Coroner's Finding: de-identified YZ
Demographics
59y, male
Date of death
2023-07-04
Finding date
2025-05-06
Cause of death
Shotgun wound to the head
AI-generated summary
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate medication management and psychological support. However, none of his treating clinicians enquired about access to firearms or reported his mental condition to police under the Firearms Act 1996, despite him holding a firearms licence and possessing a shotgun. He died by self-inflicted gunshot wound on 4-5 July 2023. Clinicians managing patients with suicidal thoughts should routinely assess for firearm access and understand their mandatory reporting obligations under firearms legislation. Coordinating care between multiple providers and proactively exploring means of suicide during risk assessments are essential safeguards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Workplace shoulder injury leading to anxiety and loss of purpose
- Untreated suicidal ideation
- Failure to enquire about access to firearms by treating clinicians
- Failure to report mental condition to police under Firearms Act 1996
- Treatment fragmentation across multiple general practices
- Patient non-disclosure of firearm access to psychologist and doctors
- Lack of proactive exploration of means of suicide in risk assessments
Coroner's recommendations
- Health practitioners should routinely enquire about accessibility of firearms in patients expressing suicidal ideation
- Health practitioners should be reminded of their reporting obligations under the Firearms Act 1996 when patients with mental illness possess or use firearms in an unsafe manner
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