Coroner's Finding: KUSKOFF Alexander Peter

Contributing factors

• undiagnosed psychotic mental illness with paranoid features
• possession of multiple unregistered and registered firearms
• failure of mental health services to directly contact police about firearms and mental health concerns
• lack of liaison between mental health services and police
• firearms check not performed by police communications following 15 September 2015 calls
• no ancillary report filed following 2010 RSPCA incident where Kuskoff had threatened armed action
• police observation position exposed to indiscriminate fire
• rapid succession of three shots with limited opportunity to assess effect of first shot

Coroner's recommendations

1. Chief Executive of Department of Health and Commissioner of Police should discuss and develop strategies to ensure SAPOL are made aware of cases requiring intervention where mental health services have concerns, particularly those involving firearms access. Proper liaison mechanisms should be developed to ensure mental health services directly contact police rather than relying on family members to do so.
2. SAPOL should review its policy regarding centre-mass targeting versus extremity shooting to ensure that in appropriate circumstances, shooting at limbs rather than torso may be considered as a proportionate response to the threat posed, recognizing that while centre-mass may be standard in many situations, there may be circumstances where such targeting results in death when not necessary and reasonable.