Coronial
NSWhospital

Inquest into the deaths of A D and Aleksander STEFANOVIC

Demographics

unknown

Coroner

Decision ofDeputy State Coroner Lee

Date of death

2020-09-04

Finding date

2022-06-07

Cause of death

Gunshot wound to the head (AD); gunshot wound to the chest (Aleksander Stefanovic)

AI-generated summary

This inquest examined two deaths resulting from gunshot wounds on 4 September 2020. AD, who had a history of mental health struggles including depression and suicidal ideation, shot and fatally injured Aleksander Stefanovic in the chest without warning. AD then shot himself in the head. Despite emergency medical treatment and ICU care including neurosurgery, AD died 2 days later from his injuries. The coroner found Aleksander's death was homicide and AD's death was self-inflicted suicide. Key clinical lessons include the difficulty of predicting suicide risk despite warning signs, and the importance of recognizing behavioural changes (appearing calm after weeks of depression) as potential indicators of completed plans. AD had been prescribed antidepressants by his GP but had not disclosed suicidal ideation during medical consultations, though community members noted concerning symptoms in the weeks preceding the incident.

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

Specialties

general practiceintensive careneurosurgeryforensic medicineemergency medicine

Drugs involved

alprazolamcitalopramdiazepamtelmisartanketamine

Clinical conditions

major depressive disorderanxiety disordersuicidal ideationgunshot woundtraumatic brain injuryintracranial haemorrhage

Procedures

external ventricular drain insertionwound debridementneurosurgeryintubation

Contributing factors

  • mental health deterioration
  • depression
  • suicidal ideation
  • access to firearm
  • lack of disclosure of suicidal thoughts to GP
  • possible poor insight into serious risk despite community concern
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