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J Urban Health. 2016 April; 93(Suppl 1): 78–88.
Published online 2015 December 14. doi:  10.1007/s11524-015-9996-6
PMCID: PMC4824693

Beacon of Hope? Lessons Learned from Efforts to Reduce Civilian Deaths from Police Shootings in an Australian State


In the 1990s, the police service in Victoria, Australia, faced a crisis of community confidence due to a spate of civilian deaths from police shootings. In that decade, twice as many civilians died at the hands of the police in Victoria than in every other Australian state combined. Most of those killed were mentally ill and affected by drugs and alcohol, and were rarely a serious threat except to themselves. The problem was also almost entirely an urban phenomenon. Shootings in rural communities, where mentally ill people were more likely to be personally known to local police, were (and remain) almost unknown. The large number of fatalities was recognised as a serious threat to public confidence, and Victoria Police introduced a ground-breaking training programme, Operation Beacon. Operating procedures and weapons training were fundamentally changed, to focus on de-escalation of conflict and avoiding or minimising police use of force. In the short term, Operation Beacon was successful. Shooting incidents were dramatically reduced. However, during the first decade of the new century, the number of civilians being killed again increased. This article examines Operation Beacon, both as a successful model for reducing civilian deaths at the hand of police and as a cautionary tale for police reform. We argue that the lessons of Operation Beacon have been gradually forgotten and that old habits and attitudes resurfaced. Fatal shootings of mentally ill civilians can be prevented, but if success is to be other than temporary, the Beacon philosophy must be continually reemphasised by police management.

Keywords: Mental illness, Policing, Police use of force, Police use of firearms, Civilian deaths caused by police, Mental health, Vulnerable communities, Victoria -- Australia, Operation beacon, Deinstitutionalization


The core mandate of a modern police agency is to protect the community it serves. When police kill vulnerable members of that community, public faith in police is gravely threatened. This article explores this problem, focussing on fatal police shootings of civilians with a mental illness. Such shootings are sufficiently common in the state of Victoria, Australia, that police can be viewed as a health risk to the mentally ill.

The state of Victoria has traditionally regarded itself as a peaceful and harmonious community, and its police service has enjoyed a generally good reputation for integrity and competence. A semi-official history of Victoria Police was titled The People’s Force, and there is substance to this description.1 The Victorian community is diverse, with large numbers of first- and second-generation migrants from every part of the world having settled in the past 50 years.2 Relations between police and ethnic and cultural minorities, though not without strain, have generally been good.3 Scandals over corruption and misconduct occur, but the vast majority of Victorians, of all social classes, see the police as a reliable source of help in times of crisis.4,5

This generally positive picture has one major anomaly. Between 1984 and 1995, 35 people were shot dead by Victorian Police. Most of those killed were mentally ill, and committing only minor offences. The number killed in Victoria in this period was more than twice as great as all the other Australian jurisdictions combined. In the mid-1990s, Victoria Police responded to the crisis and changed the philosophy of critical incidents and weapons training, under the banner Operation Beacon. The number of shooting deaths dropped greatly. But a decade later, similar tragedies again began to occur in unacceptable numbers (Table (Table11).

Victoria police shooting deaths 2000–2014

One case highlights the wider problem. In 2008, a 15-year-old boy, Tyler Cassidy, was shot dead by police in a suburban park. Tyler had a history of mental illness and was affected by alcohol. He was armed with two kitchen knives and behaving aggressively. As the coroner who investigated the case wrote: ‘it was both apparent and understandable that the death of Tyler, a 15-year-old boy at the hands of four members of Victoria Police both shocked and bewildered us as a community’.6 Particularly troubling was the time which had elapsed between the police first encountering Tyler and then calling for an ambulance because he had been shot: 73 seconds.6

The Cassidy tragedy emphasised that a problem which was thought to have been solved was re-emerging. What went wrong? Or rather, what had gone right, before going wrong again?


This article uses the state of Victoria, Australia, as a longitudinal case study of police management responses to the fatal shootings of civilians by police officers. A particular focus is the shooting deaths of civilians suffering a mental illness. The mentally ill are a vulnerable sector of the Victorian community, and are massively overrepresented among those killed by police. Victoria can be seen as an exemplar of both the best and worst of policing practices. The problem of civilian deaths from police shootings is far worse in this state than in any other Australian jurisdiction. However, police management responses to the problem have, at times, been innovative and successful.

