Inquest into the death of Ali Antoni EL HAFIANE

Contributing factors

• Inadequate operational planning and contingency planning
• Failure to follow containment and negotiation procedures
• Failure to deploy Tactical Operations Unit in timely manner
• Complex and unreliable communications using multiple radio channels and mobile phones
• Officers unable to identify each other in the field
• Some officers unprepared or unarmed for armed robbery response
• Officers acting independently without notification to commanders
• Senior officers entering premises instead of establishing perimeter
• Inadequate warning given to suspects before shooting
• Assumptions about robbery timing based on past modus operandi

Coroner's recommendations

1. Require clear chain of command with means of communication and identified officers in all Robbery and Serious Crime Squad operational orders
2. Ensure joint planning and briefing when different police units work together on high-risk operations
3. Amend Standard Operating Procedures to include contingency planning, resource assessment, predetermined actions for arrest phases, and guiding principles emphasizing prevention of violence, containment, negotiation, and reasonable opportunity for surrender before use of force
4. Develop simple checklists for situational appreciation and operational orders (modelled on Military Appreciation Process and SMEAC)
5. Amend Standard Operating Procedures to require early deployment of Tactical Operations Unit, prioritize communication interoperability, emphasize containment and negotiation over arrest, establish clear field command authority, and avoid actions placing hostages, civilians, other emergency personnel or police in further danger
6. Conduct policy and procedure analysis similar to NSW Health Root Cause Analysis following critical incidents to identify and rectify latent systems defects