Inquest into the death of Hillal Barbour

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Hillal Barbour Hearing dates: 16 to 19 June 2025 Date of Findings: 18 September 2025 Place of Findings: Coroner’s Court of New South Wales, Lidcombe Findings of: Magistrate Derek Lee, Deputy State Coroner Catchwords: CORONIAL LAW – death as a result of a New South Wales Police Force operation, critical incident, use of lethal force by police, Tactical Options Model, deployment of conducted electrical weapon (taser), use of oleoresin capsicum (OC) spray, information gathering, verbal and non-verbal communication, de-escalation strategies File number: 2023/74085 Representation: Mr P Rooney, Counsel Assisting, instructed by Ms E Leung & Mr H Zhang (Crown Solicitor’s Office) Mr T Lowe for Constable S Grammatikos, instructed by Ms A Wooldridge (New South Wales Police Force Office of General Counsel)

Findings: Hillal Barbour died on 5 March 2023 at Liverpool Hospital, Liverpool

NSW 2170.

The cause of Hillal’s death was gunshot wound to the chest.

After arriving at a private property in response to a Triple Zero call regarding a reported domestic violence incident, two NSWPF officers encountered Hillal just inside the front door to his home. Hillal was armed with a knife in each hand and exited the front door advancing towards the NSWPF officers brandishing the knives. The limited duration of the encounter and the rapidly evolving situation did not allow sufficient time for any verbal communication or other action which might have de-escalated the situation. One of the NSWPF officers, in the lawful execution of his duties, discharged his firearm at Hillal causing Hillal to sustain two fatal gunshot wounds to the chest.

Table of Contents

1. Introduction 1.1 At 8:49am on 5 March 2023, New South Wales Police Force (NSWPF) officers were called to the home of Hillal Barbour in Yagoona in response to a reported domestic violence incident. It was reported that Hillal was holding a shovel and following his mother and that there were concerns for her welfare.

1.2 Two NSWPF officers, Constable1 Jessica Lieberman and Probationary Constable Steven Grammatikos, arrived at Hillal’s home a short time later. They exited their NSWPF car and approached the front door of the house.

1.3 Hillal exited the front door holding a knife in each hand. The two NSWPF officers repeatedly told Hillal to drop the knives and get down on the ground but he did not do so and continued advancing towards them. Probationary Constable Grammatikos twice deployed a conducted electrical weapon (commonly known as a taser) at Hillal which had the effect of causing him to drop to his knees.

However, Hillal used a knife to cut the taser wires, stood up and continued to advance. He swung the knives at Constable Lieberman who lost her footing and fell to the ground.

1.4 Probationary Constable Grammatikos attempted to move Hillal away but Hillal motioned with a knife towards Probationary Constable Grammatikos causing a laceration to his cheek. Probationary Constable Grammatikos drew his service firearm and discharged three rounds at Hillal. Two rounds struck Hillal in the chest and lower abdomen and one round missed Hillal entirely. Hillal fell to the ground.

1.5 New South Wales Ambulance (NSWA) paramedics were called to the scene and Hillal was taken by ambulance to Liverpool Hospital. However, he could not be revived and was tragically pronounced life extinct at 9:58am.

2. Why was an inquest held?

2.1 Pursuant to the Coroners Act 2009 (the Act) a Coroner has the responsibility to investigate all reportable deaths. This investigation is conducted primarily so that a Coroner can answer questions that they are required to answer pursuant to the Act, namely: the identity of the person who died, when and where they died, and the cause and the manner of that person’s death.

2.2 Certain deaths are reportable to a Coroner. Some examples of reportable deaths are where the cause of a person’s death is not due to natural causes, or where the cause or manner of a person’s death may not immediately be known. In Hillal’s case, his death was reported because he died as a result of a NSWPF operation. In other words, the use of lethal force by a NSWPF officer in discharging their firearm at Hillal resulted in his death.

2.3 Section 23(1)(c) of the Act makes it mandatory for an inquest to be held in such circumstances. This is primarily because NSWPF officers are bestowed with unique powers not available to ordinary 1 The ranks of the NSWPF officers as at March 2023 have been used in these Findings. No disrespect is intended if these ranks are no longer current.

members of the community, in order to allow them to discharge their duties. The exercise of such powers, particularly in circumstances which result in the death of a member of the community, requires transparent and independent scrutiny. Doing so serves a number of purposes, including ensuring that such powers are exercised appropriately and responsibly, and to reassure the community that where lethal force is used, it is only used as a measure of last resort in appropriate circumstances.

2.4 In this context it should be recognised at the outset that the operation of the Act, and the coronial process in general, represents an intrusion by the coronial jurisdiction and inquest process into what is usually one of the most traumatic events in the lives of family members who have lost a loved one.

At such times, it is reasonably expected that families will wish to attempt to cope with the consequences of such a traumatic event in private. The sense of loss experienced by family members does not diminish significantly over time. Therefore, it should be acknowledged that both the coronial process and an inquest by their very nature unfortunately compel a family to re-live distressing memories and to do so in a public forum.

3. Hillal’s life 3.1 Inquests and the coronial process are as much about life as they are about death. A coronial system exists because we, as a community, recognise the fragility of human life and value enormously the preciousness of it. Understanding the impact that the death of a person has had on those closest to that person only comes from knowing something of that person’s life. It is hoped that what is set out briefly below acknowledges Hillal’s life in a meaningful way.

3.2 Hillal was born on 11 January 1994 to Maha and Mahmoud Barbour. Hillal had a number of siblings: older brothers, Omar and Mohamad; younger brothers, Sirraj and Mounir; and sisters, Reema and Zahar.

3.3 Hillal grew up in southwest Sydney and lived with his family in Yagoona.

3.4 Reema describes her brother as a beautiful soul and empathetic person who cared for others beyond himself. Hillal was a constant source of love and support, as well as a friend and confidant, for Reema.

3.5 Although Hillal grappled with his own personal struggles he always had time for those around him, especially his family. Serving and helping others was important to Hillal. Apart from being a loving brother, Hillal was also a kind-hearted uncle. Hillal spent much of his free time with his nieces and nephew, and they loved having him around.

3.6 Hillal was someone who showed much empathy and care for others. He was known to often walk around with a smile on his face, cheering up those around him, especially his nieces and nephew.

3.7 There is no doubt that Hillal is greatly missed by his family and loved ones. His untimely passing has left an enormous and painful void in those who miss him the most.

4. Hillal’s medical history 4.1 On 2 September 2020, Hillal presented to Bankstown Hospital Emergency Department reporting a history of auditory hallucinations for at least five years, and possibly since Hillal was 15 years old (10 years duration). Hillal said that he had been having thoughts that his family did not want him, and that he felt unsafe and anxious all the time. He also reported that the voices were “telling him to hurt people” but that he never did so. Hillal also reported a history of depression and anxiety.

4.2 Hillal was initially offered admission as an involuntary patient which he declined. He was subsequently detained as an involuntary patient only to abscond later that afternoon. On the afternoon of 3 September 2020, Hillal represented to Bankstown Hospital and was admitted overnight. Following review by a consultant psychiatrist, Hillal was found to not be exhibiting any severe mood disturbance, delusions or hallucinations, thought disorder or irrational behaviour and was later discharged on 4 September 2020 for community follow-up.

