Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of  Coroners Act 1995

I, Glenn Hay, Coroner, having investigated a death of

Mr P


Find That :

(a)                The deceased (“Mr P”) died between 6 and 7 November  2009 at his residence in Southern, Tasmania.  

(b)                Mr P was born in Hobart.  He was married and worked in his own business.  He had three children and a stepson. 

(c)                Mr P died as a result of a shotgun wound consistent with suicide. 


Mr P lived at home with his wife,and his three children. Mr P and his wife married in 2003 after being together in a de facto relationship for about ten years. Mr P built the family home after the birth of his first child and the family have resided there since 1996. Mr P worked in partnership with his brother in their own business as painters and decorators. The business was successful and very busy, took a lot of his time and employed up to four people, some of those in a full-time capacity. Mr P’s stepson, had moved from the family some weeks prior to Mr P’s death.

Mr P was a loving husband and father, and brought up his stepson as his own child. He was well liked socially, although was quite reserved.

There is evidence Mr P seemed to struggle with relating to the two older boys when they became teenagers, and arguments between himself and his wife seemed based on this together with his belief relating to her infidelity and her possible loss of money through gambling.

During the twelve months prior to his death Mr P became more reserved and began to consume alcohol more heavily. Arguments with Mrs P also seemed to escalate.

In about July 2008 Mr and Mrs P argued and as a result Mr P disappeared for two days without anybody knowing where he had gone, but he called each of his children to say goodbye as he was not coming home anymore.

Mr P had been a smoker for many years however about five weeks prior to his death he tried to quit and obtained a prescription for Varenicline tartrate or ‘Champix’ to assist him with this. He had not smoked for seven weeks prior to his death. Mr P’s wife noticed he became more irritable, aggressive, and difficult to get along with once he had given up smoking and began taking the medication. She also noticed that alcohol seemed to affect him more than usual. Mr P’s mother also noticed Mr P was complaining this medication was making him ‘feel queer’. She tried to persuade him to give the medication away, but he would not listen.


On Friday 6 November 2009 Mr P went to work at 7:00am. During the late afternoon Mrs P received a mobile call from Mr P while she was out thought he sounded "crabby". In the early evening Mr P again appeared agitated and he left the home after an argument.

About forty minutes later at 7:30pm, he returned home where the family was having dinner. Mr P became increasingly agitated and angry towards his wife, seemingly because she was not home when he arrived earlier. There was a further argument about him driving after drinking alcohol and Mr P again left the house. The arguments continued on and off for a few hours and at 9.45pm Mrs P took the children to her mother’s home. At that time Mr P stated to his wife that if she left she would never see him again.

Early the next morning Mr P’s mother went to his home and looked for him in the house as it was unlocked, and around the property with no success.

About 8.40am on 7 November 2009 Mrs P returned to her home and checked the garden shed and saw the gun safe was open and saw her husband’s legs prone on the floor. She called emergency services and the deceased’s mother. As a result Mr M (mother’s partner) went to Mr P’s home just prior to 10:00am and found Mr P on the floor of the shed with a shotgun beside him. Ambulance Tasmania arrived a few minutes later and observed Mr M enter and exit the shed. The paramedic attending observed the deceased lying on the floor, apparently deceased from head wounds. Tasmania Police seized the firearm.

A post mortem examination established the cause of death as a partial contact range shotgun wound in the mouth.

Toxicological analysis showed that the deceased had a highly elevated blood alcohol concentration of .204 g/100mL. This is a high concentration and consequently there would have been a loss of critical judgement, loss of coordination and decreased intellectual performance. Paracetamol was detected but no other common drugs were found. Varenicline is not targeted in the general drug screening and in fact there are currently no laboratories in Australia testing for it.

