Police forces across the country claim they've been hard at work training their officers to deal with people who are mentally ill, armed and posing a threat to themselves and the public. But have lessons really been learnt, and is it possible to change a police culture that doesn't admit responsibility when things go wrong?

Adam Salter was a young man with much to live for, with a good job and a loving family. But Adam also had a mental illness. Late in 2009, in the middle of a psychotic episode, Adam tried to kill himself. Showing little regard for his own safety, his father Adrian managed to disarm him, dial emergency assistance and get help. Then the police arrived.

In the moments that followed, police claimed Adam Salter rose from the floor, shrugged off one of the officers present and grabbed a knife they had failed to remove from the scene. Then, according to police, another officer at the house heard the disturbance and rushed through the kitchen door shouting "taser, taser, taser" before shooting Adam Salter dead. In her evidence, Sgt Bissett claimed she believed the seriously wounded man was threatening her fellow police officer. But others on the scene tell a very different story, saying Adam posed no immediate threat. Who's right?

Now reporter Quentin McDermott puts together a forensic account of the events leading to the young man's death and the shooting itself. Using the testimony of family, ambulance officers and interviews with the police themselves, the program examines the mistakes made by the officers and the inconsistencies in their explanations for shooting Adam Salter.

The story of Adam Salter raises many questions, including the issue of how lethal force is used by police. But perhaps the most profound question it raises is: can the police be trusted to investigate themselves?

"Closing Ranks", reported by Quentin McDermott and presented by Kerry O'Brien, goes to air on Monday 5th March at 8.30pm on ABC1. It is replayed on Tuesday 6th March at 11.35pm. You also watch it on ABC News 24 on Saturdays at 8.00pm, on iview or at abc.net.au/4corners.

Transcript

Closing Ranks - 5 March 2012

QUENTIN MCDERMOTT, REPORTER: At 8.39am on Wednesday November the 18th 2009, a distraught father in western Sydney called triple zero.

AMBULANCE EMERGENCY OPERATOR: Ambulance emergency, what's the problem, tell me exactly what's happened.

ADRIAN SALTER. FATHER: Attempted suicide, my son has stuck a knife in his chest, he's lost a lot of blood, he's punctured a lung I think... and he's, he's, he's in a bad way.

QUENTIN MCDERMOTT: At 8.51am, as an ambulance arrived at the scene, police radio issued a call for cars to assist.

POLICE OFFICER (on radio): ...in the vicinity for a self-harm incident. Wangee Road in Lakemba, cross Lakemba Street, 35 year-old male with a self-inflicted stab-wound to the chest.

QUENTIN MCDERMOTT: At two minutes past nine, an officer at the house called for back-up.

POLICE OFFICER II (on radio): Call for urgent further police to this location please.

POLICE OFFICER III (on radio): Copy that.

QUENTIN MCDERMOTT: Something had gone badly wrong, as police and ambulance officers separately reported.

POLICE OFFICER IV (on radio): We've had shots fired from Campsie, 14 shots fired. Campsie cars make your way ASAP.

AMBULANCE OFFICER (on radio): Incident at Lakemba, self-inflicted stab-wound, now it appears that the police may have shot the patient.

QUENTIN MCDERMOTT: The man with the knife was 36 year-old Adam Salter - and he died, not from self-inflicted stab wounds, but from a police bullet. It's a death that should never have happened.

For the first 35 years of his life, Adam Salter showed no sign of mental illness.

ADRIAN SALTER: I guess that what I'd have to say about Adam was that he was a normal kid growing up. He was a 100 per cent mischievous little boy, bright, inquisitive. He looked after his young brother and sister. They always looked up to him.

ZARIN SALTER, SISTER: He was my big brother. I loved him very much, and I miss him a lot. Adam had an incredible sense of love and kindness and compassion for others. He embraced anyone you know that came into his life.

QUENTIN MCDERMOTT: Adam Salter had a passion for the outdoors, with the challenges it brought and the demands it put on him physically.

ZARIN SALTER: He was a rock climber and really fit and agile and he wanted to keep it that way.

QUENTIN MCDERMOTT: But tragically, although his body was fit, his mental state suddenly unravelled. In July 2008, devastated by the break-up of his own marriage and his parents' decision to split up, Adam Salter suffered a psychotic episode. His bizarre behaviour shocked and alarmed his family.

ZARIN SALTER: He was starting to say some strange some of these strange things, and saying that, you know, he thought he was a prophet of God, and had all these divine inspiration and things, and I thought, "No, Adam."

ADRIAN SALTER: I remember him coming home and saying to me, "Dad, have you noticed a lot of P-plates on cars? They seem to be everywhere, P plates." And I thought, well that's a bit funny, but, "No, I haven't noticed them particularly, no more than usual." And then, I think it was the next morning, he went out and started removing P-plates from cars. He believed he was a messenger of God and that "P" stood for "promiscuous", and someone punched him out.

QUENTIN MCDERMOTT: When the police intervened, they found Adam Salter wandering in traffic and, realising he was unwell, took him to hospital.

LYNNE SALTER, MOTHER: In that case the police were very kind and gentle and helped him.

