The Northern Territory coroner has found NT Police missed several opportunities to support a veteran officer before he took his own life.
It has called for sweeping changes to police culture and mental health support, particularly in remote postings.
The findings, handed down on Friday, come four years after the death of Constable Michael Deutrom who died by suicide at 44 in April 2022, after more than 20 years serving on the front line across the Northern Territory.
It was a tragedy that devastated colleagues and cast a stark light on the toll of a policing career.
In a 113-page report, coroner Elisabeth Armitage found Constable Deutrom was suffering from chronic post-traumatic stress disorder (PTSD) and major depressive disorder after years of exposure to trauma, distressing jobs and a false allegation of sexual assault.
She identified Constable Deutrom had likely been experiencing "subsyndromal" PTSD symptoms by at least September 2021, which the coroner highlighted are symptoms that increase in severity over time but can fall short of the clinical threshold for a formal diagnosis.
According to the findings, Constable Deutrom attended a number of "check-ins" with the Police Wellbeing Unit after several jobs involving fatalities, including a police pursuit early in his career that ended in a vehicle crashing and catching on fire.
Judge Armitage said Constable Deutrom was still having recurring thoughts 22 years later about pulling the driver from the burning car and carried scars from the incident which served as a constant reminder.
In another incident, in the remote community of Millingimbi in 2020, a pregnant woman experiencing a mental health episode assaulted him and another officer, spitting, biting and throwing faeces at them.
She then falsely accused them of sexual assault.
The following year Constable Deutrom was transferred to the remote and isolated community of Kintore, a posting Judge Armitage found was "harmful given his mental wellbeing" as there was limited support and frequent on-call work that left him unable to switch off.
The coroner also noted his posting came during COVID, a time which "created significant resourcing demands and institutional challenges for the NTPF (NT Police Force)".
Constable Deutrom was not required to undergo a psychological assessment before transferring to Kintore, which the coroner said may have picked up "flags" such as the length of his career and growing dissatisfaction with the job.
Officers transferring to remote communities still are not required to undergo such assessments, she noted.
Judge Armitage said the NTPF must, as a matter of priority, introduce psychological screening before members are sent to long-term remote postings.
She argued that such screenings would not necessarily result in blocking postings for officers if they were struggling, but could ensure better supports were put in place.
"Normalising screening within NTPF culture would be critically important for its effective implementation," Judge Armitage reported in her findings.
She also noted NTPF missed opportunities to intervene after Constable Deutrom sought psychological help in 2021 and built up an extensive amount of leave.
Judge Armitage said the force should also be mindful of other "flags" more broadly including fatigue, out of character irritability and decreased motivation — symptoms Constable Deutrom was exhibiting.
She said the force's "institutional culture" of "making do" and "service before self" was a material factor in how Constable Deutrom came to be exposed to significant trauma and stress.
Judge Armitage said more broadly the police culture problem posed a "significant risk to the long-term wellbeing of members".
Citing research by Beyond Blue, Judge Armitage highlighted police officers who have worked more than 10 years in the job are almost twice as likely to experience psychological distress and six times more likely to experience symptoms of PTSD.
At the beginning of 2022, just three months before his death, Constable Deutrom emailed his superiors and the NT Police Association detailing the difficulties he was facing, including community dysfunction and staff shortages.
He said expectations by police leadership, the government and community were "extremely high and often unreasonable", while also noting his immediate supervisor was "doing all he can to offer us further support with an additional member".
At the end of January, Constable Deutrom made what he described as the "difficult decision" to take personal leave.
Journal entries in the aftermath of leaving work detailed his struggles with shame and suicidal thoughts.
The coroner found that though Constable Deutrom was seeking help there was "a missed opportunity to arrive at a proper diagnosis of Michael's condition at the earliest time reasonably possible".
Constable Deutrom eventually concluded he would not be able to return to Kintore, the coroner said.
In her findings, Judge Armitage said she hoped Constable Deutrom's death would help others in frontline roles better understand the mental health risks they face and recommended his story be incorporated into future police training.
"I have not definitively found that, but for these missed opportunities, Michael's tragic passing would necessarily have been avoided," she said.
"This does not lessen the importance of my conclusions and the lessons to be drawn from Michael's experiences."
While the coroner stopped short of referring anyone for prosecution, which was suggested by the NT Police Association and the family, she said the option remained open to them to commence criminal proceedings for possible contraventions of the Work Health and Safety Act.
In a statement, Police Commissioner Martin Dole said the NTPF's thoughts remained with Constable Deutrom's family, friends and colleagues.
He said additional wellbeing resources had been made available for officers.
He said the NTPF was now carefully considering the coroner's findings and recommendations.
In her recommendations Judge Armitage included calls for stronger mental health protections for police middle management, a formal psychiatric referral pathway, and consideration of a Remote Operational Psychosocial Risk Management Framework.
She further called for a root cause analysis model for investigating suspected self-inflicted deaths.
