GH, an Iranian national on a permanent protection visa, died from a self-inflicted gunshot wound at a shooting range during an unlicensed 'try shooting' session. He had documented suicidal ideation for years and attempted suicide previously in Iran. In April 2015, GH's friend Mr Hashemi emailed the range warning they should not allow GH access to firearms due to depression and suicidal intent. The range apparently did not act on this warning. Two years later, despite this prior knowledge, GH was permitted to participate in another try shooting session and gained access to an unsecured pistol. The coroner found systemic failures: no alert system linking intelligence between clubs and the Firearms Registry; inadequate P650 form verification; and unethical access to unsecured firearms. Clinical lessons include the critical importance of integrating mental health risk information into firearms access decisions, improving communication between healthcare/community sources and regulatory bodies, and implementing physical safety barriers (tethering systems) when access cannot be prevented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Failure of shooting range to act on warning email from friend about suicidal intent
Lack of communication between shooting range and Firearms Registry
No alert system linking intelligence received by shooting clubs to Firearms Registry
Inadequate P650 form verification procedures
P650 form did not specifically ask about suicide attempts or self-harm history
Unsecured firearm permitted in unlicensed shooting session
Lack of database cross-checking at shooting range to identify flagged persons
No Registry oversight of unlicensed shooters accessing firearms via try shooting courses
Coroner's recommendations
Refer proposed recommendations to the Firearms Registry Review (McKechnie Review) for consideration
That the Commissioner of Police consider developing and maintaining at the Firearms Registry an alert system linking pieces of intelligence received by shooting clubs
That amendments to clauses 101 and 104 of the Firearms Regulation 2017 be considered to extend obligations to unlicensed persons not club members who apply for try shooting courses
That the Commissioner of Police consider imposing conditions on all approved shooting ranges permitting unlicensed persons to use firearms, requiring pistols to be securely tethered to prevent turning toward the shooter or others, with exemption only for approved pistol club members who have completed safety training
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