4.3 On 15 September 2020, Hillal was reviewed by Dr Andrew Kaill who noted that Hillal had risk factors for psychotic illness and considered Hillal may have previously experienced drug-induced psychosis on a background of prolonged cannabis, and intermittent cocaine, use. Hillal was offered a trial of antipsychotic medication (aripiprazole) daily.

4.4 On 29 September 2020, Dr Kaill reviewed Hillal again who reported side effects from the aripiprazole and indicated that he did not want to take it anymore. Hillal also indicated that he was under a lot of stress but denied any suicidal ideation. Dr Kaill prescribed a low dose quetiapine for Hillal.

4.5 On 13 October 2020, Dr Kaill reviewed Hillal again who reported continued auditory hallucinations, stress, unhappiness and continued cannabis use. Hillal declined offers of antidepressant medication and an increased dose of quetiapine, indicating that he was “sick of attending medical appointments”.

4.6 On 8 February 2022, Hillal’s sister contacted the NSWPF to report that Hillal was behaving aggressively, including threatening family members with a knife, and endangering himself. NSWPF officers attended Hillal’s home. He met them at the door and told them to, “Fuck off”. Hillal was observed to be agitated and later detained under the provisions of the Mental Health Act 2007.

However, Hillal resisted this process and attempted to jump off a balcony leading him to be restrained and then taken to hospital.

4.7 Later that evening, Hillal was assessed by a Mental Health Team which found that he was calm and coherent, and not acutely thought disordered or displaying pervasive depression symptoms.

Following consultation with Dr Kaill, it was considered that Hillal was not displaying acute psychosis and there was no basis to detain him on an involuntary basis. Hillal was discharged and referred for follow up in the community.

4.8 Following the above incident, the NSWPF applied for an apprehended domestic violence order (ADVO) nominating Hillal’s father, mother and brother (Sirraj) as the persons in need of protection.

On 2 March 2022, the ADVO was issued for a period of two years.

4.9 On 15 February 2022, Dr Kaill reviewed Hillal noting that he was irritable, reporting ongoing dissatisfaction and social isolation but denying any auditory hallucinations.

5. The events of 5 March 2023 5.1 At 8:49am on 5 March 2023, Hillal’s brother, Mohamad, contacted Triple Zero and reported the following: I’ve got my brother, he’s aaaah, he’s got a bit of mental issues but ah, but he’s going crazy and he’s threatening everyone in the house . And he’s walking around with a shovel, following his mum with a shovel. I just need youse to come in and … 5.2 Later in the call, Mohamad reported: He’s got a shovel, I don't know where it is now. He’s got a shovel and wherever his mum is going he’s following her and she's worried he will knock her out with it.

5.3 Mohamad also confirmed that Hillal was having a mental health episode, that he been diagnosed with schizophrenia and that he did not take any medication. When asked whether he wanted Hillal assessed or that if an ambulance was needed, Mohamad replied: Yeah assess, nah assess, police and aaaah, because you’ll probably have to detain him and hold him down. Cause when you get there and the cops get there, he's going to go berserk.

5.4 In response to a question whether Hillal had consumed any drugs or alcohol, Mohamad said: Well, he’s already berserk. Ah, I know he regularly smokes pot. Ah and he has […] me up and said he's […] threatening me saying oh I’m going to get you and this and that.

5.5 At 8:49am, a job broadcast was made over NSWPF radio (known as VKG) and the incident details contained in the Computer Aided Dispatch (CAD) were as follows:

INFT BROTHER HILLAL BARBOUR APPROX 270LD IS HAVING A MH EPISODE AND THREATHENING [SIC] EVERYONE IN THE HOUSE WITH A SHOVEL -THREATENING INFT MUM WITH IT - NIL CHILDREN -POSS AVO - PREV OCC -POI DIANOSED WITH SCHIZOPHRENIA - NOT TAKIGN [SIC] HIS MEDS -NIL CURR INJ -AMBOS REQ FOR HIS MH -REG SMOKES WEED 5.6 The job was designated as a Priority 2 which meant that an urgent response was required.

5.7 At the time, Constable Lieberman and Probationary Constable Grammatikos were working together in a NSWPF vehicle with callsign Bankstown 17 (BK17) at the time. They acknowledged the job and proceeded to Hillal’s address in Yagoona, arriving at 8:51am.

5.8 After exiting their vehicle, both NSWPF officers activated the Body Worn Video (BWV) device attached to their uniforms and approached the front door of the house. At a point when he was on a grass area in front of a concrete porch, and at a distance of approximately two metres, Probationary

Constable Grammatikos saw Hillal standing behind a screen door. Probationary Constable Grammatikos opened the screen door and saw Hillal move forward through the outward opening screen door and produce a knife in each hand.

5.9 Probationary Constable Grammatikos stepped backward and drew his taser. Both he and Constable Lieberman instructed Hillal to drop the knives. Hillal continued to advance with the knives in his hands. Probationary Constable Grammatikos deployed his taser with the two projectiles making contact with Hillal. This caused Hillal to take a step back into the wall of the porch and drop down to the ground. Probationary Constable Grammatikos initiated a second cycle on his taser.

5.10 However, Hillal used one of the knives that he was holding to cut the wires of the taser. He stood back up and continued advancing towards the NSWPF officers. Constable Lieberman moved backwards and lost her footing, causing her to fall to the ground. Hillal advanced quickly towards Constable Lieberman. As he did so, Probationary Constable Grammatikos moved towards Hillal who suddenly turned his attention to Probationary Constable Grammatikos, advanced towards him and used the knives in his hand to make a slashing motion towards Probationary Constable Grammatikos. Probationary Constable Grammatikos felt something sharp strike his left temple and neck.

5.11 Probationary Constable Grammatikos moved to the right as Hillal continued to advance towards him, still holding the knives. Probationary Constable Grammatikos unholstered his firearm and discharged three rounds at Hillal who collapsed to the ground. Constable Lieberman had withdrawn her oleoresin capsicum (OC) spray by this point and discharged it at Hillal who was lying on the ground.

5.12 Probationary Constable Grammatikos made a broadcast on NSWPF radio that shots had been fired and called for an ambulance as a male person had sustained gunshot wounds to the chest. Both Probationary Constable Grammatikos and Constable Lieberman commenced providing first aid to Hillal.

5.13 At 9:06am, NSWA paramedics arrived on the scene and assessed Hillal. He was found to be displaying agonal breathing with no signs of a pulse. A NSWA Medical Retrieval Unit, including a pre-hospital and retrieval Registrar, also arrived on scene a short time later. Hillal was by this stage unresponsive and in cardiac arrest. An ultrasound was performed which showed cardiac activity with no obvious pericardial effusion or tamponade.

5.14 Hillal was conveyed by ambulance to Liverpool Hospital, arriving at 9:54am. Despite continued treatment, Hillal could not be revived and was pronounced life extinct at 9:58am.

6. The post-mortem examination 6.1 A post-mortem examination was performed by Dr Lena Quinto, forensic pathologist, on 7 March 2023 at Forensic Medicine Sydney. The significant findings from the examination can be summarised as follows:

(a) An entrance gunshot wound situated on the right upper chest with the wound track extending through the 3rd rib and sternum anteriorly, perforating all lobes of the lung and 8th rib posteriorly. The projectile was lodged in the right lateral back inferior to the shoulder blade.

