were Mr SK’s drug use and his lack of training or experience in firearm safety whilst operating an unregistered firearm.

FAMILY CONCERNS

46. In May 2023, Mrs QF submitted concerns that her son was able to obtain a firearm and that no one had been charged in relation to supplying her son with the firearm.

47. While I share Mrs QF's concerns, for the reasons outlined below, the provenance of the firearm that inflicted the fatal injury cannot be unascertained.

FURTHER INVESTIGATION Type of firearm

48. According to the police investigation, the firearm that caused the fatal injury was a .38 special calibre, Smith and Wesson brand, model 10 variant, selective double action six shot revolver bearing serial number 883484.

49. This type of firearm was manufactured in the United States between 1940 and 1944 and would have been supplied to Allied Forces under the United States Lend Lease Program of World War II.

50. Examination of the firearm indicated that at an unknown time, modifications were made to the firearm by persons unknown.

Known details of use in Australia

51. The Ballistics Unit at the Victoria Police Forensic Services Centre examined the seized revolver, ammunition, fired bullet jacket, fired lead bullet core, and fired cartridge case. Their examination revealed that the fired bullet and the fired cartridge case had both been discharged from the revolver.

52. The Australian Firearm Information Network had no record of the firearm. The Victorian Licensing and Regulation System also had no record of the firearm.

53. There was no evidence of the firearm being linked to any other incident.

54. The last known date of legal ownership of the firearm is unknown and unable to be ascertained.

How Mr SK came into possession of the firearm

55. DNA from the firearm, cartridges, and shell was also tested and revealed DNA contribution solely from Mr SK.

56. As noted above, Ms KL stated that Mr SK had obtained the firearm in about December

2021. Text messages on Mr SK’s mobile phone confirmed this timeframe.

57. Following Mr SK’s death, Ms KL and Mrs QF gave police the name of a person who may have supplied the firearm to Mr SK. Sergeant Leggatt advised that police had made enquiries in accordance with the information provided. However, no charges were able to be laid due to insufficient evidence.

58. All avenues of enquiry regarding the provenance of the firearm have been exhausted and unfortunately there is no further information available.

Review of Mr SK’s mental health treatment

59. As part of my investigation, I also obtained advice from the Coroners Prevention Unit8 (CPU) about the mental health care Mr SK received in the lead up to his death. The CPU subsequently reviewed the statements from Mr SK’s treating clinicians and the medical records.

Background

60. By way of background, the CPU noted that Mr SK reported to mental health clinicians a history of physical and emotional abuse during childhood, leaving home at age 14 years, and contact with criminal gangs leading to exposure to guns while living with his cousins who he 8 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit 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. The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.

described as drug users. He was diagnosed with ADHD as a young teenager and also reported attending Headspace where he was diagnosed with a personality disorder.9 He self-reported a history of cannabis use from the age of 14 and polysubstance abuse from the age of 18 years.

61. On 11 June 2021, Mr SK self-presented to the Northern Hospital Emergency Department following a reported attempt to hang himself two days earlier and a subsequent overdose with alprazolam. These events occurred on a background of multiple psychosocial stressors and significantly increased drug use, but Mr SK had limited recall of the events.

62. He was assessed in Emergency Department as being medically stable and by a mental health clinician as experiencing a flat mood with ongoing self-harm ideation but no plan or intent.

Mr SK was considered to be at chronic to medium risk of accidental injury/harm secondary to his use of illicit drugs but able and willing to be discharged with support from his partner.

He was provided with psychoeducation about the impact of substances on mental health and judgment, and he agreed to follow-up by the Hume Community Mental Health Team (CMHT). A safety plan was discussed with Mr SK and his partner inclusive of removing medications and work tools from the house and provision of emergency contact details.

63. The following day, Mr SK was assessed by a mental health clinician and stated that he did not want to end his life and was motivated to cease using illicit substances. He was provided with psychoeducation on the risks associated with sudden withdrawal from illicit substances and information on the referral process to drug and alcohol services. There was no evidence of risk of harm to self or others, but Mr SK was assessed as moderate to high risk of deteriorating physically due to withdrawal symptoms from non-prescribed alprazolam and a moderate to high risk of deterioration in his mental state due to themes of hopelessness and helplessness. He agreed to a crisis plan and to present to Emergency Department if he was struggling with withdrawal symptoms.