Information on fatal shootings of civilians by police over the past 35 years has been gathered from the official published findings of coronial inquests, supplemented where necessary with news media reports. The history of formal policy and training procedure has been sourced from Victoria Police reports and policy documents, and from reports published by external agencies, notably the Victorian State Coroner and the Office of Police Integrity, Victoria (OPI).

Coronial reports of civilian deaths due to police shooting were analysed for key variables, such as whether mental illness was an element in the deceased person’s behaviour and the geographical location of the fatality. These findings were then examined for trends and used to test Victoria Police formal policy and training against the reality of civilian fatal shootings.

Background: the Victorian Community and Policing Traditions

Victoria is the second-most populous Australian state, with a total population of 5.8 million people. Most of Australia’s population is concentrated in a small number of large coastal cities, and Victoria follows this pattern: 4.3 million people (74 %) live in the capital city, Melbourne. There are three regional cities: Geelong (with 181,000 residents), Ballarat (88,000) and Bendigo (83,000). The remainder of the population (20 %) live in towns of fewer than 50,000 people.7

Policing in Australia has a dual character, a consequence of the nation’s history of settler colonialism within the British Empire. European settlers demanded British rights and liberties, including the preference for an unarmed civilian police service, based on the model of the London Metropolitan Police. However, administering a thinly populated colonial society required a centrally controlled, armed police force: the model here was the Royal Irish Constabulary.1,8 Which model should define policing in Australia has been a continually contested matter. One symbol of this has been changes to police uniforms and equipment. Traditionally, police on ordinary duties in Victoria did not carry visible firearms. This began to change in the 1980s, and over time, the number and visibility of weapons have increased. More than a decade ago, McCulloch argued that the establishment in the 1970s of ‘elite’ counterterrorism units in Victoria Police began a slow process of eroding the traditional minimum force philosophy of general policing.9 Her argument has proven prescient. In 2011, Victoria Police standard uniform changed from a light blue shirt and royal blue trousers and jacket to a much darker navy blue. This colour, along with an array of visible weapons and a protective vest, gives police on ordinary duties a para-military appearance.10

This increased ‘weaponisation’ of Victorian policing, though by no means a straight-line progression, reflects a shift in perceptions of threats to officer safety over the past 30 years.

The Shooting Crisis

In the mid-1980s, the Victorian community was shocked by several high-profile incidents in which police were killed or seriously wounded.11 These included the detonation of a car bomb outside police headquarters in 1986 which killed a young female constable and the assassination-style murder of two police officers in 1988. These acts of extreme violence which situated police as targets contributed to what Victoria Police referred to as a ‘heightened sense of vulnerability’.12

Victoria Police responded by retraining officers in methods of controlling violent criminals. The focus was on firearms and defensive physical tactics, and there was little or no training in controlling violence without physical confrontation, or understanding and dealing with people affected by mental illness.13 The number of civilians killed by police firearms, already high by Australian standards, continued to rise sharply. Victoria stood out as by far the worst state in the nation.14 The State Coroner of the time, Hal Hallenstein, became very critical of what he referred to as a police ‘culture of bravery’ and an emphasis on resolving situations quickly and forcefully.15

The failure to train police in how to handle people with a mental illness was significant, because a change in health policy meant that police were increasingly likely to encounter people with serious mental health problems. From the mid-1990s, Victoria began to replace its institutional mental health service system with one oriented to community care.16 Between 1994 and 1998, psychiatric institutions were closed and replaced with area-based services. Though well-intentioned, the process of deinstitutionalisation was fraught. Funding of community-based mental health services was inadequate, and these programmes became overwhelmed.16 The inadequacy of mental health supervision and support meant that police, the ‘community service of last resort’, found themselves with a disproportionate share of responsibility for managing mental illness in the community.17

This was a role for which police training was singularly unsuited.18 A second peak of police shootings in the mid-1990s has been attributed in part to police shooting mentally ill people displaying aggressive behaviours in public.19

Operation Beacon

Controversy over police use of force prompted five inquiries and a rethinking of how police approached volatile situations. One of these, Task Force Victor (hereafter Victor), found that physical methods taught to police for handling violent but rational criminals lacked a complementary non-physical component. Victor also raised a key issue: police methods of control rested on a ‘presumption of rationality’.18 The presumption by police that a potential offender is thinking rationally can prove a significant barrier to the de-escalation of potential conflict when mental illness is involved. Common police tactics, such as shouting commands or displaying weapons, may serve to panic or aggravate a mentally ill person.20

