Police made multiple errors when they shot and killed a 22-year-old woman suffering a “severe episode of psychosis”, the New South Wales coroner has found.

Courtney Topic was shot within 41 seconds of police arriving after she was spotted holding a kitchen knife in the car park of a Hungry Jacks in western Sydney in February 2015.

On Monday, the coroner found police tactics were “entirely inappropriate” and her death exposed a “compelling need for change” in the way police dealt with mentally ill people.

Topic was shot on 10 February after she left her home carrying a large kitchen knife. Police radio said she was visibly “distressed”, “hitting herself in the head” and pointing the knife at herself in the carpark of the fast-food outlet in West Hoxton.

Three officers arrived on the scene, pointed their weapons at her, and told her to drop her knife, but she did not respond. Topic was then pepper sprayed, and shot by Senior Constable Ethan Tesoriero after she moved towards him.

Another officer, Constable Angela Tyson, had previously attempted to shoot Topic with a taser, but it malfunctioned due to battery degradation and damaged cartridges.

Deputy NSW state coroner Elizabeth Ryan found that Topic’s death was preventable, and raised “broad issues about how police officers are trained to deal with people suffering a mental health crisis”.

“The NSW Police Force understands that responding to people in mental health crisis can be difficult,” she wrote. “But Courtney’s inquest has exposed gaps in the way these processes work.”

Between 1989 and 2011, 42% of the people shot by police were suffering from a mental illness.

Since 2013, all NSW police officers have been required to complete a one-day mental health training program in identifying the signs of mental illness and de-escalating situations.

A more extensive four-day program exists but is optional, and has been completed by 2,500 officers. None of the officers present when Topic was shot had completed the four-day course.

Sydney woman Courtney Topic, who was shot dead after coming toward police with a large kitchen knife in a fast-food restaurant’s car park at West Hoxton in western Sydney. Photograph: Nsw Police/PR IMAGE

The coroner found the officers’ attempts to disarm Topic were “entirely inappropriate” and they should have tried other means to persuade her to drop her weapon.



However, she ruled the officers did not breach police procedure for use of force by drawing their weapons, and that Tesoriero had a reasonable basis for believing his life was in danger when he shot Topic.

The coroner’s inquiry heard Topic was suffering from undiagnosed schizophrenia, including paranoid episodes, and was probably suffering a severe episode of psychosis at the time.



Described as a “gentle-natured young woman”, she had never previously displayed aggressive or antisocial behaviour. “For reasons we will never know, [that morning] she took with her a large knife from the kitchen ... Courtney had never done anything like this before,” the coroner wrote.

She recommended NSW Police consider making the four-day training mandatory for more officers, or that if it is clear that a person is suffering a mental health episode, those with the four-day training be prioritised for dispatch.

Outside court, Topic’s parents Leesa and Ron said they had never blamed the police and were pleased with the coroner’s mental health training recommendations.



“Don’t remember her as a statistic, she is not a statistic she is my beautiful girl, who I just want to hold and hug and I’ll never ever be able to do that again,” her distraught mother told reporters.



“We just hope she is remembered for the beautiful soul she is and if something positive can come out of this so no other family has to live this heartache, then we’ll be grateful for that.”

NSW Police told the inquiry they have plans to have all frontline officers undertake the four-day program.

The officer who received the initial 000 call about Topic said she flagged it as a potential mental health episode in an attempt to dispatch an officer who had completed the four-day training.

Constable Grace Beasant wrote that observers were “concerned that she is MH [mental health issues] and going to hurt herself”, and gave it an incident header of “Concern 4 welfare”.

• In Australia, the crisis support service Lifeline is 13 11 14. In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. Other international suicide helplines can be found at www.befrienders.org