(b) An entrance gunshot wound situated on the right lower lateral abdomen with the wound track extending through the surrounding muscle, causing haemorrhage to the surrounding soft tissues, and right hip bone. The wound track did not enter the abdominal cavity, and there was no identified injury to any large blood vessels in the region. The projectile was located in the posterior superolateral gluteal region.

(c) Two taser marks present on the skin of the chest and abdomen, just to the right of the midline in the lower chest and to the right and superior to the umbilicus.

(d) Toxicological analysis of preserved femoral blood detected cannabinoids.

6.2 In the post-mortem examination report dated 21 August 2023, Dr Quinto opined that the cause of Hillal’s death was gunshot wound to the chest.

7. What issues did the inquest consider?

7.1 Prior to the commencement of the inquest a list of issues was circulated amongst the sufficiently interested parties, identifying the scope of the inquest and the issues to be considered. That list identified the following issues for consideration: (1) Was the response by police to the 000 call on 5 March 2023 appropriate, and in accordance with NSW Police Force policies and procedures?

(2) Were the interactions between police and Hillal Barbour conducted appropriately, lawfully, and in accordance with NSW Police Force policies and procedures, including the use of force?

(3) Even if NSW Police Force policies and procedures were followed, does a review of the circumstances of Mr Barbour’s death indicate that other measures should have been taken?

7.2 As part of the coronial investigation, Associate Professor Danny Sullivan, consultant forensic psychiatrist, was instructed to provide a report addressing a number of questions regarding the circumstances of Hillal’s death.

7.3 In addition, Sergeant David Lamb, NSWPF Senior Operational Safety Instructor, provided a statement commenting on the actions of Constable Lieberman and Probationary Constable Grammatikos on 5 March 2023.

8. Was the NSWPF response to the Triple Zero call appropriate?

8.1 Consideration of the appropriateness of the NSWPF response to the Triple Zero call made on 5 March 2023 centred around two issues:

(a) whether appropriate information was gathered by Constable Lieberman and Probationary Constable Grammatikos prior to attending Hillal’s home; and

(b) whether Constable Lieberman and Probationary Constable Grammatikos conducted appropriate planning before approaching the front door to Hillal’s home.

Information gathering 8.2 At around 8:49am on 5 March 2023, this initial broadcast was made over VKG: Bankstown car, car in the vicinity you've got a domestic. 20 ... correction, 221 William Street, Yagoona nearest cross is the Hume Highway. Informant’s brother, Hill al Barbour approximately 27 years old, suffering a mental health episode, threatening everyone in the house with a shovel, is threatening the informant's mother with it currently, is possibly a AVO, living with schizophrenia and is not taking his meds. For a Bankstown car or car in the vicinity.

8.3 Constable Lieberman and Probationary Constable Grammatikos acknowledged the job and were advised by VKG that they were the only NSWPF car available.

8.4 Shortly after BK17 acknowledged the job, this further broadcast was made on VKG: For Bankstown 17, um and Bankstown 14 when you're making your way, um the checks for that location there's no warnings, no ILS, got 29 events, most recently mental heath act. Hillal Barbour is known to location with warnings, he's not the only person known there with warnings. Ah, Hillal has 5 warnings, level of resistance, unarmed resistance control wrestle, is violent and aggressive towards police, strong hatred for police, exercise caution thanks. He has been warned about fishing without a licence, zero tolerance for future offences, will try to film police interactions, may be in possession of a knife, search with caution as knife was located in close proximity after a search. Ah he's got 153 events, 23 intel if required um there is a enforceable AVO […] Hillal is the person listed as the POI, conditions 1, A, B, C.

8.5 It is clear from the above VKG broadcasts that Constable Lieberman and Probationary Constable Grammatikos were required to attend a location where a suspected domestic violence incident was occurring. This mean that the Code of Practice for the NSW Police Force Response to Domestic and Family Violence (Code of Practice) applied to their response. The Code of Practice, under the heading The steps police take in the process, relevantly provides the following: Safety first The primary responsibility for police when responding to any incident is safety first. This includes the safety of attending police and any/all persons who are present at the incident, especially children.

Before attending the scene of a reported domestic and family violence incident, police, where possible, will gather all available information about the location, incident and the persons involved.

This includes the existence of any current or expired ADVOs, and whether any party is in possession of, or has access to, firearms or other weapons. This information enables police to conduct an operational risk assessment prior to attending the scene.

8.6 During her NSWPF directed interview on 6 March 2023, Constable Lieberman stated that after the above VKG broadcasts were made she attempted to access further information from the NSWPF Computerised Operational Policing System (COPS) via the Mobile Data Terminal (MDT) installed inside the NSWPF vehicle. Constable Lieberman stated: So on the , the job, that states the, there’s a male threatening their parents it comes up with the job information and then there was section where you can attach links of people and locations and […] any information about them , any warnings , charges , events , intel um , so I could see the front CAD page but I couldn’t load the links that it takes you to on , on COPS.

8.7 Constable Lieberman went on to explain the rationale for seeking to access the links referred to above: It just gives you information about their previous dealings with police, any warnings about them that would be helpful to us to know their nature or um, any other yeah previous events or charges.

8.8 However, Constable Lieberman stated that whilst she was able to use the MDT to access to links relating to Hillal’s parents, she was unable to access any links relating to Hillal because it was “taking time to load”. Constable Lieberman also stated that she did not have any discussion with Probationary Constable Grammatikos regarding being unable to access the links relating to Hillal.

8.9 Constable Lieberman gave evidence that if the links had actually worked she would have been able to access, amongst other things, information regarding Hillal’s previous interactions with the NSWPF and intelligence reports. When asked whether having this information available to her would have changed her approach, Constable Lieberman gave this evidence: No. It wouldn’t have changed our approach. We already got given the warnings from radio which is the most important part.

8.10 Probationary Constable Grammatikos gave evidence that he had previous experience generally of information from an MDT being slow to load due to “connection issues” or “technical difficulties”.

However, Probationary Constable Grammatikos gave evidence that he was unaware whether the MDT in BK17 was experiencing such issues on 5 March 2023 and that he was “unable to comment” on whether Constable Lieberman only had access to some, but not all, information links via the MDT.

When asked whether Constable Lieberman relayed anything to him from what she was reading on the MDT, Probationary Constable Grammatikos gave this evidence: There would have been some form of discussion but I can’t recall - I can’t recite or recall the exact discussion that took place then.

8.11 Notwithstanding, Probationary Constable Grammatikos gave this evidence as to the extent of his knowledge of the job, drawn from the initial VKG broadcast, prior to arriving on scene: Obviously, it was a domestic - it was obviously - I was aware that it was a domestic violence incident.

Like, there was, like, my understanding there was mention of a mental health episode but it’s - how I primarily talk about it is as a domestic violence incident.

8.12 Constable Lieberman and Probationary Constable Grammatikos both gave evidence that their approach on 5 March 2023 would have been the same regardless of whether:

(a) there was only a domestic violence component to the job;

(b) there was only a mental health component to the job; or

(c) there was both a domestic violence component and a mental health component to the job.

