Errors were made: Shooting death of Courtney Topic by police was preventable, coroner finds
Forty-one seconds. That was the amount of time between police arriving to find Courtney Topic holding a knife near Hungry Jack's at West Hoxton and an officer firing a fatal shot into her chest.
NSW Deputy State Coroner Liz Ryan found Ms Topic's death was preventable as she recommended sweeping improvements to police mental health training, a number of which have been backed by NSW Police Commissioner Mick Fuller.
"Courtney's death is a tragedy ... Errors were made that morning which made the resort to lethal force a tragic inevitability," Ms Ryan said as she delivered inquest findings on Monday.
"Courtney's death is emphatically not one where it can be said, 'This couldn't have been prevented'.
"Her death raises broad issues about how police officers are trained to deal with people suffering a mental health crisis."
Speaking outside the NSW Coroner's Court, Leesa Topic said the Coroner's finding that her daughter's death should not have happened amounted to "justice for Courtney".
"Courtney isn't coming home, and we will live with that forever," she said.
"But we don't want any other family to live with the pain we are living with now. We will take this to our graves."
Her husband Ron Topic said his family had never blamed the police officers involved for their daughter's death.
"If we can stop this ever happening again, we could live with that, that would make her death not in vain."
Ms Topic, 22, was fatally shot in the chest seconds after police arrived to find her wielding a knife at an intersection near Hungry Jack's in West Hoxton on February 10, 2015.
The deputy state coroner found she was likely suffering a psychotic episode due to undiagnosed schizophrenia when she grabbed a knife from home and walked to nearby shops about 11.30am.
Witnesses called police after they saw the woman clutching a kitchen knife in the car park of the fast-food outlet.
Dramatic footage of the incident showed three police officers surrounded her wielding OC spray, a faulty Taser and a gun as they yelled at her to drop the weapon.
She was shot in the chest less than a minute after they arrived.
Ms Ryan said it was probable Courtney was not able to understand that police were telling her to put down the knife.
"Although her death should not have happened, it would be wrong to understate the seriousness of this situation."
While Ms Topic's intentions were unclear, she was moving towards the police officer who shot her and was within two metres of him when he fired his pistol, Ms Ryan said.
"He had reason to believe his life was in danger," she said.
"But that cannot be all.
"If changes are not made, there will be more deaths like Courtney's."
Ms Ryan said the fatal shooting exposed gaps in police mental health training and made 10 recommendations, including a review of the police force's mental health training programs.
She recommended all police radio and triple-0 operators undergo mental health training to help them recognise signs of mental illness, and a system to dispatch officers who had completed a four-day mental health training course as first responders in potential mental health incidents.
The four-day mental health intervention training course should also include more role play exercises and be followed by booster training every couple of years.
In response to Ms Topic's case, a NSW Police spokesman previously told Fairfax Media: "Police often have to make a split-second decision and the impact is long-lasting for family members, the community and police officers.
"[We] recognise this is a challenging space where safety of the community and police are a priority."