Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster

Contributing factors

• mental health crisis
• substance use
• hostile presentation with weapons
• rapid incident escalation
• inadequate pre-incident information sharing about mental health history
• lack of de-escalation training
• communication failures between agencies
• replica firearm mistaken for real weapon

Coroner's recommendations

1. Implement incident command training for all operational police below the rank of Sergeant
2. Review Operational Skills and Tactics Training to incorporate training on appropriate radio communication and active listening techniques
3. Revise first aid training policy for operational police to be consistent with Australian Resuscitation Council guidelines regarding bleeding control
4. Continue reviewing methods for reporting use of force to provide accurate data for policy and training
5. Conduct review of how often and in what manner firearms skills should be refreshed through OST training
6. Continue exploring ways to deliver use of force training in low light conditions using dedicated facilities
7. Incorporate 'lessons learned' from previous shootings into scenario-based training
8. Review standing orders governing ESC investigations of critical incidents involving fatality, including: initial short interviews; walk-through interviews; viewing of video recordings; forensic testing within two hours; and separate senior officer oversight
9. Adopt service-wide approach analogous to SERT post-incident support system for officers, with appropriate local adaptations
10. Mandate officers involved in critical incidents involving fatality to attend at least one session with independent psychologist/psychiatrist, with separate review of medium to long-term support mechanisms
11. Develop referral pathways through Victim Assist Queensland for families and witnesses of police shootings
12. Conduct comprehensive review of Mental Health Intervention Project to ensure revitalisation and sustainability, including: full-time dedicated MHICs in each district/region; extended hours for embedded clinicians in Brisbane Communications Centre; dedicated training model; state-wide governance framework; review of co-responder models; embedding mental health training in OST; and appropriate flags in Q-Prime for mental health history
13. Amend Chapter 6 of OPM so that police are not required to subjectively assess whether incident is a 'mental health incident' and are encouraged to call for mental health assistance
14. Retain mental health training as core component of Recruit and First Year Constable Training Programmes
15. Continue allocating funds to body worn camera rollout to enable all frontline officers to be equipped with technology
16. Consider whether scheme for regulation of replica firearms with linkages to QPS intelligence should be established, having regard to interstate legislation
17. Continue providing SERT officers with training in negotiation and de-escalation skills for siege situations
18. Continue examining ways to deal with threats from nuisance calls with focus on improving communication training for call takers regarding callers with mental illness and/or cognitive impairment
19. Incorporate options for dealing with nuisance callers in standing instructions and mandatory training, including early diversion to PoliceLink, interrogation of Q-Prime for mental health history, local supervisor discretion, engagement of embedded mental health clinicians, and engagement of negotiators