8.13 In this regard, Probationary Constable Grammatikos gave the following evidence: [W]e have, as a police officer, have a duty of care to ensure that members of the community are safe, even - even for Hillal, ensuring his safety as well.

8.14 Detective Acting Superintendent Virginia Gorman, the Senior Critical Incident Investigator, was asked whether there might have been additional information available to Constable Lieberman (and Probationary Constable Grammatikos) prior to their arrival at the scene. Detective Acting Superintendent Gorman replied: I don't think anything essential over and above what she was already told by VKG, who obviously provide the most essential information in the radio call.

8.15 In his report, Associate Professor Sullivan noted that the attending NSWPF officers were apprised of at least some of Hillal’s mental health concerns and his past antagonism towards the NSWP.

Associate Professor Sullivan also noted that whilst appropriate information was contained within the COPS system the urgency of the NSWPF response required precluded further information gathering. Associate Professor Sullivan went on to express this view:

[A] review of the clinical notes suggest that Mr Barbour preferred to see female clinicians rather than male and although there was no evidence of antagonism specifically towards men, had that information been available, it may have been preferable that the female police member approached the door rather than the male. Having said this, given that Mr Barbour already had knives in his hand, I do not consider this would have made any difference in his level of aggression or would have enabled any negotiation.

8.16 Detective Acting Superintendent Gorman also gave evidence that she made a number of enquiries regarding the MDT that was installed in BK17 and learned that no repairs had ever been made to that device, leading her to conclude that it was functioning on 5 March 2023. Detective Acting Superintendent Gorman gave evidence that as the MDT relies on internet connectivity it is susceptible to slow download speeds. However, from her enquiries, Detective Acting Superintendent Gorman was unable to identify any specific reason why the MDT in BK17 was functioning slowly on 5 March 2023. However, Detective Acting Superintendent Gorman gave evidence that the MDTs are no longer in use, having been replaced by tablets installed in certain NSWPF vehicles.

8.17 Sergeant Lamb gave evidence that he had personal experience with information being slow to load, or not loading at all, on a MDT. Sergeant Lamb also gave evidence that this was not an uncommon issue, particularly in the western regions of Sydney due to issues with reception. Sergeant Lamb gave evidence that since the MDTs had been upgraded he personally had noticed an improvement in connectivity by the replacement tablets.

8.18 Conclusions: In accordance with the Code of Practice, whilst en route to Hillal’s house Constable Lieberman attempted to gather further relevant information regarding Hillal and the job that she and Probationary Constable Grammatikos were responding to. However, the MDT installed in BK17 was functioning slowly meaning that Constable Lieberman was unable to access this information.

The precise reason for the slow MDT performance cannot be precisely identified although it is most likely related to internet connectivity issues. This is consistent with anecdotal evidence regarding the performance of MDTs in other situations and locations.

8.19 Despite being unable to access additional relevant information from COPS via the MDT in BK17, there is no evidence to suggest that this compromised the NSWPF response. The evidence establishes that the two VKG broadcasts made at around the time that BK17 acknowledged the job provided Constable Lieberman and Probationary Constable Grammatikos with sufficient information to respond to it. In other words, they were aware that they were responding to a job with both domestic violence and mental health components to it, that Hillal was armed, that Hillal has previously been involved in an incident where he was found to have a knife, and that he had previously behaved aggressively towards police.

8.20 However, it should be noted that if the attending NSWPF officers had been able to gather more information via the MDT it might have allowed for a different approach on 5 March 2023. For example, as Associate Professor Sullivan noted, consideration might have been given to which of the NSWPF officers could have made the initial approach to Hillal at the screen door. That said, it is not possible to determine whether any different approach might have materially altered the subsequent events.

8.21 Since March 2023, the MDTs in certain NSWPF police vehicles have been replaced with tablets. Whilst this topic was not explored in detail during the inquest, there is anecdotal evidence indicating that the new tablets are less susceptible to the performance issues encountered by Constable Lieberman on 5 March 2023. Accordingly, it is neither necessary nor desirable to make any recommendation regarding this matter.

Planning 8.22 In January 2015, the NSWPF introduced STOPAR (Stop, Think, Observe, Plan, Act, Review), a critical thinking model to assist all sworn NSWPF officers when attending incidents. Sergeant Lamb explained that the aim of STOPAR “was to reiterate the importance of an officer to refocus their mind on the immediate situation at hand, and, in so doing, thereafter giving it the correct appreciation in all aspects”. STOPAR relevantly indicated that in relation to planning, NSWPF officers should “identify the best option/s and how you implement your plan”.

8.23 The Code of Practice, under the heading, What police do when they attend the scene, relevantly provides: Plan of action On arriving at the scene police should:

• Assess the risks and threats

• Gain safe entry to the premises if necessary

• Ensure the safety and welfare of persons present

• Locate any children and witnesses

• Detect any offences committed, including the breach of any court order

• Identify and apprehend offenders

• Preserve the scene and collect physical evidence 8.24 The Code of Practice also relevantly provides: Timeliness of the police response Police will prioritise all reports of domestic and family violence no matter how, or whom they are received from.

[…] 8.25 The job broadcast on VKG on 5 March 2023 was allocated a Priority 2 response. This meant that an urgent response was required and two NSWPF vehicles would ordinarily have been required to attend the job.

8.26 In oral evidence, Constable Lieberman was asked whether, after arriving at the scene, she would have waited for a second NSWPF crew to arrive. Constable Lieberman answered: No. Because - because it’s come over as urgent, it said there was possible weapons involved which was a shovel, possible victims being threatened, we don’t have time to wait for another car if there’s a possibility of someone getting hurt.

8.27 Probationary Constable Grammatikos gave evidence that it was his expectation that two NSWPF car crews would usually be assigned to a Priority 2 job and that on 5 March 2023 a second car would have attended “in a perfect world”. However, Probationary Constable Grammatikos gave evidence that although it was not common for only one NSWPF car crew to attend a Priority 2 job it was “not unheard of”. When asked whether he considered it appropriate to wait for a second NSWPF car crew to arrive at the scene on 5 March 2023, Probationary Constable Grammatikos gave this evidence: No, because I would be neglecting my duties as a police officer.

[…] No, because of the nature and seriousness of the job at hand.

8.28 Constable Lieberman was similarly asked whether, at the point that it became apparent that Hillal was armed with two knives, there was an opportunity to “pull back and wait for the second car”.

Constable Lieberman replied: No. Because there’s still other people in the house and we yeah. Then then, there’s someone standing in front of us with two knives, so we have to deal with that as it comes.

8.29 Sergeant Lamb similarly expressed the view that there was no opportunity for Probationary Constable Grammatikos and Constable Lieberman to wait for a second NSWPF car crew to arrive: [J]ust because of the urgency of the job being broadcasted as a priority [2]. Where they're told someone's armed with a shovel and making threats to the parents, that's obviously a level of urgency that requires a immediate police response.

8.30 In her directed interview, Constable Lieberman said that whilst in BK17 she did not have any discussion with Probationary Constable Grammatikos regarding the information that had been broadcast over VKG. There is no evidence that Constable Lieberman and Probationary Constable Grammatikos discussed how they would approach the incident after arriving at the scene, or after they exited BK17. There is therefore no evidence that Constable Lieberman and Probationary Constable Grammatikos engaged in any overt planning prior to arriving at the front door to Hillal’s house.

