NSWcommunity

Inquest into the death of MC

Demographics

45y, male

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2015-03-01

Finding date

2017-08-17

Cause of death

gunshot wound to the chest

AI-generated summary

A man with a long history of depression, suicide attempts, and previous violent behaviour died when shot by police during an arrest for domestic violence. His partner had repeatedly warned police that he threatened to make police shoot him, but this warning was not adequately conveyed to or taken seriously by the responding officers. The coroner found the death was self-inflicted in the sense of deliberate conduct intended to provoke a lethal police response ('suicide by cop'). Critical failures included: the senior officer discounting the partner's warning about the man's intent to provoke police shooting; failure to share this warning with other officers; inadequate planning before approaching the house; and failure to appreciate the specific risk that the man was attempting to provoke a lethal response. The shooting itself was tactically justified given the immediate threat posed by the man running at an officer with two knives, but earlier information-gathering and planning could have changed the outcome.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeneral practiceemergency medicineparamedicine

Error types

communicationdiagnosticsystem

Clinical conditions

persistent disabling personality disordermajor depressionsuicidal ideationdifficulty with emotional regulation and aggression control

Contributing factors

untreated or poorly managed personality disorder and depression
non-compliance with antidepressant medication
lack of engagement with mental health services
escalating suicidal ideation and intent to provoke lethal police response
domestic violence incident triggering police response
failure of senior officer to recognise significance of warning about risk of provocation
failure to communicate critical warning to other officers
inadequate planning and information-sharing before arrest approach
complacency about prior police warnings recorded on COPS system
lack of time for conflict resolution once suspect emerged with weapons

Coroner's recommendations

That the NSW Police Force consider using the circumstances of the death of MC as a guide for future training to highlight the risks arising from a person who intends to use police to commit self-harm
The coroner noted that targeted training should be developed so that police will be more aware of the possibility that a distressed person may be acting to provoke a lethal response and that any warnings received regarding this type of threat need to be taken extremely seriously
The coroner urged the NSW Police to review the Victorian Police's specific training package designed to assist police in identifying and diffusing situations of potential 'suicide by cop'

Full text

Official source Archived copy

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Source and disclaimer

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