Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4



I, Rodney Eric Chandler, Coroner, having investigated a death.






That the deceased, aged in his 40’s died  in  2005 at the Launceston General Hospital (“LGH”) at Launceston in Tasmania as a result of a self inflicted injury.




An investigation was undertaken into the circumstances leading to the deceased’s  death.  By that investigation it was established that:


  • In  2004, the deceased’s employment was terminated after almost 10 years service.  Shortage of work was the reason given for the termination.
  • The deceased made application to the Tasmanian Industrial Commission for payment of pro rata long service leave which his employer had refused to pay.  In May 2005 the Commission ordered the employer to pay the deceased  his entitlement.  However, this sum was not paid, presumably because the employer had been placed in administration and did not have the funds.
  • Some time in 2004 the deceased  secured employment but in November 2004 he resigned to take up a new position.  According to his wife, the deceased  regretted leaving his previous position
  • In early 2005 the deceased began to experience stomach pains and was having difficulty sleeping.
  • The deceased consulted Dr Richard Ayling, his general medical practitioner.  He was referred to a gastroenterologist who diagnosed duodenitis after a gastroscopy.  This condition was successfully treated with antibiotics.
  • In April 2005 the deceased consulted Dr Julie Ostberg, a member of the same medical practice as Dr Ayling.  At this consultation he complained of insomnia and palpitations.  He told Dr Ostberg that he had some stresses at work.  Specifically, he denied depression.  The deceased  was prescribed Temaze, an anti anxiety medication.  An electro-cardiogram showed no abnormality. 
  • In  May 2005 the deceased  attended at the Department of Emergency Medicine at the LGH.  He was seen by Dr Helen Kasby.  The case notes made by Dr Kasby report that the deceased presented with 6 months of depressive/anxiety-like symptoms.  A letter subsequently written by Dr Kasby to Dr Ayling sets out her account of the attendance and its outcome.  The letter states as follows:


(“the deceased) presented to the Emergency Department at (LGH) in  May 2005.  The presenting problem was UNABLE TO SLEEP.


The diagnosis was DEPRESSIVE EPISODE.

Thank you for following up in the care of the deceased who presented to the Department with 4-6 month history of what sounds like anxiety and depression.


At the time of presentation he was teary, poorly communicative – refusing to maintain eye contact, of low mood, with inability to sleep.  He wasn’t able to remember the last time he enjoyed himself.


The Mental Health team reviewed him and suggested the commencement of an anti-depressant with a few days Chlorpromazine for sleep.  He seemed pre-occupied at the time with self loathing over “impure thoughts” but was unable to elaborate.  I understand he is also a devout born again Christian and feels there may be conflict in the Church regarding him taking medications.


He was preferring you to keep in touch with him rather than the Mental Health team”.