8.31 Probationary Constable Grammatikos gave evidence that after he and Constable Lieberman arrived on scene “[t]here was no time for assessment”. He said that “in a perfect world” he ideally would have liked to have all the information that Constable Lieberman was seeking to obtain via the MDT.

However, Probationary Constable Grammatikos gave evidence that “there was no time to obtain that information”, with the only time to obtain such information limited to the period between when the job was accepted and when BK17 arrived at the scene. Probationary Constable Grammatikos explained: [U]nfortunately, it’s one of those jobs that you can’t just wait and review links and everything like that because it - I would say it’d be scrutinised if we, sort of, sat in the car and not attended a job and something had happened, then we’d be liable for saying, like, why - why would police be, like, why did police, like, hesitate or wait to go […]

8.32 Ultimately, Probationary Constable Grammatikos gave evidence that even having the additional information available from the MDT would not have changed his approach: [M]ental health is one of those things, you can’t - I can’t read his mind, I can’t assume how he’s going to react. It’s like he could either be violent or he could be completely normal. It’s luck of the draw, unfortunately. I’ve gone to multiple mental health incidences or mental health jobs that some people might be, like, aggressive and everything like that and some are completely fine and normal, like, completely calm, I mean.

8.33 Constable Lieberman similarly gave evidence that whilst being able to access the MDT might have provided her and Probationary Constable Grammatikos with more information about Hillal’s mental health history, it would not have changed her approach to the job.

8.34 Sergeant Lamb gave evidence that planning as part of the STOPAR model could include non-verbal communication and what he described as “implied planning”. Sergeant Lamb gave evidence as to what he identified as the planning between Probationary Constable Grammatikos and Constable Lieberman after they arrived on scene.

Yeah, because they both heard the information, so they both sort of know what they need to do for that, and that is identify that POI and secure that weapon and then identify any victims that they may need to do. So that would be an implied plan that commences with our training at the academy.

8.35 Conclusions: In accordance with the Code of Practice, Constable Lieberman and Probationary Constable Grammatikos were required to respond in a timely manner to the reported domestic violence incident on 5 March 2023. Indeed, the priority rating given to the job required an urgent response. On the information provided, there was a need for the NSWPF officers to identify whether any person at the scene was armed and whether any person was at risk of physical harm.

8.36 Constable Lieberman and Probationary Constable Grammatikos therefore proceeded directly to the front door of Hillal’s house after exiting BK17. There is no evidence that they engaged in any active planning regarding their approach or even discussed the information about Hillal that had been broadcast over VKG. It is difficult to make any assessment as to whether such discussion or active planning might have resulted in a different outcome given the firm evidence given by Constable Lieberman and Probationary Constable Grammatikos that they would not have changed their approach, irrespective of whether additional information about Hillal had been available to them.

As already noted above, had such additional information been available it might have allowed for a degree of planning and possibly a different approach.

8.37 The available evidence suggests that Constable Lieberman and Probationary Constable Grammatikos simply did not have time to engage in any such planning or discussion after they arrived on scene given that the job required an urgent response. Notwithstanding, despite the exigencies of the situation, there still was an opportunity, although brief, for at least some degree of discussion or planning regarding the information broadcast on VKG. This could have occurred after acknowledging the job and before they arrived on scene. However, given the limited time involved (approximately two minutes) it is unclear whether such discussion, had it occurred, would have allowed for any material difference in the approach of the two NSWPF officers.

9. Were the interactions between the NSWPF and Hillal conducted appropriately?

9.1 In examining whether the interactions between the attending NSWPF officers and Hillal were conducted appropriately on 5 March 2023, consideration was given to these specific issues:

(a) whether it was appropriate for Probationary Constable Grammatikos to deploy his taser at Hillal;

(b) whether it was appropriate for Probationary Constable Grammatikos to discharge his firearm at Hillal; and

(c) whether it was appropriate for Constable Lieberman to deploy her OC spray at Hillal.

Deployment of taser 9.2 Probationary Constable Grammatikos gave evidence that as he approached the front porch of Hilla’s house he observed that the front door was open but that a screen door was closed. Probationary Constable Grammatikos gave evidence that beyond the screen door he could not “clearly see into the residence” and that he could “only see a silhouette of a person”. Probationary Constable Grammatikos gave evidence that he heard Hillal (although he did not know Hillal’s identity at the time) swearing and screaming words to the effect of, “What the fuck are you doing here?”.

Probationary Constable Grammatikos also gave evidence that he opened the screen door but could not recall whether this occurred before or after he heard Hillal swearing and screaming.

9.3 When asked about his purpose in opening the screen door, Probationary Constable Grammatikos gave this evidence: [T]o see the person and basically, as part of my risk assessment, basically to evaluate what was - what was going on because it’s, like, the nature of - the nature of the call itself was the person of interest armed with a shovel threatening his family. So, there’s a risk of some form of harm to the family so it’s, like, I guess, it’s trying to form some kind of evaluation of what’s going on, I guess.

9.4 Probationary Constable Grammatikos went on to explain that this was a judgment call that he made and that he did not think whether opening the door “might not be the best thing” given that he was aware (from the VKG broadcast) that he was responding to a job involving a person who was experiencing a mental health episode and who was known to be aggressive towards police.

Probationary Constable Grammatikos explained:

Well, to be honest, police attendance in general probably would have escalated things but it’s, like, I can’t just turn away and just say, like, no worries, I’ll come back in half an hour. Because, like, what in the instance that someone’s dead inside and then after I would be scrutinised for not acting.

9.5 Probationary Constable Grammatikos gave evidence that after he opened the door he took a “reactionary step back” to create some distance between himself and Hillal who at this point had his hands behind his back and was still swearing. Probationary Constable Grammatikos gave evidence that he suspected that Hillal was holding a weapon and instructed him multiple times to show police his hands. Probationary Constable Grammatikos gave evidence that Hillal advanced and brought his hands to the front, revealing a knife in each hand.

9.6 Probationary Constable Grammatikos and Constable Lieberman continued to retreat by taking three or four steps backwards and Probationary Constable Grammatikos discharged his taser. The prongs made contact with Hillal, causing him to scream and drop to the ground on the front porch, with his back against a side wall. Probationary Constable Grammatikos and Constable Lieberman repeatedly told Hillal to drop the knives. Probationary Constable Grammatikos gave evidence that Hillal was “screaming and still getting angry and getting worked up and everything like that”.

Probationary Constable Grammatikos gave evidence that he cycled the taser for a second time.

5.1 The NSWPF Tactical Options and Use of Force Manual (TOU Manual) explains that the NSWPF first adopted a tactical options model in 1998, and goes on to provide: The current model allows for the fact that each operational situation or circumstance is unique and variable. It provides you with ten tactical options when use of force is needed to resolve a situation which poses a threat to your safety or the safety of others. It is designed to be easily understood and easily implemented.

This model also includes the risk assessment process you need to use to ensure that chosen force options and tactics are appropriate to a given circumstance.

The model:

• is non-linear, allowing you to choose force options or tactical concepts based on the unique elements present at the time

• allows you to transition between options as required

• is based on a process of risk assessment whereby you assess and reassess a given circumstance to meet ongoing potential or actual threats

• allows for rapid escalation and/or de-escalation in dynamic and changing situations

• allows for the cohesive use of multiple options to minimise injury to all involved.