In 1994, Victoria Police announced the formation of Project Beacon (hereafter Beacon) to implement the Victor recommendations. The police demonstrated recognition that some of the previous fatal shootings were preventable deaths, tragedies in which the inadequacy of police training had played a significant role.21 In one of the largest retraining programmes in Australian policing history, Beacon included a new 5-day training project for all operational officers, underpinned by a ‘safety-first’ philosophy: safety for officers, safety for the community and safety for the suspect. The aim was to balance incident planning, communication and resolution skills with firearms and defensive tactics training. The key message of Beacon was that the success of an operation will primarily be judged by the extent to which the use of force is avoided or minimised (see Table Table2).2). Beacon’s focus on minimising the use of force by police was supplemented with new training in non-physical ways to resolve tense situations.21,22 The programme appeared to be effective: subsequent to the changes implemented by Project Beacon, the number of fatal shootings reduced by half.23 Williams writes: ‘The immediate impact of this training was remarkable and a culture of “safety first” had effectively permeated through all levels of Victoria Police’.24

As a result of Operation Beacon, Victoria Police formally adopted ten operational safety principles. Victoria Police Victoria Police manual. Melbourne: Victoria Police; 2003. VPM Instruction 101–1.4

Beacon appeared to offer hope that renewed strategic focus and an update in police training could alter police operational practice for the benefit of the entire community, including police. The results were consistent with research showing that the use of firearms by police is influenced more by departmental policies and philosophy than by levels of violence against police.9 However, it remained to be seen whether these improvements were sustainable.

Drifting from the Beacon

Despite the immediate impact and initial optimism, the erosion of principles and priorities embedded in Beacon can be traced through a number of internal and external reviews. A 2009 Victoria Police progress report into training standards noted that as early as 1996, a gradual shift in the importance of operational safety had been occurring, and support for the 10 Safety Principles had begun to decline.24

This was affirmed publicly in 2005, when the OPI reviewed six fatal police shootings which had occurred in Victoria in the preceding 2 years.11 The OPI found that the principles of Beacon were waning and that there had been a gradual erosion of police training in handling critical incidents. In a number of incidents investigated, it was found that the Operational Safety Principles introduced through Beacon were not brought into play. The OPI suggested that if the safety-first philosophy and principles had been applied, some of the deaths might have been avoided. The report warned that a gradual shift in attention since the implementation of Beacon could allow the re-emergence of a police culture overtly reliant on firearms.

In 2008, the warnings of the report were realised with the shooting (described earlier) of 15-year-old Tyler Cassidy. Police response was criticised, as was the shift in police training to focus on the use of equipment rather than verbal communication and conflict resolution skills. Risk assessment skills, particularly in cases where police are required to deal with persons with mental illness, appeared to be lacking. The State Coroner, Jennifer Coate, reported that this aspect of Victoria Police training and skill development had been in decline in the years leading up to Tyler’s death and that this had contributed to the tragedy.6

A second OPI review was conducted in 2009, prompted by slow progress in implementing recommendations from the 2005 review.25 This report confirmed what the Tyler Cassidy incident had suggested—that Victorian police officers are ill-equipped to respond to individuals affected by mental illness. It was again affirmed that Victoria Police had continued to lose the strategic focus on safety and minimum force that had been promoted by Beacon. Echoing the findings of inquiries from 20 years earlier, the OPI criticised the tendency for officers to resolve incidents quickly and a lack of communication skills necessary to de-escalate situations. Training continued to focus on equipment and hands-on tactics rather than communication skills, and there was a lack of awareness of and training in mental health issues.

The Victoria Police progress report, published that same year, highlighted these training issues and noted that the policing style of Victoria had been adversely impacted by the previous decade of operational safety training which had ‘created a culture that on occasions was no longer supportive of the strategic direction and organisational safety philosophy’ of Victoria Police.24 Conflict resolution, tactical communications and techniques for diffusing violence had been absent from most training cycles. Of particular note, most scenarios in training were scripted around police being compelled to resolve an incident—leading to a confrontational style approach. This contradicts principles of risk assessment and is of significant concern where police are expected to diffuse situations where a person may be experiencing a mental health crisis.

