Inquest into the death of Matthew Richard Lothian
Deceased
Matthew Richard Lothian
Demographics
37y, male
Coroner
Decision ofState Coroner O'Sullivan
Date of death
2021-01-06
Finding date
2025-09-24
Cause of death
self-inflicted gunshot wound to the head and neck
AI-generated summary
Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predicament. The coroner identified multiple systemic failures: inadequate pre-escort briefings despite policy requirements, confusion regarding restraining belt requirements due to poorly formatted transfer documents, inadequate training of escort officers in relevant policies and legislation, and critically, an unserviceable firearm holster that had been used excessively for weapons training. The holster featured excessive wear, poor retention mechanisms, and should not have been issued for operational use. Additionally, Lothian had sought mental health assistance but declined to sign the CSNSW Psychology Services consent form due to confidentiality concerns; he was not referred to Justice Health as an alternative despite indicating desire for help.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- chronic depressive illness with recent exacerbation
- substance use disorder and drug addiction
- recent assault and facial injuries
- legal predicament with limited prospect of escape
- placement in observation cell following suicide disclosure
- failed psychological intervention due to consent form barriers
- unserviceable firearm holster
- inadequate escape-risk assessment
- lack of pre-escort briefing
- confusion regarding restraining belt requirements
- impulsive decision-making and poor situational awareness
Coroner's recommendations
- Justice Health NSW and Corrective Services NSW consider the benefits of therapeutic psychological services being provided by Justice Health NSW, including how such services would be funded
- That there be an urgent review of the legislation and regulations relating to the use of firearms by officers of Corrective Services New South Wales, and, in particular, cl 299 of the Crimes (Administration of Sentences) Regulation 2014, having regard to the findings in the inquest into the death of Mathew Richard Lothian
- That Corrective Services NSW urgently develop serviceability criteria for the assessment of whether holsters and associated equipment related to the retention of firearms are in a proper operational condition and develop training for correctional officers in the assessment of the condition of that equipment according to that serviceability criteria
- That an urgent audit be undertaken of all armouries to identify and remove any holsters and associated equipment related to the retention of firearms that may not be in proper operational condition
Full text
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