9.7 The TOU Manual identifies ten tactical options including communication, OC spray, firearm and conducted electrical weapon (CEW) or taser. The Use of Conducted Electrical Weapons (Taser) Procedures relevantly provide: The Taser may be discharged at the discretion of the Taser User after proper assessment of the situation and the environment to:  Protect human life  Protect yourself or others where violent confrontation or violent resistance is occurring or imminent

 Protect an officer(s) in danger of being overpowered or to protect themselves or another person from the risk of actual bodily harm […] When considering the discharge of a Taser, officers should consider all tactical options available to them in the Tactical Options Model. Before removing the Taser from the holster, officers will assess if the deployment of a Taser is the most appropriate option in the circumstances. [original emphasis] 9.8 When asked in his directed interview why he deployed his taser, Probationary Constable Grammatikos stated: Because I felt where my life was, my, mine and my offsider’s life was in danger mainly ‘cause of the fact that there was a high chance of us being wounded with, with a knife.

[…] So I've deployed that as he was armed with two knives and I felt that my , my , my life and my partner's life was in danger or even possibly the mother of [Hillal] as she was in that, she was close to that proximity , or whether he could 've lashed out at her if he, if she tried to stop him or something like that.

9.9 Sergeant Lamb expressed this view regarding Probationary Constable Grammatikos’s decision to deploy his taser at Hillal: Given the words and actions of [Hillal], and that he was armed with 2 knives, it is clear that there is a risk of actual bodily harm. The decision by Probationary Constable Grammatikos to deploy a Taser is consistent with the Tactical Options Model and within the bounds of training.

9.10 Sergeant Lamb gave evidence that in order to achieve neuromuscular incapacitation (NMI) the probes fired from the taser needed to “break the belt line”, meaning that one probe each needed to impact above and below a person’s waistline. Sergeant Lamb gave evidence that after watching the BWV he could see that the lower probe was stuck in the pocket of Hillal’s jumper which provided an extra layer of clothing. Sergeant Lamb gave evidence that if a person is wearing multiple layers of clothing this may render a taser ineffective.

9.11 Conclusions: The evidence establishes that after Constable Lieberman and Probationary Constable Grammatikos identified that Hillal was armed with two knives they both instructed Hillal repeatedly to drop the knife whilst they retreated backwards away from the screen door. Despite these instructions, Hillal continued to advance towards the two NSWPF officers.

9.12 It is therefore evident that both Constable Lieberman and Probationary Constable Grammatikos used the tactical option of communication in an attempt to eliminate the immediate threat that Hillal posed being armed with two knives and advancing towards them. This communication was unsuccessful in eliminating the threat as Hillal did not comply with the instructions given to him. In these circumstances it was appropriate for Probationary Constable Grammatikos to deploy his taser at Hillal. As the first cycle of the taser was unsuccessful in achieving NMI and as Hillal remained armed, it was appropriate for a second cycle of the taser to be activated.

Discharge of firearm 9.13 However, Hillal used one of the knives to cut the taser wire, stood up and ran towards Constable Lieberman who was retreating backwards. Constable Lieberman lost her footing causing her to fall to the ground with Hillal standing over the top of her, still armed with both knives. Probationary Constable Grammatikos approached and pushed Hillal off Constable Lieberman causing Hillal to go to the ground.

9.14 Probationary Constable Grammatikos gave evidence that Hillal stood up and rushed towards him and performed an “overhand slash” with one of the knives which made contact his left temple and left side of his neck. Probationary Constable Grammatikos gave evidence that he “rotated to the left to sort of try and dodge” before taking some additional steps backwards and drawing his firearm.

Probationary Constable Grammatikos discharged his firearm aiming for centre mass. Probationary Constable Grammatikos gave evidence that in doing so he believed that there was a risk that he may be fatally wounded by Hillal’s actions.

9.15 In his directed interview, Probationary Constable Grammatikos explained why he made the decision to discharge his firearm at Hillal: The reason for my discharging my firearm , because at that point in time he's still, like, his actions, his like, how he was presenting, ah, how his aggression was to police, how everything escalated, how it was going to end if I didn’t discharge my firearm, he would've either seriously injured myself or he would've killed, I thought he was going to, honestly I thought he was going to kill me. It was, like, whether he was going to kill me or, or kill my partner.

9.16 The TOU Manual refers to the NSWPF Handbook which provides: The decision to use your firearm rests with you. You are accountable for your actions. If you kill or injure a person when such action is not reasonable you could face serious criminal charges and or civil action.

You are only justified in discharging your firearm when there is an immediate risk to your life, or the life of someone else, or there is an immediate risk of serious injury to you or someone else and there is no other way of preventing the risk.

9.17 Sergeant Lamb gave evidence that he was not critical of Probationary Constable Grammatikos’s actions in discharging his firearm: You could quite clearly see Mr Barbour had again charged at police, obviously striking Constable Lieberman first, and then the actions of Constable Grammatikos in his actions going towards has

drawn Mr Barbour towards him and he was also struck, and it was in close proximity. And you could even see when he fired the second and third shots, he was even closer, he was right on top of him.

9.18 Sergeant Lamb explained the rationale for discharging a firearm as many times as required: So we’re trained to stop the threat. In this case, you can see that the first shot has hit, [Hillal] slightly stops, and then he comes again. So that hasn’t stopped the threat so he needs to fire. I believe the second one may have missed. And the third one, when he was very close, that struck him in the chest.

9.19 Sergeant Lamb was also asked about the reason NSWPF officers are trained to fire at centre mass and not, for example, at a person’s limbs, and gave this evidence: So if a situation is that extreme that's happening in front of us that we need to draw and use our firearm, then we need to aim at the centre of the body mass, and that's because it's a bigger target and it's more likely that we will be able to stop that threat from occurring. We don't aim at limbs because that is too difficult to hit, and even if we do, there's a greater chance of missing.

9.20 Conclusions: The decision by Probationary Constable Grammatikos to discharge his firearm at Hillal was in accordance with applicable NSWPF policy material. Prior to discharge, attempts to use communication had proved unsuccessful and Probationary Constable Grammatikos had already deployed his taser at Hillal which was also unsuccessful in eliminating the threat posed. Despite these attempts, Hillal continued to advance at both NSWPF officers whilst still armed. Hillal had also brandished the knives he was holding at Probationary Constable Grammatikos causing injury.

9.21 It can be accepted that this situation placed the lives of Constable Lieberman and Probationary Constable Grammatikos at risk, or at the least created an immediate risk of injury to them. In these circumstances, the decision by Probationary Constable Grammatikos to discharge his firearm was consistent with the TOU Manual and NSWPF Handbook. The expert evidence given by Sergeant Lamb supports a conclusion that the manner in which the firearm was discharged in order to stop the threat which confronted Constable Lieberman and Probationary Constable Grammatikos at the time was also consistent with NSWPF training.

Deployment of OC spray 9.22 Constable Lieberman gave evidence that after hearing the gunshots she was unsure whether the projectiles discharged from Probationary Constable Grammatikos’s firearm had struck Hillal.

