In The Matter Of The Death Of Warren Geoffrey Ianson

Contributing factors

• Schizophrenia not adequately controlled
• Recent deaths of wife and close friend
• Consumption of alcohol and diazepam
• Deteriorating mental state over preceding days
• Lack of coordination between multiple mental health providers
• PRS psychologist did not advise Crisis Team of afternoon visit and assessment
• Mattress placed against door delaying forcible entry
• Critical information about deceased's stated intention to be shot by police not conveyed to responders
• Inadequate information transfer between agencies
• Assessment focused on crisis rather than proactive intervention
• Police lack of knowledge about deceased's suicide-by-proxy intent
• Absence of comprehensive case management
• Absence of updated Memorandum of Understanding between AFP and Mental Health Services

Coroner's recommendations

1. Availability of best intelligence gathering methods (surveillance equipment) at crisis scenes to provide accurate current information for decision-makers
2. Emphasis in training of mental health crisis workers and AFP officers on crisis intervention with joint exercises and scenarios followed by discussion on decision-making
3. Full evaluation and availability of alternatives to lethal force including OC/CS sprays, nets, police dogs, batons and body armour, evaluated against safety principles
4. Mental Health Services to liaise with media on understanding effects of media reporting on suicide rates and sensitize reporting on mental illness and crisis intervention
5. Development of updated information systems in Mental Health Services with complete and current client information accessible to Crisis Team workers at incident scenes
6. Maintenance of increased emphasis in AFP training on issues involving mentally ill with focus on communication and response to mental health issues
7. Full register/record of crisis interventions where AFP and mental health teams are jointly called, including satisfactorily resolved cases
8. Regular evaluation and publication of crisis intervention register information by each agency for future planning
9. Formalized monitoring group for register of crisis interventions including Office of Community Advocate to keep review and change process active
10. Establishment of joint training ventures between AFP officers and Mental Health Crisis Team workers with team approach to decision-making
11. Exposure of non-government community agency workers to training on crisis intervention and procedures for contacting Crisis Team and AFP
12. Clear protocols and supervision available to Mental Health Crisis Teams with expert clinical advice and possible attendance of psychiatrist/psychologist at scene
13. Formation and maintenance of Interdepartmental Standing Committee on Mental Health meeting regularly for holistic approach
14. AFP liaison with local media regarding dangers of offering rewards to witnesses for exclusive stories about investigations
15. Regular review of AFP approach, training, culture and attitude towards crisis intervention using Project Beacon and relevant police force experiences
16. Development of appropriate strategies for persons indicating intention to be shot by police with emphasis on negotiation and containment
17. Sensitive and non-sensational media treatment of persons indicating intention to be shot by police
18. Use of trained police negotiators with special training in mental health issues and distinct approaches for mental health crises
19. Both Mental Health Services and AFP ensure accurate knowledge of powers and procedures in emergency detention under mental health law
20. Mental Health Services ensure standardized protocol regulating operation of non-government community agencies providing community-based care
21. Mental Health Services provide funding for adequate training of community workers in non-government agencies
22. Development of accreditation, training and experience standards for persons performing tasks for mentally ill in community
23. Recognition of non-government community agencies role with adequate funding to prevent mental health crisis exacerbation
24. Formation of working party by Mental Health Services with non-government agencies to oversee protocols, training, accreditation and accountability
25. Appropriate funding for non-government community agencies providing mental health care and accommodation
26. AFP ensure written guidance available to officers on discretion to make forcible entry in mental health crisis with emphasis that forced entry does not automatically mean use of lethal force
27. Clear definition of Mental Health Crisis Team role with emphasis on early intervention, community-based assessment and on-spot treatment with hospitalization as last resort
28. Mental Health Crisis Team membership comprised of multi-skilled professionals with turnover from other mental health services