Instead of guiding Todd McKenzie through his mental health crisis, police launched a flawed operation that aggravated the situation and led to a fatal confrontation.
But Mr McKenzie is far from the only person with mental health needs to be killed by police and a coroner says law enforcement must re-examine its approach.
NSW Police were called to the state's mid-north coast on July 31, 2019, after the 40-year-old was seen with a knife and making threatening comments to neighbours during a schizophrenic episode.
They laid siege to his Taree home for nine hours, surrounding the premises before using less lethal weapons and then shooting him three times when he allegedly ran at police.
After years of delay caused by the COVID-19 pandemic and attempts by NSW Police to suppress tactical information, Deputy State Coroner Harriet Grahame finally handed down her 270-page report on Friday.
"When tactical police broke the window and broke into his home, disaster was sure to follow," she told the Coroner's Court of NSW.
"Todd was not the only person who has been killed during police operations ... in my view, it is time to grapple with these issues away from individual deaths."
The coroner took the extraordinary step of sending her report directly to NSW Police Minister Yasmin Catley and Mental Health Minister Rose Jackson in a push for change.
A NSW Police spokesperson told AAP the force has noted the coroner's findings and "a comprehensive review of the findings will be undertaken and any recommendations that are directed to police will be considered".
Mr McKenzie's death is one in a string of recent cases involving deadly police interactions with civilians during mental health episodes.
In September, 47-year-old Krista Kach died after being tasered and hit with a bean-bag round following a 10-hour standoff with police in Newcastle.
Four months before that, 95-year-old Clare Nowland died after police tasered her at a Cooma nursing home.
The coroner noted policies put officers under pressure and stress but recommended a review and audit of NSW Police's mental health training within two years, to ensure adequate and regular instruction to officers of all ranks.
She also called for a whole of government summit that brings together police, health experts, those with mental health needs and their families.
But National Justice Project solicitors George Newhouse and Karina Hawtrey, who represented Mr McKenzie's family, say you "can't train a culture of command and control out of the police".
"Instead of seeing Todd as a person, they criminalised him," Mr Newhouse said.
June and Neil Wilkins, Mr McKenzie's mother and stepfather, paid tribute to their son outside court, remembering him as an avid animal-lover, drummer and painter.
"Todd was a beloved son, he was beautiful, he was artistic, he was musical," Mr Wilkins told reporters.
"What Todd needed was medical attention and a kind and gentle word from his family.
"Instead, he got the full weight of a siege set up by NSW Police."
They maintain police had not been held to account and urged NSW Police Commissioner Karen Webb to meet with them, acknowledge the force's failings and change their procedures.
NSW Greens MP Sue Higginson has called on the premier to step up.
"There can be no more political gambits while the lives of vulnerable people are on the line - we need real change and we need it now," she said.
But Mr McKenzie's father Mark has concerns about whether NSW Police has the capacity for change.
"It's been five years but, if anything, the culture of the police force is worse," he told AAP.
"Steps need to be taken to take police out of these situations and put specialists in place."
As the family left court for what they hoped would be the last time, the back of their shirts read, "nobody deserves to die just because they're unable to comply".
Lifeline 13 11 14
beyondblue 1300 22 4636
