Forty-one seconds. That was the amount of time between police arriving to find Courtney Topic holding a knife near Hungry Jack's at West Hoxton and an officer firing a fatal shot into her chest.
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NSW Deputy State Coroner Elizabeth Ryan found Ms Topic's death was a preventable tragedy as she urged sweeping improvements to police mental health training, some of which have been backed by NSW Police Commissioner Mick Fuller.
"Errors were made that morning which made the resort to lethal force a tragic inevitability," Ms Ryan said as she delivered inquest findings on Monday.
"Courtney's death is emphatically not one where it can be said, 'This couldn't have been prevented.'
"Her death raises broad issues about how police officers are trained to deal with people suffering a mental health crisis."
Leesa Topic welcomed the recommendations - which followed a NSW Coroner's Court hearing earlier this year - and said the finding her daughter should not have died was "justice for Courtney".
"Courtney isn't coming home, and we will live with that forever," she said.
"But we don't want any other family to live with the pain we are living with now. We will take this to our graves.
"We just hope she is remembered for the beautiful soul she is and if something positive can come out of this so no other family has to live this heartache, then we'll be grateful for that."
Ms Topic, 22, was fatally shot in the chest seconds after police arrived to find her wielding a knife at an intersection near the fast-food restaurant on February 10, 2015.
The coroner found she was most likely suffering from a psychotic episode due to undiagnosed schizophrenia when she grabbed a knife from home and walked to nearby shops about 11.30am.
Witnesses called police after they saw the woman clutching a kitchen knife in the car park of the fast-food outlet.
Dramatic footage of the incident showed three police officers surrounded her, wielding OC spray, a faulty Taser and a gun as they yelled at her to drop the weapon before she was shot.
Ms Ryan said Ms Topic's mental state probably meant she was not able to understand police were telling her to put down the knife before Senior Constable Ethan Tesoriero had fired his pistol.
"He had reason to believe his life was in danger," she said.
Ms Ryan found the three officers had "subjectively reasonable grounds" to fire their weapons and had not breached police procedures.
But she said the police response to disarming Ms Topic was inappropriate.
"If changes are not made, there will be more deaths like Courtney's," Ms Ryan said.
"The court heard that in Australia, of the persons shot by police between 1989 and 2011, nearly 42 per cent were suffering from mental illness. There is no reason to believe those numbers will reduce over time.
"More families will be left grieving, and police officers profoundly affected."
Ms Ryan said Ms Topic's death exposed gaps in police mental health training and made 10 recommendations, including a review of existing programs.
She recommended all police radio and triple-0 operators undergo mental health training to help them recognise signs of mental illness, and a system to dispatch officers who had completed a four-day mental health training course as first responders in potential mental health incidents.
The four-day mental health intervention training course should also be extended to more officers, include more role play exercises and include booster training.
A NSW Police spokeswoman said the force would consider the findings "in detail" before commenting further. Ms Ryan said Commissioner Fuller supported some of the recommendations.
