Finding into death of Peter Harold Ralph Quin-Conroy

Contributing factors

• Failure to communicate firearms license information from GP to psychiatrist
• Chronic schizophrenia with command hallucinations
• Major depression and anxiety disorder
• Firearms licensing regime lacked adequate medical review processes
• No mandatory reporting requirement for health professionals regarding changes in mental health status
• Application process relied on 'honesty system' with self-reporting of mental illness
• No legislative requirement for license holder to notify authorities of changes in medical circumstances
• Variable quality of medical reports for licensing applications

Coroner's recommendations

1. Victoria Police to convene with Department of Health, Royal Australian College of General Practitioners, and Royal Australian and New Zealand College of Psychiatrists to resolve firearms licensing regime issues
2. Implement variable licensing periods for individuals with mental illness
3. Require all applicants for firearm licenses to provide a medical report from a practitioner in an appropriate position to comment on their medical history
4. Attach instructions to license application forms advising practitioners about their roles and responsibilities
5. Establish a medical review panel for applicants identified as potentially unsuitable to hold a license due to mental illness
6. Develop guidelines for general practitioners about when to report concerns of mental illness and implement medical note alerts to remind clinicians that a patient holds a firearms license