Three years ago, Judy Deacon’s son was fatally shot dead by police after he was reported to be self-harming. She has since become one of the state’s loudest voices for change in how police respond to mental health incidents.Over the past week, in the long-awaited coronial inquest, answers to lingering questions over decisions made in the lead-up to 43-year-old Jesse Deacon’s death started to crystallise as health workers, police, and the officer who fired the fatal shot, took the witness stand.They all eventually fronted 82-year-old Judy, who forewent legal aid in favour of asking the witnesses questions herself. When she came face to face with the officer who shot her son, she asked, in a calm tone largely maintained throughout the inquest: What could be done to stop such deaths from happening again?“I think [the mental health systems] in place aren’t perfect. I’m not sure how to make it perfect,” responded the officer, whose identity is suppressed.“I’m not sure if there will ever be a stage where the police will have received enough training, enough education.”No warning of mental health historyThe inquest, which is before deputy state coroner David O’Neil, will provide recommendations in an attempt to answer that question. Counsel assisting the coroner, Donna Ward, said it will build on recommendations from the inquest into the fatal stabbings at Bondi Junction shopping centre, which recommended a suite of changes to the state’s mental health system.Sign up for the Breaking News Australia emailDeacon died one year before the Bondi Junction incident. On 19 July 2023, three police officers went to a public housing estate in Sydney after a neighbour reported someone at that address had cut their wrists. The officers saw droplets of blood on the stairs as they walked to the unit on the top floor. Then they saw it smeared across the door.“Hello mate, just the police, can you open the door please,” Const Riley Avery, the most junior of the trio, said as he knocked on the door, the inquest heard.‘I regret my son died because he wasn’t in hospital,’ Judy Deacon told the coroner’s court. Photograph: Steven Markham/AAPAfter another knock, and without discussing a plan, Avery kicked down the door in a decision the officers later said was due to the “perceived urgency” of the situation.