In the matter of three deaths of AFP appointees in the Australian Capital TerritoryInquest into the Death of Richard RobertsInquest into the Death of Samantha BaglinInquest into the Death of Dominic Coleman

Contributing factors

• untreated mental illness at time of death
• inadequate Change of Health Notification Form (COHNF) system
• workplace stigma preventing disclosure of mental health issues
• ambiguous COHNF criteria not explicitly requiring mental health disclosure
• lack of mandatory psychological assessment in operational safety qualification process
• inadequate armoury access controls outside core business hours
• inadequate standardised procedures for Air Security Officer firearm storage
• absence of temporary firearms access removal during periods of leave
• lack of mental health screening integration with firearm access decisions
• poor integration and resourcing of mental health support services
• AFP mental health clinicians lacked appropriate security clearances

Coroner's recommendations

1. The AFP should simplify COHNF submission requirements to remove ambiguity, mandating submission whenever an AFP appointee is diagnosed with or treated for mental health conditions, rather than requiring judgment about whether submission is required.
2. The AFP should amend CO3 to explicitly reference the requirement to submit a COHNF, the ability of AFP Chief Medical Officer or Principal Psychologist or manager to direct submission, and the obligation to participate in regular mental health review processes as part of the framework for safe use of force.
3. The AFP should incorporate into CO3 provision for temporary removal of access to AFP equipment, including firearms, for periods when an appointee will not or should not be required to use it, such as approved leave periods.
4. The AFP should consider ways to use existing paid leave entitlements to allow supervisors or managers to require appointees not to attend work due to concerns about wellbeing or fitness for work, without stigma.
5. The AFP should progress its review of viability of increasing security clearance levels for a significant percentage of mental health clinicians and contracted psychologists to enable discussion of classified or sensitive material affecting treatment.