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Finding into death of Justin James Filardo

Deceased

Justin James Filardo

Demographics

45y, male

Coroner

Coroner David Ryan

Date of death

2025-07-30

Finding date

2026-04-14

Cause of death

Gunshot wounds to the head and left shoulder

AI-generated summary

Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clinical knowledge, leading to psychotic deterioration. On 30 July 2025, he attacked Bianca causing severe arm trauma. Police deployed tasers twice but Justin continued assaulting her. After non-lethal options proved ineffective, police discharged 10 rounds, killing him. The coroner found the use of lethal force appropriate and proportionate given the imminent threat to Bianca's life. Clinical lessons include: importance of monitoring medication adherence in community-based antipsychotic treatment, recognising early relapse signs (behaviour change, sleep/hygiene disruption), and the critical role of family communication in mental health crises. Earlier intervention when medication non-compliance was detected might have prevented the acute psychotic episode.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeneral practiceemergency medicineforensic medicine

Error types

systemdelay

Drugs involved

clozapineolanzapine

Clinical conditions

schizophreniapsychosiswithdrawal-associated psychosisviolent behaviour secondary to psychotic episodemedication non-compliance

Contributing factors

  • Non-compliance with clozapine medication
  • Cessation of antipsychotic therapy one to two weeks prior to incident
  • Withdrawal-associated psychosis following medication discontinuation
  • Acute psychotic episode with violent behaviour
  • Failure to detect medication non-compliance in community care
  • Assault on sister Bianca causing life-threatening injury
Full text

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