Finding into death of Mr PNF

Contributing factors

• Police interview regarding child sexual abuse allegations
• Elevated suicide risk in cohort suspected of sexual offences
• Notification of police investigation
• Failure to provide Information and Support Referral brochure
• Inadequate documentation of risk assessment
• Reliance on demeanor as indicator of suicide risk
• Lack of explicit communication to family of heightened suicide risk
• Absence of health-led mental health intervention program

Coroner's recommendations

1. That the Chief Commissioner of Victoria Police consider the implementation of a mandatory requirement that Victoria Police members record contemporaneous (or as close to) notes when they undertake risk assessments pertaining to the wellbeing of individuals suspected of child sexual offences.
2. That the Chief Commissioner of Victoria Police consult with the Office of the Chief Psychiatrist with the view to consider the implementation of a protocol which explicitly advises suspects and/or their families, including their 'nominated support person' (where applicable), of the increased risk of suicide and/or self-harm which affects persons investigated of certain offences and provides information on appropriate referral and escalation avenues to mitigate the same.