QUENTIN MCDERMOTT: Adam Salter was admitted to Concord's Centre For Mental Health, where he was diagnosed with psychosis and made an involuntary patient.

IAN HICKIE, BRAIN AND MIND RESEARCH INSTITUTE: It's quite clear from the history of this case, including the period of involuntary treatment, that the case was extremely serious. That's like going to intensive care in other aspects of the medical system. That's like requiring very specialised care for cancer. The implications of that are not just for the short term, they're very much for the longer term care.

QUENTIN MCDERMOTT: When he left hospital after three weeks, Adam Salter was prescribed anti-psychotic medication and his care was handed over to his GP and the local Community Mental Health Team.

ADRIAN SALTER: Now it would've been probably three months later - when I realised that nothing was happening - that I phoned Canterbury Mental Health Services and asked what was going on, and explained. And the man I spoke to said, "Oh yes, Adam Salter, we have to do something about that, we will follow it up."

QUENTIN MCDERMOTT: One of Australia's most prominent psychiatrists says that with proper specialist care, Adam Salter's eventual relapse might have been averted.

IAN HICKIE: We don't say to parents of children with leukaemia, "Go to your GP and sort out the next years of... next five years of chemotherapy." We take responsibility in the specialist systems for the complex situations where we have the skills and the knowledge and understanding of the behavioural risks. So, in this case, as in many other cases, when care breaks down, the risk of a tragic outcome is significantly increased.

QUENTIN MCDERMOTT: In Adam Salter's case, the risk was compounded by his own resistance to the idea that he was mentally ill.

LYNNE SALTER: I think he was really embarrassed about the fact that he was suffering from a mental illness.

ZARIN SALTER: I think he thought, you know, I'm fine, I'm fine. What happened then was just a strange time, and probably he believed that it was a one-off as well.

QUENTIN MCDERMOTT: Adam Salter believed he was better. And his career was taking off. In early 2009, his remarkable skills as a software developer were recognised by a creative online company which hired him.

EMANUEL KRASSENSTEIN, FRIEND AND COLLEAGUE: Adam stood out as somebody that was innovative and on the very edge of emerging technology.

QUENTIN MCDERMOTT: Using his considerable programming skills, Adam Salter transformed the popular music subscription service Kazaa into a commercial success.

EMANUEL KRASSENSTEIN: Adam drove that; that was the project he was working on. That, you know, was the... I would say that would be the high point of his career.

QUENTIN MCDERMOTT: Adam Salter was on a roll, and in April 2009 he travelled to Perth for his sister Zarin's wedding.

ZARIN SALTER: He seemed to be doing really well, yeah. He was happy, and at the wedding he just seemed to be, yeah, really, really good, stable. He gave a great speech, cracked a few jokes, tried to take responsibility for getting us together.

ADAM SALTER (speaking at wedding): Apparently he told me that I said to him that, my sister was free! And that's what got him thinking; he came back to Perth, he's like, "Wait a second, she's looking pretty good!" So - and I never say that - I'd like to make that really clear - I don't think I've ever said that before in my life…

QUENTIN MCDERMOTT: But seven months later, the pressures were piling up.

ADRIAN SALTER: Adam was thinking more about his marriage. He, not long before that, received final notice of the divorce, so the divorce certificate came through. It was coming up towards the anniversary of his wedding, and the build-up at work was that there was a lot of pressure on him at work.

QUENTIN MCDERMOTT: Suddenly, his mental condition plummeted. Feeling stressed, he saw his GP, who prescribed him an anti-depressant and advised him to visit a psychiatrist. When he went to work that day, his colleagues were horrified.

EMANUEL KRASSENSTEIN: He didn't make eye contact, he wasn't hungry; he was searching for himself. Couldn't concentrate. So he was kind of like a small piece of the Adam that was there the week before. So that... I've never seen anybody spiral so quickly. He seemed to be choked, and he was fighting it.

QUENTIN MCDERMOTT: That night when he returned home, Adam Salter's father Adrian became seriously concerned.

ADRIAN SALTER: I said, "Hi Adam", and he didn't respond, and I said, "Hi" again, and he didn't respond. And I looked up and he was standing in the one spot, and he didn't seem to be hearing me. And I became concerned then, so I went in and phoned a friend who was a psychiatrist and asked what I should do, and she advised that I take him to hospital. She said that's not... that sounds serious, take him to hospital.

IAN HICKIE: What's clear in this case, as in many cases, is the situation went from relatively stable to unstable very quickly. This situation deteriorated over 24, 48 hours. All there is is a GP response. All there is is a suggestion of getting others involved. I think others gave the correct advice: this person needs to get to a hospital.

ADRIAN SALTER: I resolved to do that. But as soon as I hung up the phone Adam came walking in and seemed okay. He said, "I'll go in the morning, I'd like to stay in my own bed tonight. I'm okay now, I'm fine." And so I didn't push the matter, I didn't push it. In hindsight, obviously I should've.

QUENTIN MCDERMOTT: At 7am on Wednesday November the 18th, Adrian Salter and his son spoke at breakfast. Adam had been given a pamphlet by his GP with a number on it for psychological services. After breakfast, Adrian went into his office to call the number.