  • In June the deceased revisited Dr Ayling.  He reported that he was depressed, tense and sleeping poorly.  Dr Ayling observed that the deceased  was agitated and appeared depressed in that he was teary, had low mood and was pessimistic in his conversation.  Dr Ayling prescribed the anti depressant Luvox.  
  • On a public holiday in June the deceased’s wife  was very concerned about the mental state of her husband on this day. She stated that “he was sitting in his chair rocking back and forth with his head in his hands, in utter despair and hopelessness”.  She called the Pastor  who came to the home.  Through a common friend they enquired whether a bed was available in Ward 1E at LGH.  (Ward 1E is a ward at the LGH dedicated to the in-patient treatment of psychiatric patients).  They were informed that a bed was available and that the deceased could be accommodated.  Arrangements were then made to transport the deceased to the LGH.  He was accompanied by his wife.  They arrived in the hospital’s Department of Emergency Medicine at 5.11 pm.
  • At 6.00 pm the deceased was attended by Dr Daniel Orr.  At this time Dr Orr was working in the Emergency Department as an intern.  He was under the supervision of Dr Bradley Dick, an Emergency Department Registrar.  Dr Orr did not have any specific qualifications in psychiatry but had received some tuition in basic psychiatric assessments as part of his under-graduate training.  He had previously undertaken approximately six psychiatric assessments whilst working in the Emergency Department.
  • The deceased gave a history to Dr Orr of increasing non specific anxiety over the previous few days.  This was associated with increasingly poor sleep and appetite, with some episodes of panic-like attacks.  He said that he was worried about not being able to obtain employment and had financial concerns that he could not support his family.  He was also concerned that his partner might leave him. 
  • Dr Orr’s examination showed the deceased  to be mildly agitated.  He appeared anxious and was unable to maintain eye contact.  His blood pressure was 117/70 with a pulse of 108 bpm.  His respiratory rate was 26/min.  Dr Orr considered these signs to be consistent with an general anxiety.
  • Dr Orr was unable to formulate a precise diagnosis.  He felt that the deceased showed clinical signs of a high level of anxiety.  He considered that there was some features of depression, including low mood, decreased appetite, poor concentration and poor sleep patterns.  Dr Orr asked the deceased specifically whether he had any thoughts or intentions of a suicidal nature and he specifically denied this.  Dr Orr did not recommend any specific treatment.  He discussed the deceased with Dr Dick who agreed to review him.
  • It was Dr Dick’s memory (he did not make any note in the hospital records of his attendance upon the deceased) that two issues arose at the time of his review.  The first concerned the deceased’s  medication.  Dr Dick understood that the deceased was taking nocturnally a dose of an anti depressant which, in the opinion of Dr Dick, would either cause or aggravate insomnia.  As this was one of the deceased’s  presenting symptoms Dr Dick recommended that he begin taking the anti depressant in the morning rather than in the evening.  The second issue concerned follow up arrangements.  It was apparently Dr Dick’s recollection that the deceased’s wife advised that a follow up had been pre-arranged in several days, although he was unsure whether it was to be with the general practitioner or with the Community Mental Health Service.  Apparently, because this was in place Dr Dick did not provide a referral for the deceased to attend for follow up with a psychologist or psychiatrist.  It was Dr Dick’s recollection that the deceased’s wife was satisfied with this plan.  It was in these circumstances that the deceased was then sent home without being admitted to Ward 1E. 
  • The deceased’s wife  reports that Dr Dick, at the meeting with him stated that he would make a follow up telephone call to the couple  the following day to check on the deceased’s condition.  This call was not made.
  • The deceased  next attended Dr Ayling in June.  On this occasion Dr Ayling recorded that the deceased  “felt much better” but that he was still having difficulty sleeping.  He was advised to continue taking the Temaze and Luvox as previously prescribed.  In Dr Ayling’s opinion the anti-depressant effect of the Luvox was the same, whether it was taken in the morning or in the evening.  In his view it was more appropriate that it be taken at night as this took advantage of the medication’s common side effect of drowsiness and would thus help the deceased  with his sleeping difficulty.  Dr Ayling noted that the manufacturer of Luvox recommends in its instructional information that the medication be taken in the evening except where large doses are necessary and then it is recommended that it be taken in two divided doses, one in the morning and the other in the evening.
  • Over the following week the deceased  continued to be psychologically fragile.  He suffered another panic attack.  However, further medical intervention was not sought.  The next morning he appeared happier and in a more normal state of mind but his mental state seemed to worsen as the day progressed. 
  • The following day the deceased visited his brother.   The deceased’s brother observed that his brother appeared anxious and was “pacing back and forth.” 
  • His brother had been preparing to go wallaby shooting that evening.  He had taken his rifle from the gun safe.  The deceased pressed his brother to let him have a shot with the rifle there and then.  His brother could see that there was a neighbour working in the paddock nearby and he considered that shooting with the rifle would be too dangerous.  He said that the deceased could instead use an air rifle.  However, the deceased kept pestering his brother to let him use the rifle. His brother could see that the deceased was in an anxious state and appeared obsessed about using the rifle.  He would not permit him to do so.  His brother took the rifle and put it in a bedroom cupboard out of sight.  The deceased was with him when he did this. His brother then returned to the paddock to resume some tractor work.  He noticed the deceased leaving the property. 
  • On the Saturday afternoon the deceased was at home with his wife and children.  She felt that he was “acting very strange”.  She went outside to check on him.  She found him under the house.  He was acting suspiciously.  She then noticed his brother’s rifle at the doorway.  His wife then telephoned the Police and the Pastor arrived.  Shortly afterwards officers from both Tasmania Police and the Ambulance Service arrived at the  deceased’s  home.  It was evident that the deceased had shot himself with the rifle.  He was conveyed to the LGH but he died of his wounds.