Therefore, Constable Lieberman deployed her OC spray at Hillal. Constable Lieberman explained her rationale for doing so: Because the violent confrontation was still occurring, I thought he was going to still come towards us to stab us.

9.23 During her oral evidence, it was suggested to Constable Lieberman that Hillal’s family recalled that Hillal was sprayed with OC whilst he was on the ground. Constable Lieberman gave evidence that she could not recall that occurring and that she could “only recall spraying [Hillal] when he was standing in front of [the NSWPF officers]”.

9.24 Despite Constable Lieberman’s recollection, the BWV footage from both herself and Probationary Constable Grammatikos clearly shows Constable Lieberman deploying the OC spray whilst Hillal was on the ground. The BWV depicts Hillal on the ground, half sitting and propped up on one elbow with a knife in each hand and still moving at the time. Both Constable Lieberman and Probationary Constable Grammatikos repeatedly instructed Hillal to drop the knives but he did not do so and was still holding the knives when the OC spray was deployed. When asked to assume that this is what the BWV footage showed, Constable Lieberman explained that “the fact that [Hillal] still had the knives” meant that “there’s still a danger for someone to get hurt”.

9.25 The TOU Manual provides: OC Spray is a less lethal force option, which uses an airborne delivery system to convey an inflammatory agent to a subject’s location to restrain or limit the subject’s actions. You use OC spray in conjunction with another tactical option.

9.26 Further, the NSWPF Handbook provides: Use defensive sprays only for:  protection of human life,  a less lethal option for controlling people, where violent resistance or confrontation occurs (or is likely to occur),  protection against animals.

9.27 Sergeant Lamb gave evidence as to the use of the OC spray by Constable Lieberman: So I wouldn’t be able to say whether she's actually sprayed him on the ground. However, because he’s holding that knife and he’s still trying to get back up, because he wasn’t lying on the ground, he was sort of up and he starts moving again, and she’s gone in to spray, so I wouldn’t have an issue with that.

9.28 Conclusions: It is evident that the situation confronting Constable Lieberman and Probationary Constable Grammatikos, as well as Hillal, was rapidly evolving. At the time that Constable Lieberman deployed the OC spray, Hillal was on the ground next to a fence but still holding a knife in each hand and still moving. Given these circumstances, there was a need to prevent a continuation of the actions that Hillal had engaged in seconds earlier in advancing towards the NSWPF officers whilst armed with the knives.

9.29 The use of the OC spray by Constable Lieberman in controlling Hillal, and after a violent confrontation had occurred, was therefore in accordance with the TOU Manual and NSWPF Handbook. It is, however, entirely understandable that Hillal’s family consider the use of the OC spray to be particularly upsetting given that a firearm had been discharged seconds earlier and he was already on the ground.

10. Should any other measures have been taken by the NSWPF on 5 March 2023?

10.1 The inquest explored several other measures that might have been taken by Constable Lieberman and Probationary Constable Grammatikos on 5 March 2023, namely whether it was appropriate to:

(a) engage verbally with Hillal before approaching the screen door;

(b) engage verbally with Hillal whilst at the screen door; and

(c) open the screen door.

Verbal engagement before approaching the screen door 10.2 One issue considered during the inquest was whether there was an opportunity for the attending NSWPF officers to identify themselves and announce their office whilst approaching the front door to Hillal’s house. This might have provided an opportunity to engage in discussions with Hillal at a distance and without NSWPF officers standing directly outside his front door.

10.3 Probationary Constable Grammatikos gave evidence that there would not have been any time to verbally engage with Hillal before approaching and opening the screen door, and that there was no opportunity to identify himself and enquire about the identity of the person standing beyond the screen door. When asked why, Probationary Constable Grammatikos sought to explain: Because the timeframe of myself being at that - in that position to him being there, it’s, like, a millisecond between me opening that door. So, there’s no time to just stop, like, and it instantly started off as being, like, it would have been some form of violent confrontation. Well, in the sense of yelling and screaming, everything like that.

10.4 Sergeant Lamb gave evidence that whilst it would have been possible for Probationary Constable Grammatikos and Constable Lieberman to identify themselves after exiting BK17 and before they arrived at the front door this was not an approach which he advocated for. Sergeant Lamb explained: I would say yes, they would have time to call out but that’s not like, in this job, we wouldn’t be doing that, because again, we wouldn’t be calling out that it’s police arriving for anyone who’s armed with a weapon in there to then formulate a plan, to then attack us, or if they are attacking someone or if they hadn't decided to yet, us being there might be a reason for them to do that. There is [sic] a number of reasons there. We’re not going to announce at our office as we're approaching until we get to the front door.

10.5 Conclusions: Whilst it would have been possible for Constable Lieberman and Probationary Constable Grammatikos to seek to engage verbally with Hillal before they arrived at the screen door, the evidence establishes that this would not have been an appropriate tactical option. This is because the NSWPF officers were responding to a domestic violence incident with reports that there was an armed person inside the premises. Had the NSWPF officers identified themselves and announced their presence and office, this might have prompted a violent response, either towards other persons inside the premises, or towards the NSWPF officers themselves.

Verbal engagement at the screen door 10.6 Constable Lieberman gave evidence that having arrived at the screen door there was no opportunity to engage with Hillal in any other way: Because he’d walked straight towards us with the knives. There was no time for communicating and trying to reason with him.

10.7 When asked whether there was any opportunity to withdraw after observing that Hillal was holding two knives, Probationary Constable Grammatikos gave this evidence: No, because I don’t know what the - how the people inside the house are, whether they’ve been stabbed themselves or what the situation may have been, unfortunately.

10.8 Constable Lieberman similarly gave this evidence when asked if there was any opportunity to withdraw and wait for the arrival of a second NSWPF car crew after observing Hillal holding two knives: No. Because there’s still other people in the house and we - yeah. Then then, there’s someone standing in front of us with two knives, so we have to deal with that as it comes.

10.9 Sergeant Lamb was also asked whether there was any possibility of retreating to wait for the arrival of another NSWPF car crew and expressed this view: Yeah, I don't believe they could have. They were basically reacting to the actions of Mr Barbour. And like I said, he's charged at them, like, three times. So they wouldn't be able to totally retreat. Again, they've got to go in, find out if there's any victims, if anything's happened. That's their primary goal.

10.10 Sergeant Lamb also gave evidence that:

(a) he did no think that there was any opportunity for Probationary Constable Grammatikos and Constable Lieberman to engage verbally with Hillal whilst they were standing in front of the screen door because they “needed to see what was [beyond the screen door] and if they were holding a weapon”; and

(b) Probationary Constable Grammatikos and Constable Lieberman “may have” identified themselves and asked Hillal to identify himself but that in this case “there was no time for any of that” and that the priority of the NSWPF officers was to determine whether Hillal had a weapon.

10.11 Sergeant Lamb gave further evidence that whilst there was an option to engage only verbally with Hillal he considered that it was “paramount” in the minds of Constable Lieberman and Probationary Constable Grammatikos to open the door and ensure that the person in front of them did not have a weapon. Sergeant Lamb gave evidence expressing doubt that there was any opportunity to do something differently:

Again, given, like, the job they were going to, someone’s armed with a weapon and making threats, that they really need to go in there to make sure everyone else in the house is safe, as well as Mr Barbour, by taking the weapon off him.