ADRIAN SALTER: While I was doing that I heard Adam, I heard sounds from the other room, a sort of cough and gargle, which was... you know, just sounded wrong. And I went out and Adam was putting a knife in his chest. And that was... just a total shock. That... and I said, "Adam, what are you doing? Please don't do this, there's no need for this. Adam, please don't." And Adam, Adam said, "I have to do it, I have to." And I said, "No, Adam, you don't have to." And during this time, I was trying to take the knife away from him, and of course he's stronger than me and bigger, but... and it was a bit of a struggle, and he said, "I don't want to hurt you." So I said, "Adam, what you're doing is hurting me, the... your actions are hurting me, this is very... this is hurting me a lot, please, please stop." And he did then, when I said that. He allowed me to take the knife, and I held him, and I took him in, back into the kitchen and threw the knife in the sink, and sat him on the floor with his back against the cupboard and called triple zero.

AMBULANCE EMERGENCY OPERATOR (on radio): Ambulance emergency, what's the address we're going to?

ADRIAN SALTER: 10 Wangee, Lakemba.

AMBULANCE EMERGENCY OPERATOR (on radio): And what's the problem, tell me exactly what's happened.

ADRIAN SALTER: Attempted suicide, my son has stuck a knife in his chest, he's lost a lot of blood, he's punctured a lung I think, his breathing's... and he's, he's, he's in a bad way.

QUENTIN MCDERMOTT: After calling triple zero, Adrian Salter wedged the front door open with a brick.

ADRIAN SALTER: When I went back, Adam had stood up and he was sort of moving towards the sink where the knife was, and I put my arms around him and I said, "Adam, come on, sit down again." But he seemed to have trouble sitting down. His knees were shaking, and I helped him down. I said, "Adam, just let me support you and go down," which I did, and I had a cushion I put behind him. And I just held him there waiting for the ambulance... um, and he reached up and hugged me and we were sort of... It was a, um... it's funny to say, it was a very special moment, when Adam was hugging me and and I was holding him. Ah, I... (crying) Sorry. And I thought he was going to be okay. I thought this is... the ambulance is coming, Adam will be okay.

QUENTIN MCDERMOTT: At 8.51am, the first paramedics arrived.

ADRIAN SALTER: When the ambos came in and they took over, they clearly knew what they were doing and I thought, oh my son's in safe hands.

QUENTIN MCDERMOTT: But when the police arrived four minutes later, the mood changed.

ADRIAN SALTER: Someone put me in the front room and said, "Stay in there." I'd put my head out around the corner, and have a look to see what was... see how Adam was. And then they'd tell me, "Get back in that room", quite somewhat... quite forcefully, "Get back in that room!"

IAN HICKIE: It's very typical in emergency services and other situations to make a fundamental error, which is to assume "to clear the scene" of the people who may be able to best communicate with the person in the situation. This is where training and understanding and experience matters. Anyone who's worked in the mental health area would understand that what you need are people who are familiar and potentially not threatening, potentially not in uniform, potentially not escalating the situation. People do not understand the extent to which a person in this situation will misinterpret - is already scared, is already terrified of what is happening.

QUENTIN MCDERMOTT: At 8.57am two more police officers arrived at the house, and the mood deteriorated further.

ADRIAN SALTER: They treated the place like it was a bloody crime scene! It was as if... as if there was some criminal, and I thought. well they're treating me like a criminal, and what's happening here?

QUENTIN MCDERMOTT: No crime had been committed, but the police deliberately left the knife in the sink, as if it were a crime scene. Adam Salter was on the kitchen floor nearby being treated by the paramedics. Suddenly, he rose to his feet and moved towards the sink. Seeing this, his father Adrian rushed into the kitchen, to try and stop him reaching the knife.

ADRIAN SALTER: He pushed me aside, and I fell over and got tangled in the leads from some of the equipment, and then he picked up the knife and started stabbing himself in the neck. And then I heard... I was still getting up from where I'd tangled on the floor, and I heard shouting, and I heard someone say, "Taser, taser, taser, taser, taser!" and then I heard a bang, a loud bang. And Adam fell over backwards and I thought... I thought thank God he's been tasered, and he'll be alright.

QUENTIN MCDERMOTT: Tragically, Adrian Salter was wrong on both counts. Far from being tasered, Adam Salter had been shot in the back with a bullet that pierced his heart.

AMBULANCE OPERATOR (on radio): Incident at Lakemba. Self-inflicted stab-wound, now it appears that the police may have shot the patient.

POLICE OFFICER V (on radio): I just want to confirm POI tried to get the knife and was shot by police, is that correct?

POLICE OFFICER VI (on radio): Got the knife radio, got the knife and was coming at us.

QUENTIN MCDERMOTT: In the chaos that followed the shooting of Adam Salter, his father Adrian was taken to hospital, suffering from shock. It was a different hospital to the one his son had been taken to, and for hours no one gave him news of his son.

ADRIAN SALTER: I heard a nurse... nurses talking outside the room. One of them was coming in to check my blood pressure again, and someone said to her, "This is the man whose son was shot and killed by police." And when the nurse came in, I said, "Look, I couldn't help hearing - I heard what was said outside." She said nothing was said. Now... and this was going on, and I said, "Look, I heard it, I know that someone said that my son Adam was shot and killed. Is that true? Just tell me, because that's what I heard." And she rushed out, she didn't say anything, she just rushed out. And about... I don't know, three or four minutes, five minutes later, the detective came in and told me... and said that Adam was dead.

