Coronial Inquest Examines Fatal Police Shooting of Man With Schizophrenia

Three years ago, Judy Deacon’s son was fatally shot dead by police after he was reported to be self-harming. She has since become one of the state’s loudest voices for change in how police respond to mental health incidents.

Over the past week, in the long-awaited coronial inquest, answers to lingering questions over decisions made in the lead-up to 43-year-old Jesse Deacon’s death started to crystallise as health workers, police, and the officer who fired the fatal shot, took the witness stand.

They all eventually fronted 82-year-old Judy, who forewent legal aid in favour of asking the witnesses questions herself. When she came face to face with the officer who shot her son, she asked, in a calm tone largely maintained throughout the inquest: What could be done to stop such deaths from happening again?

“I think [the mental health systems] in place aren’t perfect. I’m not sure how to make it perfect,” responded the officer, whose identity is suppressed.

“I’m not sure if there will ever be a stage where the police will have received enough training, enough education.”

No warning of mental health history

The inquest, which is before deputy state coroner David O’Neil, will provide recommendations in an attempt to answer that question. Counsel assisting the coroner, Donna Ward, said it will build on recommendations from the inquest into the fatal stabbings at Bondi Junction shopping centre, which recommended a suite of changes to the state’s mental health system.

Deacon died one year before the Bondi Junction incident. On 19 July 2023, three police officers went to a public housing estate in Sydney after a neighbour reported someone at that address had cut their wrists. The officers saw droplets of blood on the stairs as they walked to the unit on the top floor. Then they saw it smeared across the door.

“Hello mate, just the police, can you open the door please,” Const Riley Avery, the most junior of the trio, said as he knocked on the door, the inquest heard.

After another knock, and without discussing a plan, Avery kicked down the door in a decision the officers later said was due to the “perceived urgency” of the situation.

Deacon, who lived with treatment-resistant schizophrenia and suffered from delusions, appeared with a large kitchen knife.

One officer deployed a Taser, which failed. Then a third officer, referred to in the inquest as Officer A, fired a fatal shot from his gun.

The three police officers had not completed the force’s voluntary four-day mental health course, the coroner heard. Hugo James, the senior officer of the trio, had applied to do it, but his course was cancelled.

They were also not warned about Deacon’s mental health history, nor his tendency to carry knives for protection, despite this being part of his previous interactions with police. The system did warn that Deacon could assault police when provoked, but Officer A told the inquest he did not recall hearing that information. Under questioning from O’Neil, Officer A agreed that in hindsight it would have been good for the trio to discuss a plan before entering the apartment.

All three officers told the inquest that had they known more about Deacon’s mental health history, their responses might have been different.

‘Incredibly complex’ treatment

Deacon, the inquest heard, was intelligent, musical and liked to cook.

His adult life was characterised by thechallenges associated with living with treatment-resistant schizophrenia. He fell into a group of about 30% of people with the illness for whom treatment is “incredibly complex”.

He had suicidal ideation, had assaulted health staff and strangers, had spent time in custody and had lengthy stays in inpatient mental health facilities. He would hear voices, and in the lead up to his death believed a witch was putting thoughts in his head.

Ward told the court these facts weren’t being raised to engage in “victim blaming”, saying Deacon did “not cause his own death”.

But, she said, “we can’t understand the dreadful circumstances of Jesse’s death without confronting the difficulties he confronted in life”.

In the lead-up to his death, people who genuinely cared for Deacon, including his support workers, tried to help him.

Deacon had been a patient at Kiloh centre, an acute mental health inpatient service, but was released in March 2023. Support worker Barry Parkes said staff at the centre “often said when he was in hospital he was not fit [to be in] public … because of his erratic behaviour that could come about”.

Deacon had been doing better after he moved into his own home in Glebe, Parkes said, but then he started to decline. He told the inquest he made multiple suggestions that Deacon return to hospital. Instead, two weeks before his death, he saw a doctor who increased his medication and allowed him to remain in the community.

On Monday, facing that doctor from her position before the witness stand, Judy Deacon said: “I regret my son died because he wasn’t in hospital.”

Parkes said he quit after Deacon’s death because he felt he had failed.

“[I was not] offered any counselling support, [I was] just offered rest of the day off after I’d done the statement with police. The next day I was back at work,” he said.

O’Neil consoled Parkes: “Don’t in anyway feel that you failed.”

‘Deeply sorry’

Officer A, who fatally shot Deacon, is the only one of the three who remains a general duties officer.

James was medically discharged after Deacon’s death. A letter he wrote to Judy and Deacon’s family was read on his behalf to the court while he dabbed his eyes with a tissue.

“I wanted you to know that Jesse mattered, he was never just another job or another call out. He was a person who deserved help and that was why we were there,” he said.

“I also want you to know how deeply sorry I am that I was involved in the chain of events that ended with Jesse losing his life. I carry that knowledge with me and I expect I always will.”

Judy Deacon asked Officer A if there was anything he would like to say to her and her family. He said he too would like to write a letter to her, but didn’t “have the words”.

Sitting next to Judy all week has been Lisa Topic, whom Judy described to the court as her friend and colleague. Topic’s daughter Courtney lived with undiagnosed schizophrenia. She was fatally shot by police while she was experiencing a severe episode of psychosis in 2015.

“I don’t want anyone to live this nightmare that we’re living, and you know that’s why I’m there for Judy because I know she’s in early days,” Topic told Guardian Australia outside court. “I’m in my 11th year [since Courtney died] and every day is hard.”

In May, the police minister, Yasmin Catley, told officials at the police union conference that the police and the health department were “very close” to signing a new agreement on how to deal with mental health incidents.

The government is considering an approach similar to the UK’s “right person, right care” model, which sees health workers rather than police attend mental health callouts if there is no crime being committed and no risk to life.

On the first day of the inquest, Judy asked Glenn Browne, who investigated Deacon’s death, what could be done to prevent other similar incidents.

“I’m not completely sure, Mrs Deacon, I wish things could be done better, I wish there were better ways,” Browne responded.