After a seven day coronial inquest in November 2023 into the death of Brandon Rich, a recommendation has been made to the NSW Police Force commissioner that police need more domestic violence training.

This all came about when the 29-year-old died after losing consciousness during an altercation with NSW police at his home in Wellington on December 29, 2021.

Ms Rich said the inquest process was "extremely hard" for herself and her family.

"Having to come face to face with the police officers involved was quite distressing and while the police officers were on stand they gave no condolences to my family regarding the death of my son which was extremely disheartening to myself and family," she said.

"I felt like they didn't care at all."

Ms Rich said the outcome of the inquest was not quite what she expected.

"I believe there will be no change to the system until police are held accountable in some way," she said.

"I still continue to have nightmares, and the pain and suffering will continue for myself for the rest of my life."

But, Ms Rich plans on staying strong, not just for herself but for others going through similar circumstances.

"Nothing will bring my son back and all I can do is continue to fight for justice not only for myself and my son but for every family who has gone through and will go through this," she said.

Despite there only being one recommendation made from the inquest there was a 63 page report that included a raft of criticisms towards how the police handled the case.

It was 6am when a general duties shift for Senior Constable Kohlet and Bennett began at Wellington Police Station on December 29, 2021, the court heard on November 21, 2023 when the inquest began.

Whilst attending an unrelated incident, Denise Rich - Mr Rich's grandmother - approached Senior Constable Kohlet and asked for her help at home.

She didn't tell them it was for a domestic violence matter.

Senior Constable Kohlet did not ask Denise any questions about why their attendance was necessary at her house.

In the deputy state coroner Harriet Grahame's final report, she said she accepted the submission that this was unfortunate and that it "ultimately resulted in the police officers not knowing anything at all about the incident they were about to attend, which made planning impossible".

"Given the complete lack of information obtained, it is not surprising that the initial complaint procedures and the operational response to domestic violence as set out in the NSW Police Domestic Violence Standard Operating Procedures (DV SOPS) were not followed," she wrote.

Ms Grahame wrote Senior Constable Bennett, as the senior officer, while he did not personally speak to Denise, should have ensured that he was appraised of the situation before attending the scene.

"Quite simply, the officers could have asked Denise to wait for a minute or meet them back at the police station to obtain information prior to attending her home. This did not occur," she wrote.

"A preliminary conversation with Denise ... might have given police the opportunity to gather enough information to plan a safer approach."

Ms Grahame said there was no evidence that police needed to attend the address urgently.

Use of the term 'grub'

On November 21, 2023 in Dubbo Coronial Court, Senior Constable Kohlet told the court that when she said whose house they were going to, Senior Constable Bennett called Mr Rich a "grub".

Senior Constable Bennett explained in his evidence that the term grub is "slang that we'd normally use - and I've heard used over the years with police force - in relation to somebody who police have interacted with, whether or not it be positive or negative, but there has been some negatives, but never a negative in the extreme sense."

"There's other slangs that you refer to in other situations that I've heard and used in the past, and it's just one of those common things that we've - I've used and I've heard others use," he said.

Senior Constable Kohlet accepted the term has negative connotations but denied that SC Bennett's use of this term affected how she reacted. She said, "you hear it all the time".

In her report, Ms Grahame said the term was "unprofessional, offensive and stigmatising".

"It is unhelpful and has no place in modern policing. Brandon was demeaned to an officer who had never met him, prior to officers even arriving at the scene," she wrote.

"It was appropriate for police to conduct a risk assessment before arrival, not prejudge those who may be at the scene."

Upon arrival at Ms Rich's premises, the officers separated Denise and Brandon, who continued to argue.

After some back and forth between Mr Rich and his grandmother, the police decided to take Mr Rich back to the Wellington station for the purpose of serving an Apprehended Violence Order (AVO) on him.

According to Ms Grahame's report, the officers did not undertake a number of the other mandatory actions including:

a. Make an immediate risk assessment of the scene;

b. Enquire about children; and

c. Enquire about firearms.

"It was also clear that neither officer used the Domestic Violence Safety Assessment Tool (DV SAT) provided in the DV SOPS."

Ms Grahame wrote that the lack of information and planning at an early stage constitutes the most significant "missed opportunity" in relation to these events.

"Separating Denise and Brandon at the initial information gathering stage so that their 'bickering' did not get out of hand, may have assisted in a more peaceful process," she said.

"I accept that policing is a difficult job, made more difficult in situations of stress, but clear and helpful processes designed to obtain useful information in domestic violence situations should, as far as possible, be adhered to and followed.