QUENTIN MCDERMOTT: Adrian Salter and his family are horrified by the way he was isolated following the shooting.

ADRIAN SALTER: It seems completely bizarre to me, as the father of someone that they've just shot dead. More detectives then came to the hospital. They said, "We have to take your clothes, because there was blood on my clothes." So they took my clothes, leaving me naked, and I was given a hospital gown to wrap up in.

QUENTIN MCDERMOTT: Shortly afterwards, Adrian Salter was taken to a police station and subjected to a lengthy interview.

ADRIAN SALTER: All this time, my family is waiting. They didn't know where I was, they didn't know what was happening, but this interview went on until six o'clock at night, so here... and Adam died at nine o'clock in the morning. Thinking about it, it's bizarre. Thinking about it, it just... it beggars belief. I can't understand the process. All I can think is the police did not care one bit about me or about my family or about Adam. All they cared about was their own procedure, to follow their procedure and get things right for them.

TAMAR HOPKINS, NATIONAL POLICE ACCOUNTABILITY NETWORK: There's a culture of protection and a culture of support, and you see this in every single report that the police issue about a critical incident. The first thing that the person in charge of an incident will be worried about is the welfare of the police involved. They're not concerned about the person that they killed. They're not concerned about that person's family. Instead, it's the welfare of the police officers. You see that again and again and again.

QUENTIN MCDERMOTT: In the hours that followed the shooting, the police insisted that the use of lethal force against Adam Salter had been justified. And the media reported this.

STUART WILKINS, ASSIST. COMMISSIONER (18 November 2009): We believe he has grabbed a knife from the kitchen and confronted police. During the confrontation that male has been shot once by police.

QUENTIN MCDERMOTT: In its report to the coroner the same day, the police claimed that Adam Salter was "challenged several times by police to drop the knife, refusing to do so. The deceased lunged the knife at police."

STEPHEN RUSHTON, LAWYER FOR THE SALTER FAMILY: That was patently false, and indeed during the course of the inquest I asked some questions of the officer who was... the police officer who was assisting the coroner, Officer Gorman, Virginia Gorman and she conceded that it was untrue.

QUENTIN MCDERMOTT: Stephen Rushton represented Adam Salter's family at the inquest, challenging the police's version of what had happened.

STEPHEN RUSHTON: From that point on, the whole investigation focused and the way it was presented to the outside world through the media, in terms of a mentally ill man who had threatened the police and give them no alternative but to shoot him.

QUENTIN MCDERMOTT: In the critical first 24 hours following the shooting, a succession of false situation reports from senior officers went up the line to the Police Commissioner. On talkback radio the next day, Commissioner Andrew Scipione pledged his support to the officer who had pulled the trigger.

RAY HADLEY, 2GB (during radio interview): We've got seven or eight people there: we've got two ambos, we've got four of your officers, we've got the victim, and we've got the victim's father all in this small area, and it's portrayed to me today by officers that he's lunging a knife at one of those six or seven people. I mean, I am buggered if I know Commissioner what your officers are supposed to do? I mean, the civil libertarians say, "Get the taser out." I mean, you've got a fraction of a second and there's a knife at your throat. What are you supposed to do?

ANDREW SCIPIONE, POLICE COMMISSIONER (during radio interview): You know what you do? You rely on the experience of a very senior officer who's got 21 years on patrol to make the right call.

QUENTIN MCDERMOTT: The officer who made the call to use her firearm was Sergeant Sheree Bissett. She chose not to use her baton, handcuffs, capsicum spray, or taser. Sergeant Bissett had left her most junior colleague - Probationary Constable Aaron Abela - to keep an eye on Adam Salter in the kitchen. In their filmed police interviews, the paramedics gave vivid accounts of what happened when Adam Salter reared up and moved towards the sink.

CHERI LUTZ, PARAMEDIC (during police interview): I don't know if he was intentionally making his way to the sink, but that's where he sort of, he got to the sink and then grabbed the knife and then started stabbing himself in the throat.

MEAGAN COOLAHAN, PARAMEDIC (during police interview): From where I could see he held it like that, and he's just gone in his neck like this.

QUENTIN MCDERMOTT: Crucially, none of the paramedics said they felt their lives were in danger.

CHERI LUTZ (during police interview): It was a threatening, dangerous situation, but I think, I think that, I don't, I think he was just intent on hurting himself. I don't think that he was trying to hurt anyone else there. Like, I didn't want to get anywhere near the guy with a knife like that, but I think he was just more intent on getting that knife and just sinking it into himself, rather than actually hurting anyone.

QUENTIN MCDERMOTT: In walkthroughs filmed twelve days after the event, Sergeant Bissett and Probationary Constable Abela gave graphic descriptions of how Adam Salter was shot.

