Neil Wilkins can't escape the emptiness he felt when he learnt his stepson Todd McKenzie had been shot dead by NSW Police during a psychotic episode.
"Todd was a kind-hearted person," Mr Wilkins said.
"He needed help, and he didn't get the right sort of support."
After almost six years, Mr McKenzie's loved ones still struggle to process his death.
The only recording of the final seconds of his life — a shaky phone video from a neighbour — wasn't used as evidence during a 2023 coronial inquest into his death.
This is one of many incidents that have compelled the head of the state's police watchdog to call for change.
Nine hours of failed negotiations
Neighbours reported that Mr McKenzie was holding a knife and making threats outside his home in Taree on the Mid North Coast in July 2019.
The 40-year-old, who was diagnosed with schizophrenia, was experiencing a psychotic episode just days after he had been incorrectly denied sleeping medication.
"We were told not to come to the scene, to stay at home, which was really bad advice," Mr Wilkins said.
After nine hours of failed negotiations, where a psychologist was not called to the scene, the officers involved rammed down his front door to force him out.
Police told the inquest that multiple non-lethal weapons failed to incapacitate Mr McKenzie as he approached them with a knife.
An autopsy report stated that he was shot three times in the back and later died in hospital.
Claims of 'subjective evidence'
Because NSW tactical police are not required to wear body-worn video, the inquest relied on sworn statements from the officers involved.
The family has provided the ABC with the only known recording of the incident taken by a neighbour.
It's not clear at what stage of the breach the recording begins, but an officer can be heard yelling "put the knife down" twice, followed by at least three loud bangs.
About eight seconds later, three gunshots ring out before someone calls out for paramedics.
Mr McKenzie's aunt Margarette Hill said the lack of "preserved concrete evidence" meant the coroner only had "subjective police evidence available".
"The coroner's explanation of the [police breach tactic] in her findings could not have taken place in eight seconds," Ms Hill said.
The unit's commander told the inquest that tactical officers don't wear body-worn cameras to preserve confidentiality around police methodology.
"It's a loss of faith and it's a loss of confidence in the whole system," Mr Wilkins said.
Case for body-worn video
In 2024, the coroner presiding over Mr McKenzie's inquest recommended that NSW tactical police be required to wear body-worn video.
It was the same recommendation made by another coroner following an inquest into the death of a 17-month-old girl, who was struck and killed by a suspect's car during a police pursuit while she played with her siblings in their backyard in 2015.
None of the tactical officers were wearing body-worn video during the incident.
In response to the toddler's inquest in 2022, Police Commissioner Karen Webb committed to conduct a trial into the use of the devices for tactical officers.
In 2023, the state's Law Enforcement Conduct Commission (LECC) found the trial had not yet occurred, and more recently NSW Police would not tell the ABC whether one had even started.
This year the LECC released a review into the use of body-worn cameras, recommending sweeping reforms in response to these types of incidents.
The organisation's chief commissioner, Peter Johnson SC, told the ABC the force's current policies around the technology were "not consistent with promoting the public interest and public confidence".
"There have been some matters with critical incidents where there was no body-worn video, where it really made a difference," Commissioner Johnson said.
"It made for a longer and more drawn-out coronial proceeding and with families at times left wondering about the absence of body-worn video.
"We have raised a number of matters with them [NSW Police] over the last couple of years and we've had responses back, some of them unsatisfactory, some of them not engaging in the substances of what we're suggesting."
Promoting 'public confidence in policing'
Despite a requirement for all general duty officers to wear the cameras, it's up to the discretion of the attending officer to "use their judgement" whether to turn the device on or not.
Activating body-worn video during almost all police interactions is mandatory in Queensland, Victoria, Tasmania, Northern Territory and South Australia.
"The NSW Police Force sometimes can be more conservative and cautious than other than other states," Commissioner Johnson said.
LECC recommended the force change its policy so that all officers, including tactical, "must" turn on their cameras during any incident where they are likely to use their powers.
Another recommendation would require officers to record the reasons for not activating their camera, which Commissioner Johnson said would afford police "very few available excuses".
"I'm conscious that if the police don't take up our recommendations there may be a stand-off.
"But in the end, if we make common sense recommendations, it can, I hope, ultimately lead to police realising the sense of what we're suggesting."
He added that the force's slowness to adapt to body-worn video was not because they wanted to "hide things" but rather an "unduly cautious approach".
"Nothing that we are recommending undermines policing, what we are recommending in fact will serve to promote public confidence in policing."
NSW Police said they were still considering all LECC's 15 recommendations.
