Inquest into the Death of Shaun Andrew WILLIS
Deceased
Shaun Andrew WILLIS
Demographics
54y, male
Date of death
2019-03-08
Finding date
2022-01-17
Cause of death
Ligature compression of the neck (hanging)
AI-generated summary
Shaun Willis, aged 54, died by hanging at his home on 8 March 2019 following a turbulent separation and family violence history. He was arrested on 7 March for assaulted his ex-wife and served with a Family Violence Restraining Order (FVRO), which he breached that same night while intoxicated. After returning home, he died by suicide. Police conducted three welfare checks requested by his partner following his lack of contact, but failed to locate him until the third check on 9 March afternoon. Key clinical lessons include: communication failures (the caller was not updated on welfare check outcomes despite repeated requests), inadequate assessment during welfare checks (neighbours were not spoken to in first two visits), critical risk information (undiagnosed mental health concerns) was not effectively transmitted to frontline officers, and there were no standardised protocols for welfare checks. The coroner found no police action caused or contributed to death, but made recommendations regarding calling cards and neighbour contact during welfare checks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Alcohol intoxication
- Recent arrest and charging with aggravated common assault
- Family Violence Restraining Order served same evening
- Breach of FVRO hours after being served
- Volatile relationship with ex-wife
- History of self-harm threats (not previously acted upon)
- Psychological stress from legal consequences and impact on family
Coroner's recommendations
- When attending the known address of a person the subject of a welfare check, police officers who have not had their door knocks answered should leave a card at the front door explaining the purpose of their attendance and their contact details.
- When attending the known address of a person the subject of a welfare check, police officers who have not had their door knocks answered should, if it is appropriate to do so, speak to neighbours to ascertain the whereabouts of the person.
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