AARON ABELA, CONSTABLE (during filmed walkthrough): As he got up, I've gone to grab him first, and sort of push him back. Then I've gone for his left... gone to get, get his left arm. So I've pulled him and he's... he was very aggressive. I couldn't, I couldn't pull him back. I was just doing all I could. He's made it obviously with two steps towards that sink area. I was concentrating on him, just using all my energy to pull him back, and obviously my hands was also sliding, with the blood that was on his arms...

QUENTIN MCDERMOTT: Constable Abela's account was flatly contradicted by the senior paramedic treating Adam Salter. She said he didn't move from his original position by the refrigerator.

MEAGAN COOLAHAN (during police interview): There was only one police officer in the room at that stage. He, I believe, responded slowly. He was trying to put his gloves on rather than apprehend the patient.

STEPHEN RUSHTON: Everybody else who was in the room did not see him move away from the refrigerator, which was away from the sink and where he had been standing since he arrived at the scene.

QUENTIN MCDERMOTT: So in your judgement and in the judgement of the coroner, was his account truthful?

STEPHEN RUSHTON: No it it can't be. It can't be, and and indeed the coroner so found.

QUENTIN MCDERMOTT: When Constable Abela failed to act, the paramedics called for help.

MEAGAN COOLAHAN (during police interview): I have yelled for the police outside to, "Come in, come in," with a few more expletives than that. And then the police have raced in. I've seen the female officer, with a weapon drawn, yelling, "Taser, taser, taser." I've seen the other male police officer jump out of the way of the patient, and then a loud bang.

CHERI LUTZ (during police interview): It wasn't like he sort of lunged at anyone or did anything like that. It was almost like he was stabbing, stabbing, bang and then down.

QUENTIN MCDERMOTT: In her own filmed evidence, Sergeant Bissett claimed she fired at Adam Salter because Constable Abela's life was in danger.

SHEREE BISSETT, SERGEANT (during filmed walkthrough): I saw them struggling. He's got the knife in his hand. I thought about going in and grabbing the other side, but then I said, no, it's too dangerous.

RUSSELL OXFORD, DETECTIVE INSPECTER (during filmed walkthrough): Dangerous for who? For yourself, for the other, or anyone else present?

SHEREE BISSETT (during filmed walkthrough): Dangerous for me and anyone present. So I've just drawn my gun, gone, "Taser, taser, taser", and at that stage, he has gone... he has turned like that, and Aaron was a bit more around... like, sort of like that. Bit in, like your body... yeah, like that. And so I shot him here.

RUSSELL OXFORD (during filmed walkthrough): Is there any reason why you yelled taser at the time?

SHEREE BISSETT (during filmed walkthrough): They... they were the words that just came out of my mouth.

RUSSELL OXFORD (during filmed walkthrough): Well it's certainly not the case you pull out and go, "Gun, gun, gun," do you?

SHEREE BISSETT (during filmed walkthrough): No.

RUSSELL OXFORD (during filmed walkthrough): No. Constable Abela was smaller than the man?

SHEREE BISSETT (during filmed walkthrough): Yeah. Yeah. And he... at that stage it, it swung around towards him. So I thought he was gunna stab him and kill him.

QUENTIN MCDERMOTT: At Adam Salter's inquest, the coroner praised his father Adrian Salter as "a most impressive witness, truthful and candid."

(to Adrian Salter) Was Adam attacking Constable Abela?

ADRIAN SALTER: No. Constable Abela was off to one side, nowhere near Adam.

QUENTIN MCDERMOTT: So was Adam struggling with Constable Abela?

ADRIAN SALTER: No.

QUENTIN MCDERMOTT: The most damning evidence that Sergeant Bissett's account of what occurred was untrue came from the clothes that Constable Abela was wearing on the day.

STEPHEN RUSHTON: Now, one would have expected, having regard to the amount of blood which was on Adam's body through self-harm, that if there had been this close contact that Bissett claimed there had been just before she fired the shot, he would have been covered in blood. You look at his shirt and there are some specks down the back, nothing on the front. Not not a bit. And that's inexplicable if what Bissett was saying during her interview was correct. Her account and the account of some of the other officers is at complete odds with the evidence given by the paramedics, and indeed Adam's father Adrian.

QUENTIN MCDERMOTT: So in your view, and in the view of the coroner, was her account truthful?

STEPHEN RUSHTON: No, it wasn't truthful.

QUENTIN MCDERMOTT: This walkthrough interview with Sergeant Bissett formed a key part of the investigation into Adam Salter's death, carried out for the coroner by Homicide Squad detectives. Last year, Sergeant Bissett applied unsuccessfully to stop the ABC broadcasting this footage. But the walkthrough itself, conducted by the head investigator, Detective Inspector Russell Oxford, was criticised by the coroner as a "deeply flawed process".

STEPHEN RUSHTON: Words were put into her mouth. At the time the walkthrough was conducted with Detective Inspector Oxford, he was aware that her version of events was at odds with a number of other witnesses - the ambulance officers and Adrian Salter. None of that was put to her, none of it was raised with her. Rather, he gave the appearance of trying to assist her to come up with reasons why what she was saying was credible.

QUENTIN MCDERMOTT: So, to put it crudely, he was on her side.

STEPHEN RUSHTON: Absolutely. And any fair-minded observer of that interview would come to that view.

RUSSELL OXFORD (during filmed walkthrough): The fact that you said "Taser, taser, taser" is merely a warning to others that you're intending to use a taser?

