Inquest into the death of Officer A
Deceased
Officer A
Demographics
43y, female
Date of death
2013-07-03
Finding date
2015-12-18
Cause of death
External neck compression due to self-inflicted hanging
AI-generated summary
A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incident, treating it instead as a recurrence of a pre-existing injury. This failure to investigate meant her condition was not adequately reassessed. She was transferred without proper support person present after a PMO assessment that underestimated her suicide risk by questioning the genuineness of her previous attempt. Key lessons include: all self-harm acts require formal investigation; PMO assessments must consult treating clinicians; support persons must be independent of management; and conflict of interest awareness among senior police is inadequate. The case demonstrates failures in injury management systems, workplace culture issues including inappropriate relationships between supervisors and subordinates, and insufficient safeguards for officers in crisis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- work-related Major Depressive Disorder
- Post-Traumatic Stress Disorder from exposure to traumatic incidents at work
- failure to investigate suicide attempt in November 2012
- failure to reassess mental condition after suicide attempt
- inadequate workplace environment and toxic relationships
- inappropriate relationship with supervisor (Officer B)
- brief affair with colleague (Officer C)
- perfectionist personality
- reluctance to engage with treatment and support
- alcohol use for self-medication
- workplace stress and workload issues
- reduced salary impact from end of income protection scheme
- loss of therapeutic relationship with treating psychiatrist
- flawed Police Medical Officer assessment on 2 July 2013
- immediate transfer decision without adequate support
Coroner's recommendations
- Revise injury management policies to require mandatory P902 reporting and investigation within 24 hours for all suicide or attempted suicide incidents by police officers
- P901/P902 investigation process must include urgent reassessment of diagnosis, treatment, and ongoing management when officer has pre-existing injury
- Conduct psychological injury investigations by independent officers from another unit or command rather than the injured officer's supervisor to avoid conflicts of interest
- Police Medical Officers and psychologists should ordinarily consult with officers' treating clinicians when assessing psychological injuries, with priority given to consultation in self-harm risk cases
- Hold regular case conferences with supervisors, injury management advisers, clinicians, spouses, and support persons to assess progress and identify solutions when engagement in treatment is difficult
- Urgent review and amendment of Conflict of Interest Policy, with training for all senior officers on conflict of interest principles and recognition
- Amend Procedures for Managing Conflicts of Interest to extend beyond domestic relationships to include other ongoing intimate relationships
- Provide training to senior officers on identifying and managing conflicts of interest arising from intimate relationships between officers
- Ensure independent support persons specifically nominated by injured officers are available at decision-making meetings affecting their interests
- Amend Critical Incident Guidelines to remove distinction between service weapon and other methods used in suicide attempts, treating all suicide/attempted suicide incidents equivalently
Full text
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