Deficient police planning and poor communications with health staff led to the fatal shooting of a mentally ill man in his View Street apartment, a coroner has found.
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Ian Fackender was 47 years old when he was shot four times by a police officer in the bedroom of his Kelso home.
The long-time schizophrenia sufferer was delusional at the time police entered his home on August 30, 2017, attacking them with a sword before being shot. He died at the scene.
"At the time he was shot, Mr Fackender was acutely psychotic. Mr Fackender was moving towards officers with a large sword when he was shot by the police officer, who acted in defence of himself and another police officer," State Coroner Teresa O'Sullivan wrote in her inquest findings which were released in their entirety on Wednesday morning.
Ian's extended family including his mother, Sue Slatcher, and her husband, Jeremy, father Peter and partner Mavis, his sister, Bronwyn, and other family members all attended the Coroner's Court the day prior to hear the findings.
Given its length (60 pages), Ms O'Sullivan chose not to read out the entire document, but said it would be immediately available to the family, a move which they found upsetting.
Fighting back tears outside the court house, Mrs Slatcher, said it was very disappointing more wasn't mentioned in the court.
She said she would have liked "to hear the Coroner go into things a little bit more, and acknowledge the fact Ian would have been terrified as well".
Mrs Slatcher said she felt what was read out minimised what had happened, but said "her (the Coroner's) tribute to Ian was lovely".
In her written findings, Ms O'Sullivan said when Mr Fackender approached police with his sword, "he would have genuinely thought his life was in danger because of his mental condition".
However, this attack was out of character for Mr Fackender, who was described by family members and neighbours as a warm and gentle soul.
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With seven children, he was diagnosed with schizophrenia in 2002. He was then cared for by his family until he moved to live alone in his Kelso flat.
"The evidence of the inquest made plain that Ian was a warm and generous man, but also one who had suffered as a result of a debilitating mental health condition. Ian's family suffered with him, and their plight is the plight of so many other families who have loved ones who experience mental illness," Ms O'Sullivan wrote.
It was "deeply regrettable" that the officer found himself in a position where he had to fire his weapon at Mr Fackender.
The death might have been avoided had proper police processes been followed, including formulating a proper plan to attend Mr Fackender's home and dealing with the schizophrenic man as a high risk individual.
Police were called to the home after he failed to comply with a community treatment order which required him to take medication at certain times to treat his condition.
He had previously threatened police with a bow and arrow during a home visit in September 2016 after he had failed to medicate and was delusional, barricading himself in his room.
Ms O'Sullivan said police planning around talking with Mr Fackender and entering his home in 2017 was "seriously deficient", underestimated the level of risk and involved virtually no operational planning.
"I find, in accordance with the submissions of Counsel Assisting, that the decision to enter Ian's house was premature, unnecessary and created a dangerous situation for both Ian and the officers who entered," the coroner wrote.
There were many things which could have been done to improve the "seriously flawed" plan in accessing the home, including conducting a full briefing with staff from Bathurst Community Mental Health Services beforehand.
While Mr Fackender's clinicians did their best to provide medical care, there were failures in communications between both the multidisciplinary healthcare team taking care of him, and between medical staff and police, Ms O'Sullivan found.
"The lack of communication about when and how the operation should be carried out was a contributing factor to Ian's tragic death."
The coroner made a number of recommendations, including how NSW Police, NSW Health and NSW Ambulance guidelines operated regarding mental health, and the provision of proper training to local police officers about handling individuals suffering from mental conditions.
The NSW government was also advised to amend the Mental Health Act to be more flexible with urgent situations or matters of public health where police assistance was necessary.
In a statement, NSW Police said it would review the findings and would consider the recommendations.
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