Inquest into the death of Ian Fackender

Contributing factors

• Inadequate risk assessment and planning by police before the operation
• Poor communication between Bathurst Community Mental Health Services and NSW Police regarding the sword possession
• Failure to inform police that mental health staff intended to accompany police for the breach order execution
• Premature and unnecessary decision to enter the unit without containment or communication attempts
• Conflicting understanding of entry plan among police officers; lack of clear briefing on arrival at the scene
• Absence of mental health worker or family member at the scene to assist de-escalation
• Absence of Senior Constable Towns' supervisor (Sgt Shoulders, the most experienced MHIT-trained officer) who did not attend in person
• Miscommunication from senior officers that conveyed sense of urgency and that entry was required without specialist support
• Absence of ambulance and NSW Ambulance despite guidelines recommending their presence
• Inadequate training of general duties officers regarding Community Treatment Order procedures and the Memorandum of Understanding
• Shortages of psychiatrists in Western NSW Local Health District affecting frequency of psychiatric review
• Limited handover from previous case manager RN Mooney to RN Day regarding Ian's case
• Ian's deterioration not detected until late in August despite history of rapid decline

Coroner's recommendations

1. NSW Police Force: Re-introduce MARIA guidelines from 2007 MOU into current MOU with express guidance on risk assessment for CTO breach orders, accounting for limited after-hours mental health services
2. NSW Police Force: Provide practical guidance to general duties officers on interaction between risk assessment section, ANZPAA guidelines, and search warrant procedures
3. NSW Police Force: Engage experienced forensic psychiatrist within 6 months to review Weapons and Tactics training curriculum and integrate mental health considerations
4. Chifley Police Area Command: Implement system to prioritize MHIT-trained officers as responders to mental health incidents
5. Chifley Police Area Command: Introduce operational SOPs for radio use or reinforce radio as primary communication device between officers
6. NSW Health, NSW Ambulance, NSW Police Force: Comprehensively review and revise 2018 MOU to include section on CTOs and breach orders covering: handover requirements, locating responsibility, ambulance contact protocols, applicable legislation and policies, firearms use guidance, after-hours resources, and use of PACER and MHIT officers
7. NSW Health, NSW Ambulance, NSW Police Force: Develop section on handover/information exchange between police and mental health staff with risk assessment tool covering violent history, weapon possession, delusions, compliance, de-escalation techniques, and family contact details
8. NSW Health: Review nature and layout of Breach Orders under s.58 Mental Health Act to ensure guidance regarding relevant MOU is provided
9. NSW Health: Review pro forma terms of CTO Treatment Plans
10. NSW Attorney General: Consider modifying s.58 Mental Health Act for more flexible service methods where patient is not contactable but clinical urgency exists
11. NSW Attorney General: Ensure any reform to s.58 safeguards rights, dignity and use of restraint as last resort
12. NSW Attorney General: Remove word 'apprehend' from s.59 Mental Health Act