SHEREE BISSETT (during filmed walkthrough): Yeah.

RUSSELL OXFORD (during filmed walkthrough): And as I said, when you produce your firearm, you don't yell out, "Gun, gun, gun", do you?

SHEREE BISSETT (during filmed walkthrough): No.

RUSSELL OXFORD (during filmed walkthrough): So, it could be the case that by simply giving some, in the, in the, in the... I suppose in the, the timing of all this - it was very traumatic, a very emotionally charged type of incident - you're trying to give some warning to police officers here that you're about to take some action.

SHEREE BISSETT (during filmed walkthrough): Yeah…

RUSSELL OXFORD (during filmed walkthrough): The first thing you thought of was, "Taser, taser, taser."

SHEREE BISSETT (during filmed walkthrough): Yeah.

RUSSELL OXFORD (during filmed walkthrough): OK, 'cause the least you couldn't think of was, "Oh I pulled my gun out, what do I say?" Is that wrong?

SHEREE BISSETT (during filmed walkthrough): Yeah.

RUSSELL OXFORD (during filmed walkthrough): So we just... once you've "Taser, taser, taser", and then you've fired the shot.

SHEREE BISSETT (during filmed walkthrough): Yeah.

RUSSELL OXFORD (during filmed walkthrough): OK.

QUENTIN MCDERMOTT: In his final report for the coroner, Detective Inspector Oxford concluded that Sergeant Bissett was reasonable in her belief that Constable Abela was at immediate risk of death or serious harm.

(to Stephen Rushton) What's your reaction to that conclusion?

STEPHEN RUSHTON: It's a joke. It's a joke. It's entirely inconsistent with the version of events given by all except the officers who were involved. It's nonsense; and what's frightening about this too, Quentin, is this is not a junior officer putting together a report that's unreliable for whatever reason; this fellow was, and presumably still is, a Detective Inspector within the New South Wales Police Force. Indeed, he's the holder of an Australian Police Medal, and if this is an example of good policing, then God help us.

QUENTIN MCDERMOTT: Despite the glaring inconsistencies in the evidence, Detective Inspector Oxford's report was hailed as "an outstanding and thorough investigation" by a fellow police officer who was called on to review it.

(to Stephen Rushton) In your view, did the police deliberately lie? Did they simply invent a scenario that they knew was untrue?

STEPHEN RUSHTON: I believe so. During the inquest I put a submission on behalf of the family that what had occurred following this incident was just a cover-up, a white wash, that the police closed ranks; and rather than, you know, face the embarrassing prospect of saying, "Heavens we stuffed up", a version of events was invented.

QUENTIN MCDERMOTT: Remarkably, the officer reviewing the police investigation recommended that all four officers involved in the fatal incident "receive formal recognition for their actions in the performance of their duties."

ADRIAN SALTER: My first reaction when I heard that was disbelief, and then disgust. I find that suggestion to be abhorrent. And more than that, I believe that it is an insult to Adam's family and to Adam's memory.

QUENTIN MCDERMOTT: The coroner at Adam Salter's inquest concluded that, "At best, the police intervention was an utter failure. Police killed the person they were supposed to be helping." Questions are now being asked about the ability of the New South Wales Police Force to investigate its own officers rigorously and impartially. And there are calls for investigations of police shootings to be conducted independently, as happens in some other countries.

TAMAR HOPKINS: Examples from overseas reveal that non-police are perfectly capable of doing very adequate investigations of deaths in custody. The Police Ombudsman of Northern Ireland is a civilian organisation that investigates deaths in custody, and they pride themselves on getting out there within the golden hour and collecting all of that evidence straight away, and they do so with the faith of the community. The community have much higher faith in these independent investigations than the police conducting their own investigation.

QUENTIN MCDERMOTT: As the police close ranks around Sergeant Bissett and her colleagues, an inquiry has been launched by the Police Integrity Commission into how Adam Salter's death was investigated. The Commissioner, Andrew Scipione, would not be interviewed by Four Corners, citing the PIC investigation.

New research from the Australian Institute of Criminology, soon to be published, will argue that the vast majority of interactions between police and people with a mental illness end constructively. But it will also reveal that 40 per cent of those who have been fatally shot by police since 1990 - including such high-profile cases as Roni Levi, Elijah Holcombe, and Tyler Cassidy - were suffering from a mental illness.

IAN HICKIE: What is entirely predictable in these situations, entirely predictable, is that they will recur. If you do not have the systems in place people will die, and it will mainly be the people with illnesses themselves or their close family members. So, if you look over the last 20 years in Australia, you can find an incident in each state, in each place, in each year, where a coroner does another report, where a police does another report, where there's another state government enquiry. What is entirely predictable is if there is no serious system change to this hard end of the business, these tragedies will recur.

STEPHEN RUSHTON: To Officer Bissett, this man who she shot was nothing more than what she described as "a schedule". Her response was, to this incident, to dehumanise somebody who had a mental illness and treat them in a particular way. I don't know how we overcome that problem - whether it's education, training or the like - but whatever's being done so far quite clearly isn't enough, and unless something is done so that officers better understand how to respond to somebody who is going through a mental crisis, then this is going to happen again. It's happened in the past and it will happen again.

