A coroner says a police sergeant was right to Taser a mentally ill Canberra father, who went into cardiac arrest and died.
James Stewart, in delivering his findings on Friday, said Anthony Romanas Caristo, 54, "passed away in tragic circumstances" at his Waramanga home on October 31, 2017.
He said police, alerted by Mr Caristo's neighbour, found him on the floor of his home behind broken windows. The coroner said Mr Caristo's blood was smeared over the house in "quite a horrifically confronting" display; he had obviously severed one of his fingers and was cutting himself with a large knife.
Mr Stewart said police officers couldn't communicate with Mr Caristo in any meaningful way, and should have made sure the man wasn't holding the knife before they went into the house.
Instead, Mr Stewart said they planned to go in "under cover of Taser", which was unsafe. He agreed with Professor Johan Duflou's findings Mr Caristo died from cardiac arrest after Sergeant Nathan Macklin Tasered him.
The professor said Mr Caristo exhibited features of "excited delirium syndrome" and had in his system "potentially lethal levels" of methamphetamine at the time.
It was up to the coroner to determine whether police were wrong to have Tasered Mr Caristo, but Mr Stewart on Friday said Sergeant Macklin was reasonable and justified in his decision to do so.
"I find that there was nothing negligent or blameworthy in the conduct of the police in using the Taser that could be said to have contributed to [Mr Caristo's] death," Mr Stewart said.
Sergeant Macklin earlier told the coronial inquest into Mr Caristo's death he thought the Canberra father was going to kill himself, and he essentially had two options: "I either Taser him to stop him harming himself, or I stand and watch."
"Mr Caristo just started staring at me, his eyes were fully focused on me but he still had that knife," he said in August last year.
"It was a thousand-yard stare like I've never seen before, like I wasn't there."
Mr Stewart said he accepted Sergeant Macklin's evidence as truthful and accurate.
He said little he could say or write could salve the deep grief of Mr Caristo's family, and he had not forgotten their sadness and concerns expressed to him during the hearing.
In January, a statement by Mr Caristo's daughter Carley Sales-Caristo was read to the coronial inquest.
"The day my dad died was the day my heart broke," she said.
She said if nothing else, she hoped her father's death raised the topic of mental illness and encouraged further awareness and education around Taser use on people with signs of mental health issues or injury.
"I know it won't bring my dad back, but to know it may save a life in the future is worth me speaking up on behalf of myself and my dad, and his grandchild, [who] he never got the chance to meet," Ms Sales-Caristo said.
Mr Stewart recommended that the Australian Federal Police review its governance and training on Tasers, particularly in relation to "the inherent risk involved in Taser use in respect of vulnerable groups", like people with excited delirium syndrome.
He said the police should report back to him about any changes to do with Tasers within 12 months, and review the communications response of October 31, 2017.
Mr Stewart said Mr Caristo's mental health had spiraled in the lead up to his death and, as at October 31, he was too unwell to put a police-assisted suicide plan into action.