10.12 In his report, Associate Professor Sullivan expressed this view: From my observations of body-worn camera footage, police had limited opportunity to engage in discussion with Mr Barbour. The body-worn camera footage captures the brevity of the interaction, and the limited opportunities for alternate courses of action such as retreating or negotiation. The verbal directions of police to Mr Barbour were clear, direct and would have been understood by a person with intellectual disability.

10.13 Associate Professor Sullivan gave evidence that it was clear that Hillal did not like the NSWPF (and that this had been made clear by his family members) but that the NSWPF officers still had to approach Hillal and make an assessment of the situation. Associate Professor Sullivan also gave evidence that in doing so, the NSWPF would have been looking for an opportunity to form a rapport, neutralise any antagonism, explain why they were there, and use verbal skills and body language to de-escalate the situation.

10.14 Associate Professor Sullivan expanded upon this in his oral evidence: I can’t over-emphasise the fact that in order to de-escalate a situation, typically one requires that period of being able to talk first […] I don’t think that the police had the opportunity there because as soon as they arrived, Hillal was angry. He was close to them and therefore there was no opportunity really to ask how things were, ask him to come outside and stand outside and have a talk, you know, to appraise the situation, which is the sort of measures that you would take to explore what was going on in a neutral and non-antagonistic way.

10.15 Conclusions: The ability of Constable Lieberman and Probationary Constable Grammatikos to further engage verbally with Hillal when they were standing in front of the screen door was limited by the need to confirm whether Hillal was in fact armed and whether any persons inside the house were safe. Further, Hillal’s almost immediate response upon seeing the NSWPF officers meant that there was no opportunity for the NSWPF officers to engage in any dialogue with Hillal.

10.16 Associate Professor Sullivan’s evidence establishes that any possibility of de-escalation was contingent upon a period of being able to talk first, which was not available on 5 March 2023.

Regrettably, there was therefore no opportunity for the NSWPF officers to seek to build any rapport with Hillal, explain why they had attended, or to use verbal communication and body language to de-escalate the situation.

Opening of the screen door 10.17 In his oral evidence Probationary Constable Grammatikos accepted that opening the screen door might have escalated a mental health episode that Hillal was experiencing. However, Probationary Constable Grammatikos explained his need to do so in this way:

[U]nfortunately, that’s sort of - that had to have happened. There was no way of avoiding that because there was no - there was no further information from other members of the family or anything like that calling out saying whether he had a knife or what the situation was. We just - unfortunately, we’re just dealing with it on the face value of what’s presented in front of us at that time.

10.18 Constable Lieberman was asked whether she accepted that it would be unhelpful for a NSWPF officer to open the screen door for someone like Hillal and gave this evidence: That is true. However, I think, in the moment, we didn’t know it was him, that was him at the door.

I’ve never met him before. But regardless, we still [sic] there’s no one else to come to job [sic], so we would still be the ones to have to speak to him.

10.19 Sergeant Lamb was asked whether Probationary Constable Grammatikos opening the screen door in order to identify the person standing beyond it was consistent with NSWPF training. Sergeant Lamb gave this evidence: So we are training with that [sic]. Obviously, it depends on the situation. In this situation, I would say he did the right thing because, again, because of the urgency in that job, he needs to see who it is, and because they were told someone was armed with a weapon, you need to be able to see if he’s, or if that person is holding a weapon, if they're a victim or a POI or whatever. In some cases that's lower urgency, then they will probably just get them just to come outside. But because of the information, someone's armed with a weapon, you need to get in there and make sure, firstly, everyone's safe and you secure that weapon.

10.20 When asked whether he accepted that a NSWPF officer opening the screen door in this situation might escalate the matter, Sergeant Lamb gave this evidence: And it's hard to say with each situation being different, but yes, it may well do. But again, the, like, the urgency of someone having a weapon, we need to get in there and sort that out.

10.21 When asked what he meant by “sort that out”, Sergeant Lamb explained further: So by that, I would mean that they need to get inside the premises, and again, identify the [person of interest], weapon, any victims. So when I say sort it out, it’s like getting there, and again, identify the POI, secure that weapon and any victims if they need first aid.

10.22 The issue of whether it would have been appropriate for the NSWPF officers to seek to engage with Hillal without opening the screen door was explored with Associate Professor Sullivan during his evidence who expressed this view: [T]he safety of the person assessing the situation is paramount so I think you can make a case for opening the door or not opening the door, but if you don’t open the door, you can’t see what’s happening outside - inside.

[…] So, in terms of entering the house or opening the door, I might take a different approach from the police but I would certainly be cautious if the person was speaking to me through a door but I

couldn’t see them properly and didn’t know what they had in their hands or whether they had a gun or a weapon.

10.23 In his report, Associate Professor Sullivan also offered this view: The rapid escalation of the situation did not in my opinion relate to any actions of police, but rather reflected that Mr Barbour was in an angry and aggressive state of mind and immediately attempted to assault police with weapons.

10.24 Conclusions: Both Constable Lieberman and Probationary Constable Grammatikos recognised that opening the screen door was likely to either be unhelpful or escalate the situation that confronted them. Equally, both NSWPF officers recognised that there was a need to do so in order to confirm Hillal’s identity and verify whether he was armed with any weapon. Associate Professor Sullivan’s evidence establishes that the manner in which the situation escalated was not as a result of the actions of the NSWPF officers in opening the screen door, or generally.

11. Findings pursuant to section 81(1) of the Act 11.1 I acknowledge and express my gratitude to Mr Patrick Rooney, Counsel Assisting. He has been assisted at various times throughout the coronial investigation and inquest by instructing solicitors, Ms Elizabeth Leung and Mr Harvey Zhang. I am also grateful for all of their tremendous assistance.

The Assisting Team has worked tirelessly to ensure that a comprehensive investigation has been conducted in a manner that has been most sensitive to Hillal’s family.

11.2 I also thank Detective Acting Superintendent Gorman, and her team of NSWPF investigators, for their thoroughness in conducting a critical incident investigation in a professional and independent manner, and for compiling the initial comprehensive brief of evidence.

11.3 The findings that I make under section 81(1) of the Act are: Identity The person who died was Hillal Barbour.

Date of death Hillal died on 5 March 2023.

Place of death Hillal died at Liverpool Hospital, Liverpool NSW 2170.

Cause of death The cause of Hillal’s death was gunshot wound to the chest.

Manner of death After arriving at a private property in response to a Triple Zero call regarding a reported domestic violence incident, two NSWPF officers encountered Hillal just inside the front door to his home. Hillal was armed with a knife in each hand and exited the front door advancing towards the NSWPF officers brandishing the knives. The limited duration of the encounter and the rapidly evolving situation did not allow sufficient time for any verbal communication or other action which might have deescalated the situation. One of the NSWPF officers, in the lawful execution of his duties, discharged his firearm at Hillal causing Hillal to sustain two fatal gunshot wounds to the chest.

12. Epilogue 12.1 On behalf of the Coroners Court of New South Wales and the Assisting Team, I offer my deepest sympathies, and most sincere and respectful condolences, to Hillal’s parents and siblings, his wider family, and his loved ones and friends for their most painful and tragic loss.

12.2 I close this inquest.

Magistrate Derek Lee Deputy State Coroner 18 September 2025 Coroners Court of New South Wales