Inquest into the Death of Desmond Edward JACK
Deceased
Desmond Edward JACK
Demographics
33y, male
Date of death
2019-03-28
Finding date
2022-06-09
Cause of death
Gunshot injury to the anterior trunk (chest and upper abdomen)
AI-generated summary
Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 March 2019. Jack had deteriorated significantly over preceding days despite engagement with mental health services; he had refused voluntary hospital admission despite his mother's concerns. When police attended, Jack emerged from his residence armed with an 18cm knife, made stabbing motions toward the officer, and advanced despite repeated commands to stop. The officer, positioned in a confined space with limited tactical options and no backup immediately available, discharged his firearm once in self-defence when Jack was 2-3 metres away. The coroner found the shooting justified and appropriate. Clinical lessons include the importance of timely risk review at mental health services, documented follow-up plans after crisis calls, and earlier consideration of involuntary detention under mental health legislation when there are clear safety concerns despite family ambivalence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- severe psychotic episode due to bipolar affective disorder
- medication non-compliance
- acute mental health deterioration not reviewed at risk meeting
- absence of involuntary detention despite escalating risk
- recent use of cannabis and methylamphetamine
- mental health service in rural area with limited crisis response capacity
Coroner's recommendations
- Continuation and expansion of Mental Health Co-Response (MHCR) model, noting it is resource-constrained and unable to serve rural areas like Mooliabeenee due to limited Authorised Mental Health Practitioners
- Continued expansion of MHCR to regional areas beyond current coverage (Geraldton and Bunbury) when resources permit
- Continuation of mental health training for operational police officers including the CS5 course introduced in January 2021
- Continuation of body-worn camera rollout for all operational police officers to provide independent evidence during mental health crisis incidents
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