64. At a telephone review on 13 June 2021, Mr SK reported struggling with withdrawal symptoms but managing. The crisis plan was reviewed and the option of attending his general practitioner for medication support for cravings was discussed.

65. On 15 June 2021, Mr SK was assessed as high priority for admission by the Odyssey House10 centralised intake service given the severity of his AOD issues, identified risks and 9 Personality disorders are long-term patterns of behaviour and inner experiences that differ significantly from what is expected of the individual’s culture and lead to distress or impairment.

10 Odyssey House provides intake, assessment and referral for AOD services in the Northern Metropolitan Region of Melbourne.

active help-seeking behaviour. A referral was made to the STAR11 program. The same day, Mr SK saw Dr Lim for management of withdrawal symptoms and was prescribed ten tablets of diazepam 2mgs and antinausea medication.

66. At a review by Dr Sekharan on 16 June 2021, Mr SK was described as having a long history of social anxiety,12 dysthymia,13 polysubstance dependence, and cluster B – borderline personality traits vs disorder14, with his recent suicide attempt likely impulsive in the context of substance abuse and work-related psychosocial stress. He was advised to contact his general practitioner for referral to a psychologist for relaxation strategies, anger management, and problem-solving skills and to a private psychiatrist to consider medication for ADHD. He was prescribed escitalopram 10mg and a short-term reducing dose of diazepam. At this time, Mr SK had been in contact with the STAR program and was awaiting an intake assessment.

67. Mr SK’s mental health remained stable until 23 June 2021 when he reported that he had relapsed on cannabis and alprazolam and stopped taking escitalopram. The relapse occurred during a period of significant financial stress and distress about the lengthy wait for admission to the STAR program.

68. On 26 June 2021, Mr SK reported he was using alprazolam and street-bought codeine and both he and Ms KL were upset about the relapse. He indicated he had obtained employment to address his financial difficulties; understood this meant he could not do a residential detoxification; but was still planning to undertake drug and alcohol counselling.

69. At a face-to-face review on 1 July 2021, Mr SK reported one instance of suicidal ideation which he successfully managed without support.

70. On 7 July 2021, Mr SK was assessed for the STAR program and placed on the waitlist for Complex AOD Counselling and for Care and Recovery Coordination. STAR staff also contacted Mr SK’s mental health treating team about his safety given he had disclosed being 11 The Substance Treatment and Recovery (STAR) program is a consortium comprising The Salvation Army and Vincent Care that provides evidence-based treatment to men and women experiencing alcohol and other drug issues across the inner-north and north-west catchment areas of Melbourne.

12 he essential feature of social anxiety disorder is significant fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.

13 Dysthymia is milder but long-lasting (minimum two-years in adults) form of depression.

14 Cluster B is a general term once used to describe a group of personality disorders: antisocial personality disorder, borderline personality disorder, histrionic personality disorder and narcissistic personality disorder. The emphasis on borderline personality suggests features of this disorder were prominent (e.g., emotional instability, unstable relationships, impulsive behaviours). A personality trait describes a habitual way of thinking, feeling and acting but unlike personality disorders, it does not affect all areas of one’s life.

in possession of a crossbow and knives and had threatened his partner during the drug-induced psychosis that preceded his hospital presentation in June 2021.

71. When a clinician telephoned Mr SK the next day, he denied suicidal ideation and indicated that if he did want to kill himself, he would use a gun although he said he did not own one.

With respect to his possession of a crossbow, he was provided with education about not using it when substance affected. Mr SK said his partner was a strong protective factor, but he admitted feeling overwhelmed and disappointed about being told there was a 12-month waitlist for an appointment with a private psychiatrist for medication management of his ADHD. He was encouraged to return to his general practitioner to explore alternative psychiatrists.

72. On 10 July 2021, a clinician contacted Dr Lim about providing referrals to a psychologist and a new psychiatrist and he agreed to take over Mr SK’s care. At a review on 11 July 2021, Mr SK told Dr Lim he was struggling to manage withdrawal symptoms and was using street-purchased alprazolam to cope. He denied suicidal ideation but was cautioned about the risk of misadventure associated with street drugs. The discussed and agreed a crisis plan.

73. On 15 July 2021, Mr SK agreed to discharge from the mental health service with a plan to work with his STAR practitioner to address his ongoing withdrawal symptoms and addiction to benzodiazepines.

74. Mr SK’s case management with STAR commenced on 2 August 2021 and AOD counselling on 11 August 2021, with STAR also referring Mr SK to a general practitioner with AOD experience.

