The death of an unarmed Indigenous man who was shot while fleeing custody has prompted a coroner to recommend an urgent review of laws governing the use of firearms by correctional officers.
Dwayne Johnstone, a 43-year-old Wiradjuri man, was shot dead outside Lismore Base Hospital as he ran in leg shackles and handcuffs from a prison van after receiving medical treatment on March 15, 2019.
A correctional officer fired a warning shot and two further shots at Mr Johnstone as he tried to flee.
The third bullet fatally struck him in the back.
Delivering her findings into Mr Johnstone's death on Wednesday, State Coroner Teresa O'Sullivan recommended the NSW attorney-general and minister for corrections conduct an urgent review of legislation regarding correctional officers' use of firearms.
Ms O'Sullivan noted Corrective Services NSW had made significant changes to training and other protocols since 2019, which she said demonstrated a sincere desire to avoid a similar incident occurring again.
"It is appropriate that correctional officers are taught what the expectations are when an inmate is unarmed and shackled," she said.
Ms O'Sullivan found that information regarding two previous escape attempts by Mr Johnstone in 1999 and 2013 was available but did not appear to have been properly "absorbed" by the officers accompanying him on the day.
Following the release of the findings, Mr Johnstone's mother Kerry Shanahan urged the attorney-general and corrections minister to "take note" of the coroner's call for a review.
"Please do it so no one else has to go through it," she said.
"That's what I was fighting for all this time."
Corrections Minister Anoulack Chanthivong said the coroner's recommendations would be carefully considered, but added changes are already being made.
"As part of broader reform in Corrective Services, we are working with staff to refine the systems in place including those related to firearms," he said.
"We want a system that protects the community, keeps inmates safe and lets staff work safely and with confidence."
Ms Shanahan said she did not hold any animosity towards the officer who shot her son, saying he was doing his job the way he was taught.
"Nothing's ever going to bring him back," she said.
"Now he can rest in peace."
The inquest was suspended in October 2020 after Ms O'Sullivan referred the case to the Department of Public Prosecutions.
The officer involved in the fatal shooting - who cannot be named for legal reasons - was charged with manslaughter in February 2021, with the charge upgraded to murder in August 2022.
His first trial in the NSW Supreme Court resulted in a hung jury in November 2022 and a second trial a year later ended with a not-guilty verdict.
The inquest also heard from Mr Johnstone's partner Kirsty Pepper, who remembered him as loyal, artistic and charming.
"I will never have kids with Dwayne, I will never see his infectious smile," Ms Pepper said.
"Going from having the love of my life next to me, to the next day not having him there is soul crushing."
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