A Queensland coroner has found a proper investigation into reports of automatic gunfire in the area where Senior Constable Brett Forte was fatally shot could have stopped fugitive killer Ricky Maddison before he murdered the Queensland police officer almost six years ago.
Handing down his findings in Brisbane today, State Coroner Terry Ryan said there were "several systemic factors that may have contributed" to Senior Constable Forte's death.
He said: "It is possible, but not certain, that his death may have been prevented if those factors had been addressed".
Senior Constable Forte was fatally shot by Maddison after he lured the Tactical Crime Squad officer and his police partner down a deserted road in the Lockyer Valley on May 29, 2017.
Senior Constable Catherine Nielsen and Constable Forte had been in an extended pursuit of Maddison, who was wanted by police.
"At 2:18 pm, Mr Maddison stopped at the gated entry to the property on Wallers Road. He can be seen on dash cam footage from the police vehicle exiting the utility before producing a Kris Corp KS30 automatic rifle," the findings said.
"He almost immediately began firing a string of fully automatic gunfire directly at the police vehicle driven by SC Forte."
Senior Constable Forte's car rolled as he tried to reverse "while rounds of ammunition penetrated the vehicle", trapping he and Senior Constable Nielson.
The findings show a total of 47 spent ammunition casings were found at the scene.
Senior Constable Nielson told the inquiry: "When we turned down that road, just before it happened, minutes before it, seconds really, Brett said to me: 'It's like he's leading us somewhere' and I said: 'I just thought the exact same thing'."
The inquest heard Senior Constable Nielsen smashed the vehicle's windscreen, while being peppered by bullets herself, in an attempt to save Constable Forte.
Maddison was shot and killed by specialist police following a 20-hour siege.
The findings handed down today followed several inquest hearings in Toowoomba and Brisbane last year.
One factor Mr Ryan considered was the investigation by Gatton police into reports of automatic gunfire in the area where Constable Forte and Senior Constable Nielson were ambushed.
Mr Ryan said the fact he lured the officers to a remote location on Wallers Rd, where the terrain was rough, had all the "hallmarks of an ambush".
Police database not updated
The state coroner said it was clear there was a "missed opportunity" to arrest Maddison before Senior Constable Forte's murder after reports by an off-duty police officer and a local resident of automatic gunfire in the area shortly after Maddison moved there.
Mr Ryan said Gatton police did not treat these complaints with "significance".
"It's clear from the investigation by Ethical Standards Command that there was a failure to respond appropriately and the information provided was not … disseminated properly," the state coroner said.
The reports were at the time attributed to a licensed firearm owner, even though it coincided with Maddison moving to the areas in early 2017.
The Queensland Coroners Court heard Maddison had avoided police detection "for almost three months".
No record of the investigation by Gatton police was placed on the police database QPRIME, the state coroner said, adding that information had become "siloed" and Maddison was not apprehended in a "timely manner".
"A more proactive approach by the QPS to the investigation of automatic gunfire at Ringwood would have resulted in Mr Maddison's arrest or significantly reduced his capacity to carry out his plans," Mr Ryan said.
"I agree with the submission of Mrs Forte … that it is not possible to conclude with certainty they [Senior Constable Forte and Senior Constable Nielsen] would have made the same decisions if they were aware there had been reliable reports of automatic gunfire in that location."
The state coroner recommended the Queensland Police Service overhaul the way officers can search for intelligence information.
Mr Ryan also recommended: "The Queensland Police Service ensure all officers are regularly trained in their obligation to enter intelligence info correctly into databases in a timely manner."
He also recommended the implementation of a "state-wide instruction in relation to shots fired incidents".
'Significant failure of leadership'
The state coroner also said there was a "significant failure of leadership" to assign a tactical commander during the pursuit of Maddison, which could have contributed to Senior Constable Forte's death.
"A tactical commander in the pursuit would have enabled the formulation and communication of an effective plan," Mr Ryan said.
"No tactical plan was communicated to those in the pursuit."
Mr Ryan added: "Unfortunately the confrontation was left to evolve on Mr Maddison's terms where Senior Constable Neilson and Senior Constable Forte were, as Ms Neilson described: 'Sitting ducks'."
He said the pursuit was within QPS guidelines but had there been more information available the decision to continue may have been different.
Mr Ryan found the failure to link previous reports of weapon possession to Maddison on the police database "impeded the effectiveness of intelligence in this matter".
He said it was clear information concerning Maddison's weapons history, including with automatic weapons, was incorrectly labelled or entered into the wrong system and officers pursuing Maddison did not have up to date information at the time.
Mr Ryan said the fact one of the investigators during the internal police investigation was also appointed as a family liaison to Susan Forte meant "she was not provided the support she should have expected as a serving police officer having lost her husband in those circumstances".
Police investigation nothing short of disgraceful: Forte's widow
The coroner also found Mrs Forte and Senior Constable Nielson should not have been placed under investigation by the internal police watchdog Ethical Standards Command for trying to raise concerns about Senior Constable Forte's death.
Mr Ryan offered his condolences to Mrs Forte and acknowledged "Mrs Forte's grief was undoubtedly amplified as she was on duty at the time of the death and heard the events over the police communication".
Speaking outside court, Mrs Forte said she accepted the state coroner's findings.
"I understand he can only examine what is put before him, however, the police investigation into my husband's death has been nothing short of disgraceful," Mrs Forte said.
"Many issues I asked questions about continue to be swept under the carpet, and there is no doubt this will happen again in the future as the problems have not been rectified."
Mrs Forte said her husband's death was "preventable."
"He was murdered in a very undignified way, however it has felt like this has been dealt with by the Queensland Police Service as if Brett suffered a papercut to his finger," she said.
"The emotional torture I've been subjected to has been worse than hearing my husband murdered over the police radio.
"I am sad, I am drained, I have not had the chance to even grieve my husband's death as I feel like I've had to be one step ahead 24/7."
Senior Constable Forte's brother Luke said the inquest had been "overwhelming and heartbreaking."
In a statement, a Queensland Police Service spokesperson said further changes may be implemented following the coronial inquest.
"The Queensland Police Service (QPS) recognises the tragic death of Senior Constable Brett Forte has had a long-lasting impact on his wife, family, colleagues, our organisation and the local community he proudly served," the spokesperson said.
"While the QPS has implemented a number of measures since the tragic event in 2017, the coroner's recommendations will be thoroughly examined to ensure any additional changes required are implemented to further protect our workforce and the Queensland community."
