Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predicament. The coroner identified multiple systemic failures: inadequate pre-escort briefings despite policy requirements, confusion regarding restraining belt requirements due to poorly formatted transfer documents, inadequate training of escort officers in relevant policies and legislation, and critically, an unserviceable firearm holster that had been used excessively for weapons training. The holster featured excessive wear, poor retention mechanisms, and should not have been issued for operational use. Additionally, Lothian had sought mental health assistance but declined to sign the CSNSW Psychology Services consent form due to confidentiality concerns; he was not referred to Justice Health as an alternative despite indicating desire for help.