Inquest into the death of Grace
Deceased
Grace
Demographics
13y, female
Date of death
2022-01-28
Finding date
2024-06-27
Cause of death
Self-inflicted single gunshot wound to the chest
AI-generated summary
Grace, 13, died from a self-inflicted gunshot wound using an unsecured .308 Winchester rifle stored in her parents' bedroom. She had disclosed suicidal thoughts to a school counsellor in September 2021, but this disclosure was not adequately responded to. Key clinical lessons include: inadequate suicide risk assessment using unstructured methods without documented frameworks; failure to conduct safety planning or communicate with parents despite suicidal disclosure; poor record-keeping by the school counsellor preventing reliable assessment of the intervention; and lack of access to means discussion. The coroner identified that structured risk assessment tools (similar to NSW policy) and documented safety planning including discussion of firearm access might have identified higher risk and prompted different intervention. School wellbeing systems failed to share critical information between staff.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Unsecured firearms and ammunition in family home
- Inadequate suicide risk assessment by school counsellor
- Failure to conduct safety planning following suicidal disclosure
- Failure to communicate with parents regarding suicidal disclosure
- Poor documentation and record-keeping by school counsellor
- Lack of structured risk assessment tools
- Failure of school wellbeing team to share information about disclosures
- Lack of means discussion (access to firearms)
- Inadequate school policy on response to suicidal disclosures
- Limited engagement with non-English speaking parent
Coroner's recommendations
- Department of Education should ensure appropriate policy, guidelines and training in all schools incorporating best practice following any disclosure of suicidality or suicidal thoughts by a student, including risk assessment, safety planning, follow up or referrals and communication to appropriate persons. Consideration should be given to adopting a policy similar to NSW Management of Suicidality in Students policy
- NT Police embed in appropriate general orders and policy clear directions as to circumstances in which it is mandatory to immediately notify the forensic pathologist of a death and provide opportunity for their attendance at scene in person or via videolink
- NT Police amend appropriate general orders and policy to identify deaths in which police attendance at autopsies is mandatory and provide guidance on any discretion
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