75. Mr SK initially engaged well with all three services, citing his return to work as a protective factor. However, his anxiety and substance use still fluctuated as he tried to manage withdrawal symptoms and function effectively at work. He was encouraged to use mindfulness and grounding techniques to help manage his anxiety and an appointment was made with a forensic psychologist.

76. At his fifth case management session on 7 October 2021, Mr SK appeared less willing to engage in discussions about his substance use and the practitioner asked him if he wished to continue with the service. Mr SK said he would be happy to continue with counselling only. However, after Mr SK’s fourth counselling session he missed two appointments without notice. STAR practitioners attempted to contact him via phone and text and to inform him he was at risk of case closure due to non-engagement. He did not respond. As a result,

case management by STAR was closed on 15 October 2021 and AOD counselling on 7 October 2021. The trigger for Mr SK’s disengagement from AOD services after a promising start is unknown.

77. On 5 November 2021 Mr SK’s much-loved dog died, and Ms KL reported his mental health declined alongside his increased use of cannabis, alprazolam, and Rikodeine. At this time, according to Ms KL, Mr SK started dealing Rikodeine and alprazolam and exchanged his crossbow for a shotgun (and subsequently for a revolver) as he felt he needed to protect himself.

78. Mr SK had his last appointment with Dr Lim on 17 November 2021 for a non-mental health related issue.

Mental health treatment

79. The CPU considered that the treatment provided to Mr SK by Northern Hospital Emergency Department and follow-up by the Hume Acute Community Intervention Service was appropriate and reasonable. Mr SK had a long history of polysubstance dependence and use of illicit drugs that placed him at risk of accidental injury or harm. The services addressed the immediate risk issues related to the use of illicit drugs and were able to engage him during a period of motivation to address his drug dependence after the self-harm episode in June 2021.

80. As Mr SK was assessed as high needs and requiring complex intervention, STAR appropriately referred him to both case management and counselling. They linked him with medical specialists and provided evidence-based therapeutic interventions. However, after four counselling and five case management appointments, Mr SK abruptly disengaged and did not respond to further contact from STAR. The reason for this disengagement remains unknown.

81. The CPU explained that recovery from a severe substance use disorder is typically a longterm process that is characterised by periods of relapse and fluctuation in capacity and motivation to engage in treatment. Mr SK was a voluntary client and there was no indication in the medical records provided to the Court that Mr SK would have met criteria either under the Mental Health Act 2014 (Vic) or the Severe Substance Dependence Treatment Act 2010 (Vic) to compel him to receive treatment.

82. The clinicians at STAR identified and appropriately managed safety concerns related to Mr SK’s self-reported access to weapons in light of his previous suicide attempt, substance use, and personality disorder. STAR checked with his mental health treating team to ascertain how they are managed this risk and then reported Mr SK’s access to weapons to police who indicated the information would be shared with the appropriate personnel who would consider what further action was required.

83. In summary, the CPU advised that the treatment provided to by STAR was also appropriate and reasonable.

84. Although Ms KL indicated in her statement that Mr SK’s mental health declined towards the end of 2021 and he was using increasing amounts of illicit drugs, she did not indicate he was voicing thoughts of self-harm or suicidal ideation. Rather, he was pleased that selling drugs was providing them with sufficient income to allow them to stay in their rental property. On the day Mrs QF incurred the fatal injury, he appeared happy and there was no indication of deterioration in his mental health or suicidal ideation.

85. The results of toxicological analysis indicated Mr SK was experiencing the effects of amphetamines, cannabis and aminoclonazolam at the time of the fatal incident. In the context of poor gun safety, this would likely have impaired his judgement, reaction time, and coordination when handling the firearm.

CPU Conclusion

86. In conclusion, the CPU noted that Mr SK had a lengthy history of polysubstance dependence, ADHD, social anxiety, dysthymia, and borderline personality disorder on a background of significant childhood trauma. In June 2021, he made a suicide attempt that was likely impulsive in the context of substance abuse and psychosocial stressors. This was followed by increased motivation to address his use of illicit substances. He engaged with the Hume Acute Community Intervention Service and at least initially with the STAR program.

The reason for his disengagement from STAR remains unknown. Although not inevitable, lapses and relapses are common features of recovery from dependence.