"Police made a decision to detain Brandon within minutes of their arrival, knowing very little. In my view the speed with which they came to this decision escalated the situation."

Mr Rich was informed by one or both officers that he had to go to the police station for the purposes of a provisional ADVO.

Ms Grahame said in her report there were some "discrepancies" in the accounts of the officers, as to whether they told him he was being taken to the station (Senior Constable Kohlet) or being detained (Senior Constable Bennett).

"It was apparent that the attending officers on the day did not clearly understand that police have the power to give a direction to a defendant and if, and only if, the direction is not complied with, do the police have the power to detain the defendant at a police station or another place," she wrote.

"In my view as a matter of principle, the misunderstanding is significant, and of concern."

Ms Grahame said the decision to take out an AVO on Brandon was "certainly hasty".

"No statement had been taken, no account had been recorded on a body worn camera or in a police notebook," she wrote.

"They had very limited information upon which to ground the 'good reason' they needed to apply for the order."

Mr Rich was told he was to accompany police back to the station - a request he agreed to.

"I do not believe a formal clear direction... was ever given to Brandon to get into the back of the caged truck," she wrote.

"Brandon found himself at the back of the truck in confused circumstances. He was told he was not under arrest."

Ms Grahame said trying to force Mr Rich into the back of the caged wagon was always going to escalate the situation.

"I am concerned that alternatives were not really explored," she said.

When Mr Rich barricaded himself in his grandmother's bathroom, Senior Constable Bennett shoulder charged the door to open it.

Entering the room, Mr Rich could be seen trying to escape out of the window.

Senior Constable Bennett told the court he grabbed Mr Rich's leg to stop him from going anywhere.

In her report, Ms Grahame writes that it would have been "very difficult, if not impossible for Brandon to escape from that window".

"It is perfectly clear that Brandon was not thinking rationally," she wrote.

The report states she carefully considered whether the period of time that Mr Rich was in the window presented an opportunity for de-escalation.

"I do not accept that de-escalation is likely at this point. Tragically I think NSW Police Force had already lost this opportunity," she said.

Ms Grahame said one of the most important issues facing NSW Police is to improve training for officers in relation to de-escalation techniques.

The court heard that after Mr Rich was brought back through the window, he was able to evade police one more time before Senior Constable Bennett pinned him in a rugby tackle hold against a wall.

At this point the officers noticed Mr Rich was breathing heavily, which they put down to his weight and exercise exertion.

Ms Grahame's findings say that during this period there was no effective communication with Mr Rich and he did not calm down.

According to the officers testimonies after a brief struggle, two officers and Inspector Russell pulled Mr Rich's legs out from under him so he slid to the ground.

After 20 seconds on the ground, Senior Constable Bennett said he heard Mr Rich say he couldn't breathe.

"I find that from the moment police officers realised that Brandon was having some kind of medical emergency they attempted to assist him," Ms Grahame wrote.

"I have no doubt the situation was by then extremely stressful and distressing for the police. Their physical condition illustrates the exertion and intensity of the struggle which had just occurred."

Ms Grahame's report said she finds that Mr Rich's death was caused by a cardiac arrhythmia triggered by myocardial ischaemia in the context of physical exertion and stress.

It was mentioned that the NSW Police Force is currently intending to roll out an online training package relating to mental health awareness which includes consideration of de-escalation techniques.

Detective Acting Superintendent Hales said the package, first used at the end of 2023, would expand to a two hour mandatory session involving case studies, and audio/video examples of best practice to then be assess during defensive tactics training roleplays.

She also confirmed that the previous one-day and four-day mental health training programs have been discontinued pending the completion of the review.

Ms Grahame's report said it was clear that both Senior Constable Bennett and Senior Constable Kohlet were required to wear body worn camera and to carry a taser and that neither complied with the policies in this regard.

"It is deeply regrettable that they did not as the incident would otherwise have been recorded, this was in the interests of the officers and important for accountability in these proceedings," she wrote.

"Perhaps even more importantly the court was denied a record it should have had access to."

She also said that the failure of both attending officers, Senior Constable Bennett and Senior Constable Kohlet, to carry a taser was also "regrettable".

"It was a requirement of police procedure, and it was best practice to do so. However, in the circumstances, it is unlikely that there would have been a material difference to the outcome if a taser had been available at the time," she said.

Senior Constable Bennett did not provide any particular reason for his failure to wear the taser.

"It was likely complacency," she wrote.