The fatal police shooting of a 29-year-old Ngarlawangga Yamatji Martu woman in Geraldton was preventable, a Western Australian coroner has found.

The woman, referred to as JC for cultural reasons, was shot by WA Police officer Brent Wyndham in September 2019, shortly after her release from custody. Police had responded to reports she was walking down the street with a knife.

Mr Wyndham, one of eight officers who attended the scene, was the only one to draw his firearm. He later became the first WA police officer in nearly 100 years to be charged with murder while on duty.

During a three-week trial in 2021, he testified that he feared JC would stab either a colleague or himself when she refused repeated commands to drop the knife. He was acquitted of both murder and the lesser charge of manslaughter.

The verdict prompted grief and anger from JC's family and the wider Indigenous community.

"It sadly reactivated and magnified the historical mistrust and antipathy that many Aboriginal persons feel towards police officers, for reasons that are well known and deeply embedded in the unfortunate and brutal consequences of colonisation," Coroner Ros Fogliani said.

A coronial inquest held in Geraldton and Perth last year examined the police response. While Coroner Fogliani ultimately ruled JC's death a "lawful homicide," she found that officers missed key opportunities to de-escalate the situation — though she acknowledged it was not possible to determine if those actions would have changed the outcome.

"I am satisfied that JC's death was a preventable death," she said.

She concluded WA Police had failed to adequately prepare officers for such encounters.

"I am satisfied that WA Police missed opportunities to effectively train the attending police officers," Ms Fogliani said.

"There were missed opportunities to communicate, which may have avoided JC being approached so quickly.

"The eight officers were not sufficiently trained in tactical and/or effective communication at the time. More formal training in respect of Aboriginal Cultural Awareness may have generated a better appreciation of JC's likely vulnerabilities."

JC was described as having lived a difficult life, marked by schizophrenia, undiagnosed Foetal Alcohol Spectrum Disorder (FASD), poverty, substance use, and family instability. Despite this, the Coroner noted she remained a devoted mother.

"Amongst the turmoil that JC endured, throughout her life she was mothered with love and affection," she said.

"JC's much loved son CJ was born in 2012, and he was mothered with the same devotion by JC and [her mother] AJ."

Following her release from custody, JC spent significant time in hospital. Although her mental health was judged as "stable", she and clinicians had expressed concern her condition could deteriorate due to methamphetamine use — something she admitted she would resume.

"At the end of JC's life, her experience of homelessness exacerbated her already fragile mental state, leading her to express suicidal ideation," the Coroner said.

"That she died three weeks after her release from prison, after spending most of those three weeks as an involuntary mental health patient, is very telling."

Ms Fogliani said JC "fell through the cracks in the system," and did not rule out that she was experiencing a psychotic episode when she was shot.

She made nine recommendations, including that WA Police consider establishing a dedicated branch to improve relations with Aboriginal communities. She also called for regular Aboriginal Cultural Awareness training, co-designed and delivered by Indigenous people, with a focus on intergenerational trauma and FASD.

"It is my hope that the recommendations I have made will assist in providing some continuity of care and follow up when Aboriginal persons are removed from Country, for treatment," she said.

She also urged the WA Department of Health to improve information sharing with police, particularly regarding mental health conditions.

Veteran justice advocate Gerry Georgatos was scathing of the outcome.

"The coronial recommendations into JC's death are shambolic," he told National Indigenous Times.

"They miss the cause of death. A police officer, last to arrive on the scene, ran past his colleagues who had clearly contained JC and were talking to her, and was the only officer to pull a firearm.

"The cause of death was a bullet, discharged from a police firearm. The focus should have been the officer who discharged the firearm... The top recommendation should be: do not shoot when seven other officers were on the scene and none of them had pulled a taser or gun.

"A human being was needlessly killed."

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