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Death of police officer Brett Forte: Coroner's findings

THE CORONER'S RECOMMENDATIONS:

* The Queensland Police Service permanently establish District Duty Officer positions in the Toowoomba District at the level of Senior Sergeant.

Coroner Terry Ryan found it was clear from the evidence in the inquest that important information relating to matters such as gunman Ricky Charles Maddison's weapons history and the investigation into automatic gunfire in the area was not accessible to frontline police officers.

* As a matter of priority, the QPS implement a solution to enable searches to occur across all Queensland Police information systems and intelligence holdings to ensure frontline officers have access to reliable and current information.

Mr Ryan stated the QPS should report on its progress in relation to the implementation of this recommendation within six months.

* The QPS ensure all officers are regularly trained in relation to their obligation to enter intelligence information correctly within relevant Queensland Police databases in a timely manner and the ongoing management of those databases.

Mr Ryan found that information about Maddison had been incorrectly labelled, entered into the wrong system or there was a fundamental failure by officers to enter any relevant information into QPRIME, the police central information system.

* The QPS consider implementing a state-wide instruction in relation to firearms assessments as a mechanism to review shots-fired incidents with clear expectations in relation to the investigation of those incidents and associated reporting requirements.

Mr Ryan found that 12 days prior to the fatal shootings, Gatton Police had started surveillance of the entrance of Maddison's property following reports of automatic gunfire in the area.

This information was not available to officers who were attempting to arrest Maddison for allegedly breaching a domestic violence order on May 29, 2017.