Inquest into the death of WX

54y · Male·gunshot wound to the head

WX, a 54-year-old with longstanding depression, substance abuse (opioids, benzodiazepines), and a 2008 suicide attempt, died by gunshot wound on 27 April 2015. Despite this psychiatric and substance abuse history, he held multiple firearms licences granted after one-hour psychological assessments by a psychologist without prior therapeutic relationship. His mental health and substance abuse deteriorated significantly in the months before death, including recent detoxification, but no periodic review mechanism existed to identify this deterioration. The coroner declined to recommend mandatory periodic medical reviews of licence holders, citing concerns that such a system might deter people with mental health conditions from seeking help from their general practitioner. Key clinical lessons include: (1) brief one-off psychological assessments may inadequately assess ongoing risk in relapsing-remitting conditions; (2) patients with substance use disorders require ongoing monitoring; (3) therapeutic alliance with treating clinicians may be compromised if doctors must report patients to regulatory authorities.