Conclusions, Findings, Comments and Recommendations:

A very thorough investigation of the death has been conducted by Tasmania Police CIB and its Ballistic Services personnel. The position of the shotgun was consistent with having fallen from the deceased’s grip after discharge. There were no signs of struggle or other violence to suggest anyone other than Mr P had discharged the shotgun. The position of Mr P within the shed, the position of the shotgun, the trajectory of the shot and the proximity of the weapon at discharge are consistent with him having been seated under a bench and discharging the weapon himself.

The enigmatic and somewhat puzzling factor in the circumstances of this death is that when first observed by attending and investigating police officers the safety catch of the shotgun was found in the ‘safe’ position. The safety catch of this weapon would normally be found in the ‘fire’ position as it does not without further intervention or act, automatically go to ‘safety’ position upon discharge. Mr P would not have had the capacity to place the safety on following discharge of the shotgun due to the severity of the brain injury probably giving rise to instantaneous death.

The only conclusion I can draw from all of the evidence is that some person unknown has touched the shotgun after the death occurred and rendered it ‘safe’. All relevant investigations have failed to disclose who may have done so and consequently when and for what purpose. From all available information it is not an indicator of foul play.

It is the experience of the Tasmania Police Ballistic Services witness in relation to firearm related suicides, that occasionally relatives or others close to the deceased may touch or move the relevant firearm when found and for unknown reasons may not admit to this or in their state of shock may not have any recollection of such actions being carried out. In my view it is also a possibility but less likely, that emergency services personnel may automatically as a result of their training render a weapon safe and as a result not necessarily recall having done so. These possible explanations cannot be ruled out and in all the circumstances of this case are the only likely possibilities. Despite this enigma I find that there were no suspicious circumstances in the death of Mr P.

Mr P had been prescribed and was taking Varenicline tartrate or ‘Champix’ anti-smoking medication about five weeks prior to his death. At the time of prescription his general practitioner supplied him with a ‘Patient education leaflet – 05. Smoking – quitting printed’ and discussed with him ‘tips for quitting with champix – take with food, aware of side effects; also having date set; faimly (sic) and friends aware’. He returned to his general practitioner on 30 October and her notes include ‘hasn’t smoked since - even been to pub with boys and not had any!!!’.

There is no evidence Mr P had any clinical mental health history or sought any advice in relation to possible mental health issues or availed himself of professional counselling for these issues, but it is clear from all the evidence and with the benefit of hindsight that he had indicators of such issues. It would seem Mr P had not disclosed to his general practitioner that he - was drinking heavily; had had possible suicidal ideations; had what in retrospect may be seen as anxiety type symptoms; was arguing with his wife; or was having any difficulty with the cessation of smoking.

However, Mr P had complained to his mother that he ‘felt queer’ while he was taking Varenicline. She has reported she had tried to persuade him to get off the medication, but he did not listen to her. She also reports that four days prior to his death Mr P requested his sister to look on the computer in relation to the side effects of the medication. His wife noticed him to be more irritable, aggressive and difficult to get along with while taking the medication.

Varenicline tartrate (Champix) is produced and distributed by Pfizer Australia Pty Ltd. That company publishes product information in relation to that medication, including the results of clinical trial study tests. Important extracts from the publication are;_

