"The following day, however, the mental health worker received a phone call from the patient advising him not to come to his home to keep an appointment because he was going to kill himself."
"The mental health worker went to the patient's home, only to be confronted by the patient holding a gun which was levelled directly at the visitor. The firearm was discharged at a 45 degree angle with the social worker warned to leave."
Paragraph one reads: "A coroner investigating the death of a Taree man has recommended that Australian medical authorities include mandatory training of suicide prevention and crisis management in their training of medical practitioners, so they can effectively and compassionately treat patients with suicidal symptoms."
Coroner's recommendations could have long term ramifications for medical industry
03 May, 2010 11:45 AM
A CORONER investigating the death of a Taree man has recommended that Australian medical authorities include mandatory training of suicide prevention and crisis management in their training of medical practitioners, so they can effectively and compassionately treat patients with suicidal symptoms.
Deputy State coroner Mr Malcolm MacPherson made the recommendation in Taree Coroner's Court after investigating the death of a man in his 30s in a house near Taree in 2007.
His recommendations are expected to have long-term ramifications for the medical industry, the coroner describing general practitioners (GPs) as the 'gatekeepers' of suicide in New South Wales and Australia.
"It is important that GPs be prepared with the necessary skills to provide support when they are confronted with a person who has an immediate and present intention to suicide," Mr MacPherson said.
A Taree GP was the last person to have a conservation with the young man, spending almost 13 minutes on the phone with him just before the patient killed himself with a single gunshot to the head.
Mr MacPherson found the wound was self inflicted with the intention of taking his own life.
The death followed a period of mental health care and treatment for the man lasting several years, during which he made several other suicide attempts, the court was told.
The man died during a police 'lockdown' situation, with the coroner also investigating whether police followed proper procedure, whether their actions and admitted errors had any effect on the death, and whether the police response was appropriate.
In his summing up, Mr MacPherson found police did not have any effect on the man's death, and that their actions were appropriate for the circumstances.
However he made several recommendations about training for medical practitioners dealing with patients experiencing suicidality.
He recommended that the Australian Medical Association and the Royal Australian College of General Practitioners include mandatory training of suicide prevention and crisis management in the regular training of medical practitioners, so that they can effectively and compassionately treat patients experiencing suicidality.
Further, he said this training should be a regular part of general practice professional development and be accredited by an independent body.
Evidence throughout the coronial inquest – firstly in Sydney and later in Taree – was that various people spoke to the deceased in the hours before his death.
In his last conversation, with his GP in Taree, the young man told the doctor he had a gun to his head and that he wanted to shoot himself because everything was going against him and "everything is all going wrong again".
The doctor tried to calm the man, who told him that a short time earlier he had fired a warning shot over a mental health social worker's head when he went to the house.
The doctor admitted during evidence that he had had training throughout his medical course in dealing with people who are suicidal, but that he hadn't any further specific training, nor had he done a course on suicide prevention "or anything like that".
Medical evidence given to the coroner was that suicide prevention training of Australian general practitioners is optional, with no provision for regular refreshers in this training.
The evidence of the Taree GP reflected this, the coroner said.
Another doctor told the inquest "there is a public interest in all general practitioners being literate in suicide prevention, crisis management and actively using documented, standard crisis and wellbeing plans with their patients.
But, "to our best knowledge, this is not widely happening," the doctor said.
"It needs to be dealt with separately with detailed, accredited and repeated suicide prevention, intervention and postvention training, as part of the training programs promoted for example by divisions of general practice, and as part of maintenance of professional standards."
The coroner in his summing up found that many people suffering from mental illness will first consult their general practitioners before possibly being referred to a psychiatrist or psychologist.
"About 60 per cent of persons planning to commit suicide and 20 per cent of those who attempt it use their general practitioners as their primary contact point," Mr MacPherson said.
"Given those close ties that a patient has with his or her family GP at the time of experiencing suicidality, it is not unlikely that the patient may turn to their GP in times of crisis, as this patient did with his (Taree doctor).
