Finding into death of X Y

Contributing factors

• Undiagnosed and untreated mental health condition, likely psychotic disorder with persecutory delusions
• COVID-19 pandemic as significant adverse psychological trigger
• Childhood trauma and domestic violence exposure
• Stress from mother's mental health decline and care responsibilities
• Marriage separation
• Loss of employment due to lockdown
• Failure to broadcast information about knife to attending police officers
• Ambiguous CAD entry by call-taker regarding knife
• Dispatcher's human error in omitting to review and broadcast weapon information
• Brief negotiation period insufficient to resolve mental health crisis
• Unexpected failure of beanbag rounds to incapacitate subject

Coroner's recommendations

1. ESTA to implement training for call takers regarding contextualised information and accurate recording of weapon information in CAD
2. ESTA to implement training for dispatchers emphasizing importance of reviewing comments for and communicating critical information such as weapons
3. ESTA CAD enhancements to automatically highlight critical words (e.g. 'knife', 'aggressive') in bold and colour
4. ESTA call takers to have capacity to mark comments as critical, resulting in bold display with red hazard symbol or exclamation mark system
5. Chief Commissioner to review training regarding beanbag shotgun efficacy to remove ambiguity about its effectiveness as a tactical option
6. Chief Commissioner to ensure all members informed and trained regarding compliance with new CCI 01/22 on witness statements and body-worn camera viewing procedures