  • Smoking cessation, with or without pharmacotherapy, has been associated with the exacerbation of underlying psychiatric illness (e.g. depression). Care should be taken with patients with a history of psychiatric illness and patients should be advised accordingly.
  • Psychiatric symptoms
    Serious neuropsychiatric symptoms have occurred in patients being treated with Champix. Some cases may have been complicated by the symptoms of nicotine withdrawal in patients who stopped smoking; however, some of these symptoms have occurred in patients who continued to smoke. Although a causal association between Champix and these symptoms has not been established, in some reports the association cannot be excluded. Patients being treated with Champix and their families should be alerted to the need to monitor for neuropsychiatric symptoms including changes in behaviour of thinking, anxiety, psychosis, mood swings, agitation, aggression, depressed mood, suicidal ideation and suicidal behaviour. Doctors should discuss the efficacy and safety profile of Champix with patients attempting to quit smoking with Champix and advise them of the possible emergence of neuropsychiatric symptoms. These symptoms, as well as worsening of pre-existing psychiatric illness, have been reported in patients attempting to quit smoking while taking Champix in the postmarketing experience. Patients and their families should be advised that the patient should stop taking Champix and contact a healthcare professional immediately if changes in behavior or thinking, agitation or depressed mood that are not typical for the patient are observed, or if the patient develops suicidal ideation or suicidal behaviour. In many postmarketing cases, resolution of symptoms after discontinuation of varenicline was reported, although in some cases the symptoms persisted; therefore, ongoing follow-up should be provided until symptoms resolve. Patients and their families should be encouraged to report any history of psychiatric illness prior to initiating treatment. Patients with serious psychiatric illness such as schizophrenia, bipolar disorder and major depressive disorder did not participate in the premarketing studies of Champix and the study and efficacy of Champix in such patients has not been established.
  • Adverse Reactions
    Smoking cessation with or without treatment is associated with various symptoms. For example, dysphonic or depressed mood; insomnia; irritability; frustration or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; increased appetite or weight gain have been reported in patients attempting to stop smoking. No attempt has been made in either the design or the analysis of the Champix studies to distinguish between adverse events associated with study drug treatment or those possibly associated with nicotine withdrawal.
  • Psychiatric disorders
    Uncommon: panic reaction, bradyphrenia, thinking abnormal, mood swings.
  • Postmarketing experience
    The following adverse events have been reported during post approval use of Champix. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
    There have been reports of neuropsychiatric symptoms such as depressed mood, agitation, hallucinations, changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, suicidal ideation and suicide in patients attempting to quit smoking while taking Champix. Smoking cessation with or without treatments is associated with nicotine withdrawal symptoms and the exacerbation of underlying psychiatric illness. Not all patients have known pre-existing psychiatric illness and not all had discontinued smoking. The role of Champix in these reports is not known (see precautions).

    There have also been reports of hypersensitivity effects, such as angioedema and of rare but severe cutaneous reactions, including Stevens-Johnson syndrome and erythema multiforme in patients taking Champix (see precautions).

It is clear that medical practitioners who prescribe Varenicline must take particular note of any neuropsychiatric indicators in patients and provide clear advice with careful follow-up. There is nothing to suggest Mr P’s general practitioner did not do so in his case.

What is clear is that Mr P did not adequately disclose important indicators and while it is impossible to say whether any such disclosures would have made a difference in his case and it is also impossible to say that his ingestion of Varenicline was a direct causal link in his death, there is sufficient connection for me to place warnings before the community to be generally aware of the side-effects and any contra-indicators when taking or considering the taking of medication such as Varenicline and to disclose to their medical practitioners any relevant background information. It is also important for patients to stop taking Champix and contact their healthcare professional immediately if changes in behavior or thinking, agitation or depressed mood that are not typical for the patient are observed, or if the patient develops suicidal ideation or suicidal behaviour.

I am satisfied that a thorough and detailed investigation has occurred into the death of Mr P, and that there are no suspicious circumstances. There was no suicide note found after investigation. However, given the circumstances surrounding his death as noted above especially the likelihood of his depressed state of mind, I further find it likely that Mr P intended to take his own life by the deliberate act of discharging a weapon at himself, and that there is no evidence that he was assisted by any person to do so.

On the information available I am satisfied Mr P, while affected by alcohol, discharged a firearm at himself causing death. I find that this was a deliberate act sadly undertaken by Mr P with the express intention of ending his life. The side effects of the prescription anti-smoking drug Varenicline tartrate, combined with alcohol and probable smoking withdrawal symptoms cannot be excluded from contributing to his death.

Mr P died between the 6 and 7 November 2009 at his residence in Southern Tasmania.

DATED : Friday 11 March 2011 at Hobart in Tasmania.  

Glenn Hay