Inquest into the deaths of Noah and Wayne Smith

Contributing factors

• Long-standing history of chronic depression and suicidal ideation
• Non-compliance with antidepressant and lithium medication (stopped September 2022 after son's boating injury)
• Accumulated psychosocial stressors: son's boating accident, financial difficulties with boat purchases, work-related stress, marital separation
• Inadequate clinical record-keeping and information sharing between healthcare providers
• Dr H.'s inaccurate medical certificate stating 5 years of stability despite May 2020 mental health crisis and suicide plan
• Dr H.'s failure to obtain full mental health history when conducting firearms licence assessment
• Firearms Registry's inadequate scrutiny of deficient medical evidence when reinstating licence
• Insufficient mental health service infrastructure and availability in rural location
• Failure to escalate deteriorating mental health to acute mental health services in May 2023

Coroner's recommendations

1. Consideration be given to statutory reform enabling amendment of processes within the Firearms Registry so as to require applicants seeking the re-issue of a firearms licence on the basis of recreational hunting/vermin control to demonstrate current permission from a landowner at time of renewal
2. The Firearms Registry additionally consider steps to improve the rigour of the information required in support of an application or reapplication for a firearms licence in reliance upon recreational hunting/vermin control as the genuine reason for the issue of the licence
3. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss how GPs can be encouraged to routinely ask patients if they have a firearms licence (just as they might ask whether patients have a driver's licence)
4. Following the post implementation review into the new Health Risk Assessment Framework, consultation occur with the NSW Ministry of Health, the Royal Australian College of General Practitioners, and other relevant health bodies, to discuss the possibility of introducing a statutory obligation requiring health practitioners to report to Police if they have safety concerns for a patient who is a firearms licence holder
5. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to requiring any applicant for the issue/re-issue of a firearms licence who has experienced suicidal ideation in the previous five years, provide a Mental Health Risk Assessment from two separate assessors (preferably their current treating GP and separately a psychiatrist or psychologist)
6. Following the post implementation review into the new Health Risk Assessment Framework, consideration be given to statutory reform that enables the reassessment of licence holders as an alternative to relying upon the imposition of special conditions to firearms licences
7. Consideration be given to statutory reform enabling the introduction of criteria to demonstrate a 'good reason' to acquire additional firearms