Finding into death of Gabriel Messo

30y · Male·Gunshot wounds to the chest

Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons include: mental health services must be readily accessible despite operational challenges; information handover between mental health and police must be thorough and comprehensive; police s351 transfers require adequate clinical assessment; Emergency Department registrars should have access to comprehensive mental health history (CMI) before making assessment decisions; less-lethal tactical options should be exhausted before using lethal force; and NDIS providers need mandatory reporting obligations and training for identifying risk of harm. Failures included: failure to access available discharge summaries; inadequate police-hospital handover; lack of consideration of alternative tactical options before firearm use; and absence of body-worn camera footage obscuring critical evidence. Gabriel repeatedly sought help days before his death but encountered barriers accessing mental health services, was discharged from hospital prematurely despite recent relapse indicators, and police used lethal force when less-lethal options appeared available.