"Thus, it is important that general practitioners be prepared with the necessary skills to provide support when they are confronted with a person who has an immediate and present intention to suicide."
He said studies have shown that structured training is required to help GPs be effective in this situation and that their capacity to assist can diminish without regular refresher training.
The inquest heard that police were called to a rural property outside Taree after the deceased had earlier fired a shot over the head of a psychiatric worker from the Taree Community Mental Health Team, who had gone to speak to him.
It heard that police turned away the deceased's mentor – a 'second father' to him – after the incident with the mental health worker.
"It is not the role of the coroner to attribute fault or make findings in relation to negligence or breach of duty of care", Mr MacPherson said as he began his sum
However an important function of an inquest is the making of recommendations, which are necessary or desirable in relation to any matter connected with a death.
"In this way the coronial proceedings can be forward-looking, aiming to prevent future deaths, rather than allocating blame," he said.
"I say this not so much for the benefit of (legal representatives), but more for the benefit of the family of (the deceased), who may not always appreciate and understand the role of a coroner or the coronial inquest."
The court heard the deceased was diagnosed several years earlier with 'depression with psychotic features', and that his symptoms had returned, leading him to what the coroner called 'unravelling' just before his death.
Family members had visited the deceased in the days before his death, and heard he was 'having suicidal thoughts'.
A mental health social worker visited the deceased at his home two days before his death and was told by the patient that his GP had reduced his anti-depressant medication. This was proved in later evidence to have been false.
Consideration was given as to why the patient had become paranoid after several years of being well.
The patient's medication was immediately increased by a doctor, and the next day the patient reported feeling a bit better.
The following day, however, the mental health worker received a phone call from the patient advising him not to come to his home to keep an appointment because he was going to kill himself.
The mental health worker went to the patient's home, only to be confronted by the patient holding a gun which was levelled directly at the visitor. The firearm was discharged at a 45 degree angle with the social worker warned to leave.
Shortly after, the patient called a Taree GP's office and told the receptionist of his intentions.
Police were called and set up a command post a short distance away from the house.
Details of previous attempts at self-harm were given to the court, involving incidents of the man sniffing thinners.
Additionally, the court saw two suicide notes, and heard from witnesses that conversations just before the death indicated the young man was 'saying goodbye'.
It heard of telephone messages just before the death indicating people were "pissing him off" and he'd "had enough of this crap that is going on".
Ballistics experts gave evidence that the firearm – owned by the deceased – did not discharge accidentally.
However the coroner took into account conflicting indications that on the morning of his death, the deceased went shopping and bought normal groceries.
A toxicology report indicated the deceased stopped taking all his medication on the afternoon before his death, but that he had consumed a large amount of alcohol before his death.
The coroner said there was evidence the deceased was probably affected by alcohol at the time he fired the shot near the social worker
and that he consumed vast amounts of alcohol between that incident and his death a short time later.
Fifteen cans of beer were found in the fridge, 69 crushed cans in a wardrobe, cartons of empty beer cans around the property, and one can in front of him.
Mr MacPherson considered whether the deceased took his own life or whether a third party might have been involved.
He came to the conclusion "there is no way anyone could have got through police" and killed the deceased. Further, police entering the building found it locked from the inside, with the keys in the lock.
The absence of DNA or fingerprints on the gun was explained in technical terms as not being unusual.
"Thus the evidence is that overwhelmingly (the deceased) fired the shot that took his life," Mr MacPherson said.
His job, he said, included determination of whether the deceased intended to take his life or whether he was under some form of psychosis at the time.
After hearing evidence from the GP, mental health social worker and another medical specialist, he said he was satisfied the deceased intended the consequences of his action.
To determine why "a talented young man" took his life, Mr MacPherson considered the deceased's heavy drinking and the return of his depression and paranoia.
