Inquest into the death of Todd McKenzie
Deceased
Todd McKenzie
Demographics
40y, male
Date of death
2019-07-31
Finding date
2024-04-05
Cause of death
gunshot wounds
AI-generated summary
Todd McKenzie, a 40-year-old man with treatment-resistant schizophrenia, died of gunshot wounds after a nine-hour police siege at his Taree home on 31 July 2019. Todd became acutely psychotic, waving a knife and expressing paranoid delusions about people entering his home and police weapons being 'disarmed'. Police pursued a breach-and-hold tactic—smashing windows and ramming doors—despite negotiation teams being present and no immediate threat to public safety. The coroner found this tactical approach was misconceived and almost certainly destined to produce violent confrontation. Critical clinical lessons include: early mental health assessment and family consultation were inadequate; a consultant psychiatrist should have been engaged; less-lethal options were compromised by environmental constraints and Todd's severe psychosis; and de-escalation through rapport-building failed due to confrontational early police engagement by an untrained general duties officer. The coroner emphasized that Todd's severe mental illness meant he could not rationally respond to overwhelming police force, and that mental health expertise was insufficient in decision-making.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- acute psychotic episode with paranoid delusions
- inadequate early mental health assessment
- failure to consult treating clinician or family effectively
- confrontational informal negotiation by untrained general duties officer
- inappropriate challenge to delusions causing agitation and disengagement
- inadequate consideration of consultant psychiatrist input
- breach-and-hold tactic executed prematurely without sufficient alternatives explored
- inadequate consultation with family despite their expertise
- limited information sharing between responding teams
- reliance on tactical solution despite negotiation being possible
Coroner's recommendations
- Tactical police should be required to wear body-worn video
- A review and audit of mental health training be undertaken within two years to ensure that adequate and regular mental health training is being provided to NSWPF officers of all ranks
- The Commissioner consider updating the NSW Police Force's 'Standard Operating Procedure – Negotiation Unit, Counter-Terrorism and Special Tactics Command' to include an additional paragraph requiring consideration of consulting a consultant psychiatrist about possible responses and consequences of effecting a breach and hold against someone suffering a mental health episode such as psychosis where there are otherwise no immediate risks
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