87. The CPU did not identify any prevention opportunities.

88. However, the CPU noted that to obtain comprehensive treatment and support for his substance use and addiction, Mr SK had to move from the Hume Acute Community Intervention Service to an AOD service. It was noted that the Royal Commission into Victoria’s Mental

Health System (RCVMHS) found that most Victorian mental health services are unable to provide integrated mental health and AOD services.15

89. Mr SK therefore had to navigate a completely new system to access services involving twice retelling his history, and waiting six weeks between his presentation to hospital and his first AOD counselling session. The reforms recommended by the RCVMHS provide opportunities to improve access to integrated treatment for people living with mental illness and substance use or addiction and this is supported by the Court.

FINDINGS AND CONCLUSION

90. Pursuant to section 67(1) of the Act I make the following findings:

(a) the identity of the deceased was SK, born 12 April 1996;

(b) the death occurred on 30 January 2022 at Royal Melbourne Hospital, 300 Grattan Street, Parkville, Victoria;

(c) the cause of Mr SK's death was gunshot injury to the head; and

(d) the death occurred in the circumstances described above.

91. Having considered all of the evidence, I am satisfied that Mr SK did not intend to take his own life and that his death resulted from misadventure and his unsafe handling of an illicit firearm while his judgement was impaired by substances.

COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.

92. Mr SK’s death highlights the dangers of unregistered – and unsafe – firearms circulating in the community where they may be obtained and used by persons without prior experience or training. There is also the additional concern about their use by persons with criminal intent.

It is trite to say that illicit firearms pose an ongoing threat to community safety.

15 State of Victoria, Royal Commission into Victoria’s Mental Health System, Final Report, Volume 3: Promoting inclusion and addressing inequities, Parl Paper No.202, Session 2018-21 (document 4 of 6).

93. The last national firearms amnesty was held over a period of three months in 2017 and resulted in over 57,000 firearms being handed in across Australia. There have also been previous ‘buyback’ programs and time-limited amnesties.

94. A new permanent and nationwide firearm amnesty (the Amnesty) commenced on 1 July

95. The Amnesty allows members of the public to anonymously surrender any illegal or unregistered firearms, firearm parts, or ammunition in their possession without fear of prosecution or penalty.

96. Crime Stoppers Australia conducted two campaigns in relation to the Amnesty. A campaign from July September 2021 encouraged the surrender of unregistered and unwanted firearms, and the second campaign from February to April 2022 encouraged anonymous reporting of illicit firearms.16

97. As of 30 June 2023, the Amnesty has seen 29,733 firearms and weapons and 1,243 parts and accessories surrendered.17

98. In line with the Amnesty, Victoria Police encourages members of the public to contact their nearest licensed firearm dealer regarding surrender. If this is impractical, members of the public can contact their local police station for advice.18

99. A national and permanent amnesty provides an ongoing nationally consistent and coordinated approach to the surrender of firearms without fear of repercussions. In addition, it is an important community safety measure as it reduces the overall number of firearms in circulation.

100. I therefore strongly encourage members of the public to contact their local police station or nearest licensed firearm dealer to discuss the surrender of any firearm, firearm parts, or ammunition they may have in their possession.

101. The circumstances of Mr SK’s death also highlight the importance of members of the public reporting illicit firearms to authorities.

16 Australian Government, Attorney-General’s Department, Permanent National Firearms Amesty Annual Report 20222023, p 5, https://www.ag.gov.au/sites/default/files/2024-03/permanent-national-firearms-amnesty-annual-report-202223.pdf, accessed 15 November 2024.

17 Australian Government, Attorney-General’s Department, Permanent National Firearms Amesty Annual Report 20222023, p 3, https://www.ag.gov.au/sites/default/files/2024-03/permanent-national-firearms-amnesty-annual-report-202223.pdf, accessed 15 November 2024.

18 Victoria Police, Disposal of firearms and ammunition, https://www.police.vic.gov.au/disposal-firearms-andammunition, accessed 15 November 2024.

I convey my sincere condolences to Mr SK’s family for their loss.

Pursuant to section 73(1A) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.

I direct that a copy of this finding be provided to the following: Ms KL, senior next of kin Mrs QF & Mr WF Dr Lim Muy Huk (care of Avant Law Pty Ltd) Royal Melbourne Hospital Melbourne Health (NorthWestern Mental Health Service) Victims of Crime Assistance Tribunal Sergeant Shane Leggatt, Victoria Police, Coroner’s Investigator Signature: ___________________________________ Deputy State Coroner Paresa Antoniadis Spanos Date: 02 December 2024 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.