Demographics
51y, male
Date of death
2019-12-09
Finding date
2023-05-10
Cause of death
self-inflicted chest injuries due to gunshot wound to chest
AI-generated summary
A 51-year-old man with a 37-year history of depression and alcoholism died by self-inflicted gunshot wound. He had ceased anti-depressant medication (desvenlafaxine) in September 2019 without documented clinical reason, several months before his death. His depression was not adequately treated, and he consumed large quantities of alcohol regularly. At firearms licence renewal over 22 years, he falsely declared no mental health or alcohol problems. The coroner noted that had Firearms Services sought medical information from his GP, his depression and alcohol abuse would have been revealed, enabling proper risk assessment. The clinical lesson emphasises the importance of: documenting reasons for ceasing psychiatric medication, maintaining continuity of mental health care, and ensuring coordinated communication between mental health providers and other agencies assessing fitness and safety.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
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