Finding into death of Gabriel Messo
Deceased
Gabriel Messo
Demographics
30y, male
Coroner
State Coroner Judge John Cain
Date of death
2020-07-16
Finding date
2022-12-01
Cause of death
Gunshot wounds to the chest
AI-generated summary
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons include: mental health services must be readily accessible despite operational challenges; information handover between mental health and police must be thorough and comprehensive; police s351 transfers require adequate clinical assessment; Emergency Department registrars should have access to comprehensive mental health history (CMI) before making assessment decisions; less-lethal tactical options should be exhausted before using lethal force; and NDIS providers need mandatory reporting obligations and training for identifying risk of harm. Failures included: failure to access available discharge summaries; inadequate police-hospital handover; lack of consideration of alternative tactical options before firearm use; and absence of body-worn camera footage obscuring critical evidence. Gabriel repeatedly sought help days before his death but encountered barriers accessing mental health services, was discharged from hospital prematurely despite recent relapse indicators, and police used lethal force when less-lethal options appeared available.
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Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to adequately access mental health services on 14 July 2020 due to COVID-19 restrictions and/or misunderstanding of protocols
- Withdrawal of urgent referral to acute crisis team on 9 July 2020 with inadequate clinical documentation
- Inadequate handover of information from arresting police to transporting officers regarding circumstances of s351 apprehension
- Inadequate handover of information from police to hospital staff at Royal Melbourne Hospital
- Emergency Department registrar did not access available discharge summary containing relevant mental health history
- Emergency Department registrar did not consult with embedded mental health clinician despite patient having recent mental health history
- Absence of body-worn camera footage by police officers at critical incident
- Police failure to consider and attempt less-lethal tactical options before using lethal force
- Lack of coordination and planning between police officers at the scene
- NDIS support provider (ABC Aged and Disability Services) had no mandatory reporting obligations or training to manage clients expressing self-harm or harm-to-others ideation
- Unmedicated bipolar affective disorder with history of relapses linked to non-compliance
- Recent psychotic symptoms and deteriorating mental state in preceding weeks
Coroner's recommendations
- Chief Commissioner of Police should review feasibility of acquiring automatic body-worn camera activation technology (such as Axon Signal-Sidearm) triggered upon firearm withdrawal from holster
- Victoria Police should undertake further training of members regarding critical importance of thorough handover being provided by Police members to hospital staff on s351 transfers, with focus on ensuring police understand information regarding person's history and circumstances proximate to apprehension is important and relevant to hospital staff
- Melbourne Health/NWAMHS should ensure that clinical information (past medical history, mental health history, recent contacts) are collated and readily accessible to all staff in a single, easily accessible module to facilitate timely assessments
- Royal Melbourne Hospital Emergency Department should review opportunities to utilise embedded Emergency Mental Health clinician more regularly in s351 transfers, particularly where patient has recent mental health history, and consider implementation of mental health navigator role
- Hospital management should implement processes enabling Emergency Mental Health clinician to be consulted early in cases where clinically appropriate
- NDIS Quality and Safeguards Commission should conduct review of outsourcing arrangements to ensure registered NDIS service providers have appropriate policies, guidelines and training for staff to manage clients suffering mental health conditions who make threats of self-harm or harm to others, including identification of deteriorating mental health, concerning behaviours, and guidelines for management, escalation and referral to appropriate services
Full text
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