Inquest into the death of Jacob Carr

53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exsanguination

Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr brandished a loaded shotgun and attempted to fire at police at close range (approximately 5 metres). A police officer discharged his firearm in defence, striking Mr Carr in the leg. Paramedics applied a tourniquet to control bleeding, but it subsequently failed during transport, resulting in catastrophic secondary haemorrhage. Clinical lessons include: the tourniquet failure appears related to either patient manipulation or equipment issues with the MAT tourniquet model then in use; ambulance protocols should ensure constant visual monitoring of tourniquets without covering them; and the failure to urgently transition from the problematic MAT to the superior SOFTT-W device contributed to the risk environment, despite management awareness of multiple prior failures.