The death of Ian Fackender, who was experiencing psychosis when he was shot four times by police in 2017, was "anything but inevitable", a New South Wales coroner has found.
Handing down her findings on Tuesday, State Coroner Teresa O'Sullivan called police's decision to enter Ian Fackender's home in Kelso NSW "premature", "unnecessary" and "dangerous."
The coroner added many steps could have been taken to reduce the risk, and that two officers who entered Mr Fackender's home acted on their own "seriously flawed" plan.
Magistrate O'Sullivan made a number of recommendations, including that a system be introduced where officers with more mental health training are prioritised as police first responders "to mental health incidents".
She also recommended mental health legislation be amended to allow for greater flexibility in responding to patients who need to be located and transported after failing to comply with community treatment.
Police operation 'would have terrified Ian', says coroner
Ian Fackender struggled with the side-effects of his schizophrenia medication and sometimes wouldn't take it.
After he missed an appointment for his monthly dose of medication, police were alerted and were supposed to take him to hospital on August 30, 2017.
Officers arrived at night and were unable to contact Mr Fackender from outside his home.
An inquest heard the senior police officer on the ground sought advice from a superior officer back at the station.
She asked her superior, who had mental health training, to attend the scene. The superior officer didn't.
Police then entered Mr Fackender's home.
The coroner found there was no need to do so, and there were many steps that could have been taken to reduce the risk to Mr Fackender and the officers.
"I hope her recommendations are taken seriously," Mr Fackender's mother Sue Slatcher told 7.30 after the findings were handed down.
When police entered the bedroom, they removed Mr Fackender's doona cover to find the 47-year-old lying in bed listening to loud music through headphones, with a sword.
Ms Slatcher said her son held his Star of David sword when he was unwell.
"I think he just wanted something that he felt would protect him," Ms Slatcher said.
Mr Fackender had intense fears about emergency service sirens.
"Their conduct, in shining a light in Ian's face and shouting 'police', while consistent with their training, would no doubt have terrified Ian given his entrenched fears about police and his mental state at the time," the coroner said.
After initially moving away from officers, Mr Fackender was then shot four times by police as he moved towards them with the sword.
The inquest heard the officer who shot Mr Fackender "feared for his life" when he fired his weapon. An initial tasering had been unsuccessful.
The coroner found entering the home was "unnecessary and inappropriate" and the planning and communication prior to police attending was "seriously deficient."
"It's really hard to think about him dying alone, in the way he did, because it was his worst nightmare, something like that [happening]," Ms Slatcher said.
The coroner noted that Mr Fackender was remembered as a "gentle and loving person" who was "brilliant" with computers.
NSW Police told 7.30 it's reviewing the findings and all recommendations directed to police will be considered.
Damning statistics
Out of 35 people fatally shot by police between 1997 and 2017, at least 19 people — or 54 per cent — had a mental illness.
Former detective Vince Hurley said police often aren't the best equipped to deal with mental health patients, but frequently they're the only ones available.
"I think generally, the police try to do the best job that they can, under the circumstances," Mr Hurley said.
"It's challenging because I don't think there is enough frontline services put into mental health."
Police 'untrained and ill-equipped', father says
Two years after Mr Fackender's death, another man named Todd McKenzie was also fatally shot by police while in the grips of psychosis alone in his home.
Police were called after Mr McKenzie was seen with a knife on his residential street at Taree, on the NSW mid-north coast.
"I didn't worry until I heard the fact that there was a knife — I could see that this thing was going to take on a different dimension," Todd's father Mark McKenzie told 7.30.
"Todd was in his house when police arrived and he had the doors locked."
Todd had been diagnosed with schizophrenia as a teenager and was managing his illness with medication.
Mark McKenzie relayed to police that his son lived with mental illness and sought reassurance they wouldn't break in.
He told 7.30 police reassured him the situation would be resolved "peacefully."
But during a nine-hour stand-off, Mark McKenzie said some police were verbally confrontational with his son.
"Todd was goaded and he was spoken to in a very unprofessional manner by the police," he said.
Like in Ian Fackender's case, police entered Todd McKenzie's home at night.
Officers failed to subdue the 40-year-old with non-lethal methods, before shooting him.
"Within eight seconds he was dead," said Mr McKenzie.
"I don't know that there's ever going to be an adequate explanation as to why he had to be shot three times.
"And I don't think I'll ever get an answer as to why he was shot in the back."
Emergency psychiatrist Dr Jacqui Huber works in the emergency department at St Vincent's Hospital in Sydney and understands some of the difficulties police face in such situations.
She didn't work on either of these cases.
"A person who has severe symptoms in the throes of a crisis, may absolutely believe that these hallucinations are indeed coming from the outside world," Dr Huber told 7.30.
"It's likely that the person who is experiencing overwhelming emotion, especially if they're experiencing symptoms of psychosis, are probably scared. They're probably experiencing symptoms that are frightening them."
Calls for mental health specialists onsite
Mark McKenzie believes an onsite, acute mental health clinician could've saved his son's life.
"They're obviously going to be trained not to confront and they're going to be trained to try and communicate," he said.
"The only way you can deal with someone who's suffering from mental illness is to just navigate them through and to process it with them."
A coronial inquest into Todd McKenzie's death is due next year.
NSW Police told 7.30 it can't comment on a matter before the coroner.
Both families are urging police to work more closely with mental health specialists, particularly in regional areas.
"I definitely think that changes should and can be made," Ms Slatcher said.
"I believe that the regional areas are somewhat left behind as far as caring for mentally ill people.
"I don't think it's the job of [the] police to go out to take a mentally ill person to hospital."
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