A coroner has recommended police develop new arrest warrant protocols after the fatal shooting of Aboriginal man Stanley Leonard Russell.
Mr Russell, 45, was shot dead at his aunt's home in the Sydney suburb of Seven Hills by officers executing an arrest warrant on November 9, 2021.
An inquest heard he had confronted officers with an axe and Bowie knife before two constables fired their weapons.
Mr Russell had an intellectual disability and other mental disorders, including substance dependence and depression which worsened after his brother's suicide death in jail in 1999.
On a number of occasions after being incarcerated, the Gomeroi man engaged in acts of self-harm, saying he would rather die than be put in jail.
In her findings delivered on Friday, Coroner Carmel Forbes found the constables who shot Mr Russell had reasonably perceived an immediate risk to their lives.
But she found the four officers who attended the home had done so "without any co-ordinated plan to deal with the possible risks they would face".
They were unaware Mr Russell was intellectually disabled and did not consider that he might fear or distrust police as an Aboriginal man.
"We will never know... what was going on in Mr Russell's head at this time," Ms Forbes said.
"He is likely to have felt cornered and agitated at the prospect of going back into custody."
Ms Forbes recommended NSW Police and the Aboriginal Legal Service consider jointly developing a new protocol for executing bench warrants which encourages Indigenous defendants to hand themselves in to authorities.
Dubbed the 'Stanley Protocol', it would involve mandatory notification to the Aboriginal Legal Service and the involvement of Aboriginal community liaison officers who would support and advise people to report to police or a court.
There should also be Aboriginal liaison officers in all communities with high populations of First Nations people, she said, and police working in those areas should be required to undertake cultural competency training.
"Hopefully, the recommendations will help to provide alternatives to confrontational arrests," Ms Forbes said.
"Mr Russell had an intellectual disability ... he had suffered the loss of his brother in custody, he was so desperate not to go into custody he had taken extreme measures in the past to avoid it.
"The police who attended his home to execute the warrant were not, but should have been, aware of all of these matters."
If this story has raised issues for you, call 13YARN 13 92 76, Aboriginal Counselling Services 0410 539 905, Lifeline 13 11 14, or beyondblue 1300 22 4636.
