Finding into death of GC

42y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 42-year-old male with a long history of schizophrenia and dissocial personality disorder was released from prison in August 2011 without parole conditions. Despite police and forensic mental health concerns about his risk to self and others, he was assessed as not meeting Mental Health Act criteria for involuntary treatment two days before his death. Mental health services attempted limited outreach without success. On 19 January 2012, he presented to hospital with bizarre behaviour including references to being the devil; he was assessed by a mental health nurse and psychiatrist who determined he did not meet involuntary admission criteria and released him pending community follow-up. Two days later, he engaged in erratic driving behaviour that prompted a police pursuit. He entered the Princes Freeway via an exit ramp travelling in the wrong direction at high speed and collided head-on with another vehicle, killing both drivers. The coroner found the clinical decision to release him on 19 January was appropriate and the crisis plan reasonable. However, the coroner was critical of the police pursuit decision-making, particularly continuation beyond the Jane Street lights and entry onto the freeway exit ramp, and recommended reform of pursuit policies.