Inquest into the death of MC
Demographics
45y, male
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.
Error types
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'
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