QUENTIN MCDERMOTT: Adam Salter's death was sudden, unexpected and violent. Two years later, Adrian Salter is still struggling to come to terms with what occurred. The family hasn't pushed for Sergeant Bissett to be charged. But they do want an apology.

ADRIAN SALTER: I think it was a terrible mistake. I really, I really believe that she had... I don't know, a rush of blood to the head and didn't know what she was doing, and pulled out the gun instead of the taser. And I don't know why the police can't just say so, and say "Look, we are sorry we killed your son". What's so difficult about that?

QUENTIN MCDERMOTT: So far there is no sign of an apology. In reports on fatal shootings, Adam Salter is just another unfortunate statistic. But for Adam's family and friends, his warmth and humanity will always be a cause for celebration.

ADRIAN SALTER: He was an upstanding, fine member of the community by anyone's estimation. They were... anyone would say, "There's the sort of young man that we'd like to have as a citizen." He had a good job, he was well respected, he got on well with everyone, he was friendly, he had a great sense of humour, he was active and adventurous. He paid his taxes. He paid his debts. So he was looking forward to a productive life and a productive career. So how I remember Adam... yeah, a great mate, a friend, and a son to be proud of.

END

Background Information

NEWS UPDATES

Salter posed no risk to police, paramedic tells inquiry | SMH | 28 Aug 2012 - A paramedic present when police shot dead a mentally ill Sydney man says that, at no stage, did the man pose a threat to anyone other than himself... The commission heard yesterday that officers misled the public and their senior command about the incident, which occurred after Mr Salter, 36, tried to harm himself with a knife.

NSW POLICE RESPONSE

For the Record - A response from NSW Police | 5 Mar 2012 - The NSW Police have responded further to Monday's Four Corners report with a note on their website. Read more.

Statement NSW Police | 1 Mar 2012 - The New South Wales Police sent a statement to Four Corners in response to the report "Closing Ranks". Read the response. [PDF 258Kb]

Read the statement sent by NSW Police in 2009 in response to Quentin McDermott's report "Lethal Force", first broadcast October 2009. [PDF 128Kb]

AIC STATISTICS

Police Shootings Statistics | Australian Institute of Criminology | Mar 2012 - This is a summary of research from the AIC, in advance of their latest report on the National Deaths in Custody Program (NDICP), to be published later this year. [PDF 95Kb]

RELATED NEWS AND COMMENTARY

Shooting deaths spark call for mental health overhaul | ABC News | 5 Mar 2012 -Tragedies like the shooting death of Sydney man Adam Salter will happen again without systemic change to Australia's mental health system, experts say. By Four Corners reporter Quentin McDermott.

Police to revamp training for handling mentally ill | The Age | 25 Feb 2012 - All operational police and new recruits are to receive special coaching to deal with the mentally ill after an internal review found previous training was flawed and increased the risks of violent confrontations.

Adam Salter's death a horrible mistake, coroner says | The Daily Telegraph | 15 Oct 2011 - Police killed a man by mistake, then carried out an inadequate and flawed investigation "to avoid embarrassment" to the force and officers involved, a coroner ruled yesterday.

Police misrepresented shooting, court told | SMH | 1 Oct 2011 - A series of official reports produced after the police shooting of Adam Salter falsely stated the mentally disturbed man had been told by police to drop the knife he was holding before he was shot, leading to accusations in the NSW Coroners Court of a ''monumental police cover-up''.

Shooting inquest finds police inconsistencies | ABC Lateline | 30 Sep 2011 - New South Wales police have rejected suggestions of a gross cover-up over the fatal shooting of Sydney man Adam Salter nearly two years ago.

Suicide by cop | SMH | 23 Mar 2011 - It is, many say, one of the more discomfiting phrases to enter the English language, not to mention the Australian legal lexicon. Suicide by cop: it screams tabloid headline, at once a judgment and a declaration of fact. By Farah Farouque.

Opinion: Poor training and bad tactics to blame for police shootings | The Age | 23 Mar 2011 - Over the past three decades, Victoria has had more fatal police shootings than any other state. This is not because Victorian police are encountering more mentally unwell or dangerous people, but because their training, culture and tactics have not equipped them properly. By Hugh de Kretser.

NSW Police Commissioner Andrew Scipione on Tasers | 2GB Radio | 6 Oct 2010 - Listen to the 2GB inteview with the NSW Police Commissioner Andrew Scipione about the death of a man who was tasered by police.

Two men shot by Melbourne police in less than 24 hours | ABC PM | 2 May 2011 - One man is dead and one is in hospital after two separate police shootings in Victoria. Senior Victorian police have today defended the officers involved in the fatal shooting but debate is raging again over Victoria Police tactics in dangerous confrontations.

KEY REPORTS AND FURTHER READING

Coroner's Report on the Adam Salter Case | Glebe Coroner's Court | 14 Oct 2011 - Read the report of the Deputy State Coroner, Magistrate Scott Mitchell, on his findings in the case of the death of Adam Salter. [PDF 209Kb]

VIC Police Response - Inquest into the death of Tyler Cassidy | Victoria Police | 20 Feb 2012 - Download the response from the Victoria Police to the Coronial findings from the Tyler Cassidy Inquest.

