The State Coroner has labelled the domestic violence murder of a young mother and the subsequent fatal police shooting of her killer - who was also the father of her small child - as a "tragedy", at the end of "a terribly sad inquest".
In her findings into the deaths of Gabriella Thompson and Tafari Walton, Magistrate Teresa O'Sullivan said on Friday Ms Thompson died of multiple stab wounds at John Hunter Hospital on March 13, 2019, in a case of "homicide by a known person, in the context of domestic violence".
She further found that Walton, 22, died a day later at Glendale, of gunshot wounds to the head and abdomen.
"Tafari was shot as he moved towards a police officer while armed with a knife, intending to provoke the officer to shoot him," she said.
Magistrate O'Sullivan found that the relationship between Walton and Ms Thompson, which began in 2014, involved "significant, ongoing domestic violence, including physical violence and other forms of controlling behaviour" and that Walton was the perpetrator.
Walton was shot dead in the backyard of a home after going on the run when he fatally stabbed 27-year-old Ms Thompson. He was on parole at the time.
The inquest heard that Walton was brandishing a knife and moving towards police while repeatedly saying "just shoot me".
Magistrate O'Sullivan recommended that NSW Police consider further training around the risks and responses to people likely to use police to attempt self-harm. She was not critical of the police involved in Walton's shooting and found the two officers who fired were justified in doing so.
In response to evidence from Ms Thompson's friend that she called police about a "concern for welfare" for Ms Thompson on the day she was killed, Magistrate O'Sullivan recommended NSW Police consider amending policy to require officers to record matters of suspected domestic violence as domestic violence on the internal log system and for police to attend and speak to the victim personally.
She recommended Corrective Services NSW provide further guidance to staff on when community corrections officers should report breaches of bail to police and when a parolee should be drug tested if they admit to using illicit substances.
Magistrate O'Sullivan found that it was "likely that [Walton] had a methamphetamine-induced psychotic disorder at the time of the events which led to his death" - despite having a specific condition in his parole not to use drugs.
Walton was not required to take a drug test after admitting to drug use a little over a month before killing Ms Thompson, who was at "increased risk from Tafari, partly in consequence of his undetected drug use".
A NSW Police spokesperson said in a statement on Friday afternoon: "The NSW Police Force acknowledges the findings handed down by the State Coroner and will consider the recommendations in detail. No further comment will be made at this time".
Meanwhile, a Corrective Services NSW spokesperson said: "We are reviewing the Coroner's findings and will consider amending our policies in line with the recommendations".
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