I am satisfied that there are not any suspicious circumstances surrounding this death.  I am also satisfied that the deceased died from injuries caused by a self-inflicted gunshot wound to the head. 


It is apparent upon the evidence which I have set out above, that the deceased’s mental health had been deteriorating, at least since late 2004, and that this deterioration was accelerating from April 2005.  The deceased’s general practitioner elected to treat his condition with medication and it seems did not, at any time, refer him for counselling support or for psychiatric assessment.  The deceased’s  illness reached a watershed on a Monday in June when his wife and friends were so concerned by his condition that they took him to the LGH, this time with the expectation that he would be admitted to Ward 1E for psychiatric treatment. 


In my opinion, the LGH did not, on this day serve the deceased well.  I do not make any criticism of Dr Orr.  He was a junior doctor with no specialised psychiatric training and only modest experience in the assessment of psychiatrically ill patients.  He quite properly, after carrying out an apparently thorough and properly documented assessment, referred the deceased to his supervisor, Dr Dick.  It was at this point that the standard of medical care provided to the deceased did, in my opinion, fall short of that standard which could reasonably be expected.


The history would have made it apparent to Dr Dick that the deceased had been ill for an extended period, that he had been consulting his general practitioner for over seven weeks, that his illness had caused him to attend the LGH previously, that his medication regime was not alleviating his symptoms and that, in Dr Orr’s opinion, he was exhibiting a high level of anxiety with some features of depression (although he denied any suicidal thoughts).  Given these matters it was not in my view an adequate response to simply refer the deceased back to his general practitioner (whose treatment to that point had been largely ineffective) with the sole suggestion that his insomnia (which was only one of the presenting symptoms) may be better managed if his anti depressant was taken in the mornings rather than the evenings.  Rather, the deceased should have, in my view, been referred for psychiatric review by a psychiatrist attached to ward 1E.  One could expect that such specialist review would have led to the proper diagnosis of the deceased’s illness and a more comprehensive plan being put in place for its management.  Such a management plan may or may not have required the deceased’s hospital admission. 


It does not follow that had the deceased been managed by LGH in the manner that I am suggesting that his tragic death occurring 12 days later would have been avoided.  However, the risk of such a tragic outcome would, in my view, have been significantly reduced if his attendance at the LGH on this day had led to the involvement of a psychiatrist in his care. 


I make these recommendations:


  • That the LGH consider reviewing its processes for the handling of mentally ill patients by its Department of Emergency Medicine with particular consideration being given to the adoption of protocols which better ensure that decisions upon the ongoing management of such patients are taken by staff psychiatrists rather than by personnel trained in emergency medicine. 


  • That the LGH put in place processes to ensure that the medical staff in its Department of Emergency Medicine maintain proper written records of the treatment and care provided to all patients.


I make this final observation.  The deceased was able to gain access to his brother’s rifle because it was not securely locked in a gun safe.  This case should serve as a reminder to all firearm owners of the need to ensure that their weapons, when not being used by themselves, are kept in a locked, purpose-built gun safe. 



I conclude these findings by conveying my sincere condolences to the deceased’s family  



Dated the 28th day of January 2008. 



Rodney Eric Chandler