He determined that his progress with overcoming his depression was continually hampered by his use of alcohol, however he was a "virtual tea-totaller" for several years until beginning to drink heavily again. Evidence was that at the time of his death he had consumed the equivalent of 18 standard drinks.
The court heard the deceased was found to be in possession of scales and needles and what appeared to be weights associated with the use and purchase of amphetamines. Although he had earlier told the social worker he was not abusing amphetamines, and there were no such drugs in his blood, the social worker believed the deceased had returned to the use of amphetamines, which could kick off paranoia.
The court heard details of the deceased's last phone call, to his doctor, the GP telling him he had got well before and could do so again.
The deceased exhibited a sense of hopelessness that getting well again was "all too hard to face", the court heard.
Mr MacPherson said it was "a safe conclusion" that the deceased intentionally misled his family, friends and mental health nurse about having had his medication lowered by a doctor. Reasons could have included that he was keen to deny his own illness or that he wished to become independent of his medication and his illness after years of maintenance.
"He wanted a normal life, without medication and where he could drink," the coroner said. "He had told (his GP) that he had a desire to cut down his medication, however (his GP) resisted this."
The summary of factors, however, led to the conclusion that the deceased had a past history of serious attempts at taking his own life, suffered from severe mental illness, was affected by alcohol on a background of chronic alcohol abuse and amphetamine use. He had access to a firearm and at the time of his death was agitated, paranoid and depressed.
Mr MacPherson said if he found that the deceased died during a police operation then there were consequences, both on the inquest and as to the procedure police should have followed.
Evidence was given that police after being called to the house set up a perimeter some 150 metres away to keep it under constant surveillance.
Police did not hear any gunshot, but it appeared from evidence the deceased was unaware of any police presence, as no sirens were used.
A police investigation team from a separate police Local Area Command found the Critical Incident Investigation had been carried out in a professional manner, the coroner said.
"The police did not have any effect on (the deceased's) death," Mr MacPherson found. "The evidence clearly establishes that he was dead by the time the police commenced surveillance."
Mr MacPherson found the police response was quick and involved good quality police. It was categorised a high risk incident and police made the appropriate response, which was 'contain and negotiate'.
After establishing a perimeter to contain the threat, the plan was to talk to the person and get him to come out without a firearm, Mr MacPherson said. If he tried to crash though a second containment line, police cars were blocking the road.
After police failed to make contact with the man inside, they used phone calls to a loud hailer, making 33 calls or more.
was used, however could not be used until an appropriate vehicle was in place. This took place several hours after the initial operation began, and two hours after that, after still receiving no response, police jemmied open the door and found the man's body.
In total, about eight hours elapsed from the firing of the warning shot at the social worker, to the time police forced their way in to discover the man's body.
Mr MacPherson said in his summing up that police admit they made various errors. They apologised for them to the man's family at the time and again at the inquest.
Police had left a gate open "and as we know in the country you leave gates as you find them because stock can wander", he said.
An electric fence was cut, and an apology was made about that also.
Police acknowledged they did not follow policy which required them to made a formal handover, by checking with the property owner
that all was in order.
Checks of the house the next day also found some important evidence which had not been secured by police.
"Apart from these errors, (an investigating officer) was of the view that the police response was appropriate to the circumstances," Mr MacPherson said.
"Whilst it did take some time for police to finally enter the home I am satisfied that their actions were appropriate in all circumstances."
Mr MacPherson heard that the dead man's mentor/father figure pleaded with police several times to be able to talk to the man. His biological father made similar requests but was stopped by police.
Evidence was given that it is NSW Police policy "not to use third party negotiators because they do not work", he said. An inspector had explained "it doesn't help and sometimes exacerbates the situation".
"In fact neither (the mental health worker) nor more importantly his mentor could talk (the man) out when they tried earlier in the day.
"I am satisfied that the police were not in error in refusing to allow (either the mentor or father) to negotiate with him."
Mr MacPherson completed his summary by extending his sincere sympathies to the family of the young man, and to his mentor, for their sad loss.