Officers were not properly briefed amid "inadequate" Queensland Police procedures before a violent offender was shot dead at a hospital, a coroner says.
A failure to share information led to poor decisions and complacency by officers before Tyson Jessen, 28, was killed under police guard at Ipswich Hospital in November 2018, State Coroner Terry Ryan said.
However, Mr Ryan recommended one of the police guards - Senior Constable Leesa Richardson - and hospital nurse Gabrielle Kelly be recognised for their bravery.
Sen Const Richardson was pulled to the ground and punched repeatedly by Jessen who then tried to grab her firearm when she was left alone at the hospital, an inquest heard last year.
After being distracted by Ms Kelly, Jessen was shot three times by Sen Const Richardson and later died.
Sen Const Richardson and Constable Isaac Collihole were at the hospital's cardiac ward guarding Jessen after his arrest on an extradition warrant issued by Victorian police for armed robbery.
They didn't know Jessen was a dangerous and high-risk prisoner, and were unaware of his violent history.
Information about Jessen was available on the internal police database, QPrime, but Mr Ryan said in his findings more on his history should have been provided on the system.
Officers had also relied on verbal briefings that had become "distorted" in the absence of paperwork, he said.
"There was a wider failure by officers in leadership positions in the Ipswich District to share pertinent information relevant to the risk posed by Mr Jessen which would have informed the officers tasked to guard (him)," Mr Ryan said.
"I conclude that the policies and processes of the Queensland Police Service concerning managing the risk of guarding an offender, such as Mr Jessen ... were inadequate.
"Poor communication, inadequate documentation and a lack of systems can result in poor decisions being made."
Mr Ryan said there was also "some complacency and a false sense of security" adopted by the two officers due to Jessen's polite behaviour before the attack.
"It is apparent that this was regarded as a routine or mundane task with little appreciation of the specific risks attaching to Mr Jessen," he said.
Jessen's handcuffs had been removed to let him eat and use the toilet before he attacked Sen Const Richardson when she was left alone when Const Collihole went to get dinner and another officer was arriving at the hospital.
Mr Ryan did have some praise for Sen Const Richardson and Ms Kelly.
"He (Jessen) clearly expressed an intent to harm her and likely would have caused serious harm to other persons in the hospital had he managed to seize her service revolver," he said.
"I consider that the courage both she and RN Kelly displayed should be formally recognised and I understand that process has commenced."
Mr Ryan recommended that Queensland police consult with Queensland Health to establish a "consistent approach" by security staff when managing patients in custody.
A better use of technology to "reduce the need for medical transfers of persons in police detention watchhouses" was also needed.
Mr Ryan said West Moreton Health had taken measures to "avert this type of incident from occurring again" at Ipswich Hospital and wanted Queensland Health and police to consider whether they be applied to other districts.
It was also recommended Queensland Police review its operational procedures manual and consider an order that risk assessments be completed, with relevant information recorded in QPrime.
