WA coroner makes nine recommendations after finding policeman acted 'too hastily' before shooting JC

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A Western Australian coroner has found the fatal shooting of a woman by police on a Geraldton street was preventable, and has made nine recommendations to prevent a similar outcome in the future.
WARNING: The following story contains discussions of suicidal ideation and the image of an Indigenous person who has died.
The 29-year-old Ngarlawangga Yamatji Martu woman, referred to as JC for cultural reasons, was shot dead by officer Brent Wyndham, after she was recently released from prison and reported to be walking down a suburban street holding a knife in September 2019.
Two years later, Mr Wyndham was acquitted of murder after telling his WA Supreme Court trial he acted in self-defence, believing she was going to stab him before he fired his weapon.
The verdict sparked an outpouring of grief from JC's friends and family as well as the local Indigenous community.
A two-week coronial inquest last year in Geraldton and Perth examined the actions of the eight officers at the scene of the shooting.
The inquest focused on factors including the circumstances of JC's death, the adequacy of WA Police policies and training concerning de-escalation and use of force, and the adequacy of mental health care she received in the weeks prior to her death.
Coroner Ros Fogliani ultimately found JC's death to be a "lawful homicide".
However, she found there were a number of opportunities for police to de-escalate the situation.
Coroner Fogliani said JC's death was preventable, despite it being unknown whether a de-escalation tactic could have prevented the shooting.
The findings detailed how JC had endured a difficult life, which was marred by long-term impacts, with her likely fetal alcohol spectrum disorder contributing to her volatility.
She said JC's social factors became "overwhelming" and contributed to some instances of poor decision-making in her life.
The findings stated JC's homelessness exacerbated her "fragile mental state", leading to suicidal thoughts.
Both the inquest and trial highlighted the significant challenges JC faced accessing effective mental health care, particularly after her return to Geraldton.
She had been diagnosed with antisocial personality disorder and drug induced psychosis by age 20, with an additional diagnosis of schizophrenia made in later years.
But with the bulk of her treatment taking place in Perth, the inquest heard she effectively fell off the radar of local support services after her return to country.
Amongst Ms Fogliani's recommendations is a call for better information sharing between WA's various health services, as well as between health and WA Police, about potentially vulnerable people re-entering the community.
"That she died three weeks after her release from prison ... is very telling," Coroner Fogliani said.
The coroner said Mr Wyndham shot JC within 17 seconds of leaving his vehicle.
"He acted too hastily in running towards the threat posed by JC, not considering communication with the other police officer who was trying to engage with JC and putting himself in a situation where he perceived the need to fire," she said.
Coroner Fogliani said JC's premature death caused immeasurable grief for her family and caused distress for Aboriginal communities.
"It sadly reactivated and magnified the historical mistrust and antipathy that many Aboriginal persons feel towards police officers, for reasons that are well known and deeply embedded in the unfortunate and brutal consequences of colonisation," she said.
The coroner said she was satisfied WA Police missed opportunities to effectively train the attending officers at the incident.
"There were missed opportunities to communicate, which may have avoided JC being approached so quickly," she said.
Coroner Fogliani said she could not exclude JC was having a psychotic episode when she was fatally shot.
"JC fell through the cracks in the system," she said.
The coroner said she was hopeful her recommendations would assist in providing "continuity of care and follow up" when Aboriginal people are removed from Country for treatment.
The findings also included nine recommendations from the coroner, the first being improving relations with Aboriginal communities.
Coroner Fogliani said consideration should be given to establishing a section or branch within WA Police dedicated to improving the relationship between police and Aboriginal people.
Coroner Fogliani recommended WA Police oversee Aboriginal Cultural Awareness training, to be co-designed with and delivered by Indigenous people — on a regular basis.
She asked for the effect of intergenerational trauma, fetal alcohol spectrum disorder, and the importance of cultural wellbeing, to be a focus.
There was a recommendation for six police officers to undergo additional training.
Coroner Fogliani also made a number of recommendations into the treatment of people with mental health issues.
She called for the Department of Health to consult with WA Police, in working on how relevant information, such as mental health conditions can be shared between agencies.
A recommendation was also made for discharging health service providers to consider notifying local health services a patient was returning to Country or an area they habitually reside.