Mental Health and the NSW Police Force |August 2011 - Read about the NSW Police Force's Mental Health Intervention Team training.

Review: Investigating Deaths Associated with Police Contact | OPI | Jun 2011 - In November 2009, the Director, Police Integrity commissioned a review of Victoria Police policy to examine issues to do with the investigation of deaths associated with police contact. The report can be found here.

Submission: Investigation of Deaths Associated with Police Contact: calling for an independent and effective investigation body | CLC | 13 May 2010 - Read the Submission from the Federation of Community Legal Centres, Victoria, to the Office of Police Integrity for their 'Review into Deaths Associated with Police Contact'. [PDF 95Kb]

People Living with Psychotic Illness | Dept Health and Ageing | 2010 - The second national survey of psychotic illness was conducted in 2010 to provide updated estimates of the number of people being treated for psychosis and to determine who these people are, the health services they receive and the impact of these illnesses.

People Living with Psychotic Illness: A SANE Response - SANE Australia is a partner, with the Dept Health and Ageing, in the study and has produced A SANE Response which outlines the findings and outlines the action needed in response to them.

The Impact of the NSW Police Force Mental Health Intervention Team [MHIT] | Charles Sturt University | Dec 2009 - Read the findings of this report from the Charles Sturt University Centre for Inland Health Australian Graduate School of Policing, on the impact of the MHIT program in the NSW Police force. [PDF 916Kb]

An Effective System for Investigating Complaints Against Police | 13 Apr 2009 - A study of human rights compliance in police complaint models in the US, Canada, UK, Northern Ireland and Australia. By Tamar Hopkins, Victorian Law Foundation Community Legal Centre Fellow and Principal Solicitor, Flemington and Kensington Community Legal Centre. [PDF 1.11Mb]

ADVICE AND SUPPORT

The Australian Centre for Grief and Bereavement | 1300 664 786 - A not for profit organisation established to provide a range of education, counselling, research and clinical services for those working in and affected by experiences of grief and bereavement. www.grief.org.au/

The Black Dog Institute - A not-for-profit, educational, research, clinical and community-oriented facility offering specialist expertise in depression and bipolar disorder.

www.blackdoginstitute.org.au/

Beyond Blue | 1300 22 4636 - A national, independent, non-for-profit organisation working to address issues associated with depression, anxiety and related disorders in Australia. www.beyondblue.org/

Just Ask - Lifeline's rural mental health information service. It provides a telephone counselling service and information. www.justask.org.au/

Lifeline | 13 11 14 - Lifeline provide 24-hour telephone counselling services for the cost of local call. They also offer offer face-to-face counselling services in many Lifeline Centres. www.lifeline.org.au/

The Living Is For Everyone (LIFE) - This website is a suicide and self-harm prevention resource managed by Crisis Support Services and funded by the Department of Health and Ageing. www.livingisforeveryone.com.au/

MensLine Australia | 1300 78 99 78 - A dedicated service for men with relationship and family concerns. www.mensline.org.au/

Mental Health First Aid - Mental Health First Aid is the help provided to a person developing a mental health problem or in a mental health crisis. www.mhfa.com.au/

The Mental Health Legal Centre VIC - Provides a free and confidential legal service to anyone who has experienced mental illness in Victoria where their legal problem relates to their mental illness. Tel: 03 9629 4422 or Victorian Country Callers freecall: 1800 555 887. www.communitylaw.org.au/mhlc/

Multicultural Mental Health Australia (MHiMA) - The MHiMA project is funded by the Dept of Health & Ageing and Qld Health to provide a national focus for advice and support to providers and governments on mental health and suicide prevention for people from culturally and linguistically diverse backgrounds. www.mhima.org.au/

R U OK? - An independent, not-for-profit organisation whose purpose is to provide national focus and leadership on suicide prevention by empowering Australians to have open and honest conversations and stay connected with people in their lives. www.ruokday.com.au/

SANE Australia | Helpline 1800 18 SANE (7263) - Information, advice and referral on mental illness. www.sane.org/

Schizophrenia Fellowship of NSW - The Schizophrenia Fellowship is a nonprofit, community based organisation working in the field of mental illness. www.sfnsw.org.au/

Police Accountability Project | Flemington & Kensington Community Legal Centre - In response to the ongoing reports, the Police Issues Working Group of the Federation of Community Legal Centres formed in 1983 to work collectively on the human tragedy these reports represent. Read more. www.communitylaw.org.au/flemingtonkensington/

Police Integrity Commission - PIC's principal functions are to detect, investigate and prevent police misconduct, and as far as practicable, it is required by law to turn its attention to serious police misconduct by NSW police officers. www.pic.nsw.gov.au/

WATCH RELATED FOUR CORNERS

Lethal Force | 26 Oct 2009 - An investigation that asks if police are being adequately trained to deal with potentially violent situations involving mentally ill people. Reporter Quentin McDermott. Flash Video Presentation

Hidden Voices | 9 Aug 2010 - The story of an Australian town that holds a lesson for each and every person who's been touched by mental illness. Reporter Quentin McDermott. Flash Video Presentation