Inquest into the death of Courtney Topic

Contributing factors

• undiagnosed schizophrenia and acute psychosis
• failure of responding officers to recognize mental health crisis despite radio broadcasts indicating it
• lack of integration between mental health training and tactical response training
• responding officers took aggressive disarming approach rather than de-escalation
• lack of perimeter preventing public access
• failure to task MHIT-accredited officers as first responders despite protocol
• rapid escalation of force without assessment period
• Taser malfunction due to inadequate battery maintenance

Coroner's recommendations

1. MHIT and WTPR establish and document joint review of training packages for defensive tactics where mental health likely relevant
2. Greater integration of mental health training into tactical options training with emphasis on de-escalation techniques via role play
3. All current Operational Safety instructors complete four-day MHIT training as soon as practicable
4. MHIT and WTPR jointly review international learning on first responder interactions with persons in mental health crisis and design defensive tactics training embodying this learning
5. All police radio and Triple 000 operators undertake MHIT training in recognizing signs of mental health disturbance
6. Develop criteria for police radio operators to identify incidents as possibly involving mental health crisis
7. Develop and implement system to dispatch four-day MHIT accredited officers as first responders in cases meeting mental health crisis criteria
8. Develop mandatory training package for all police officers except commissioned officers and Local Area Commanders on protocol for responding MHIT accredited officers
9. Review four-day MHIT program to include more experiential learning via role play exercises
10. Offer MHIT booster training on one to three year basis