The drift away from principles promoted by Beacon has been attributed in large part to a lack of organisational focus and the neglect of senior management to ‘champion’ the importance of operational safety training. The experience has highlighted the risk of deprioritisation by management over time, resulting in adverse impacts on the safety of both the community and the police.26 For vulnerable members of the community living with mental illness who might come into contact with the police, these deficiencies are a serious problem—it remains the case that the mentally ill are at a disproportionate risk of being shot and killed by police.23 While a 2012 OPI review into policing and mental illness identified a commitment by Victoria Police to improve responses to people who have a mental illness, it also noted an important message from the Beacon experience—‘while it is important to learn lessons, it is incumbent on Victoria Police to ensure that these lessons are remembered’.21

Police Shootings and Mental Illness

In the period between 1989 and 2011, Australian police across all jurisdictions fatally shot 105 people. Of these, 42 % were suffering a mental illness at the time of the shooting, with psychotic disorders such as schizophrenia the most prevalent.27 In Victoria, the situation was much worse, both in terms of the number of civilians killed and the proportion of those killed having a mental illness. Out of 48 fatalities in Victoria between November 1982 and February 2007, all but six of those killed had recorded histories of mental health problems.23

An analysis of civilian deaths due to police shootings in Victoria reveals some clear trends. One is the short time which elapses before police resort to the use of firearms. A study of 45 fatal incidents in Victoria found that the amount of time between the police arriving at the scene and them discharging their weapons was less than 10 min in 73 % of cases. In 38 % of cases, the time elapsed was 1 min or less.28 Such short timeframes reinforce concerns that the OSP philosophy of de-escalation is not being applied. There are, of course, an unknown number of cases in which patience and de-escalation on the part of police have successfully averted a fatality. However, the speed with which fatal shootings do occur reemphasises that in cases where a person is experiencing a mental health crisis, a desire on the part of police to resolve incidents quickly and forcefully can have dire consequences.

Another notable trend in Victorian Police shootings is that these are almost entirely an urban phenomenon. The Victorian population is predominately urban but a significant minority, 20 %, live in towns of fewer than 50,000 people.7 These communities are notably disadvantaged. Health and life expectancy in rural Australia are consistently worse than is the case in metropolitan areas.29 There are many factors contributing to this disparity, including the prevalence of financial stress in rural areas, high rates of drug and alcohol misuse, and low levels of both general education and health literacy.30 Access to mental health services in these areas is often difficult, and rates of suicide are consistently higher, particularly among young men.31 Although Victoria has much lower rates of gun ownership than is the case in the USA, gun ownership and the existence of a ‘gun culture’ are both more common in rural areas.32 Given all these factors, one would expect rural areas to be somewhat overrepresented in police shootings, but this is not the case. Shootings in rural communities are extremely rare. Of the 15 fatal police shootings in Victoria since 2000, 13 have occurred in the suburbs of Melbourne or on the urban fringe and two in large regional cities. The one exception occurred in Shepparton, which is a large regional town.

This pattern suggests that people with mental illness who live in small communities in rural areas are less likely to experience violence from police. This could be related to the differing policing environment of urban and rural areas. One of the significant aspects of policing the mentally ill in rural areas is community knowledge of what Teplin calls ‘neighbourhood characters’.33 These are persons whose idiosyncrasies are well known to police whose familiarity with the particular symptoms of the individual can assist in their response to situations. Despite other problems, measures of social cohesion, such as involvement in voluntary activities and feelings of safety, tend to be greater in rural areas.34 This familiarity would affect police perceptions of dangerousness when encountering an individual whose symptoms they are familiar with, and in turn affect risk assessment and the manner in which police decide to resolve the situation.

The short time frame in which police commonly resort to use of firearms in encounters in Victoria and the fact that incidents are occurring almost exclusively in urban areas where individuals are less likely to be personally known to police suggest that there is a structural problem in the training and culture of police in Victoria’s urban areas. In particular, a lack of skill in identifying and responding appropriately to behaviours attributable to mental illness, coupled with a culture which emphasises resolving situations quickly, is challenging the ability of Victoria Police to apply the safety-first principles promoted by Beacon.35

Implications for Policing

The death of citizens at the hands of police has wide-reaching implications. The effects are felt not only by the immediate family and friends of the deceased but also by the police officers involved and their departments, other people present at the scene, and the wider community. Police shootings in Victoria, as elsewhere, can have significant implications for the trust and credibility afforded to police by the people they serve. Force, including deadly force, is sometimes necessary in the performance of police duties.19 However, if use of deadly force is questionable, it has the potential to destroy the relationship between the police and the community like no other issue.36

While violence against police in Victoria during the mid-1980s seemed to reiterate the necessity of using force for the protection of the public and themselves, the continuation of fatal shootings through the late-1980s was accompanied by claims that the police ‘had ceased to be victims and were now oppressors’.18 This demonstrates the risks of changing perceptions of the police and their powers when violence is occurring frequently. The legitimacy of the state monopoly on the use of force, exercised by police on behalf of the whole community, is challenged when police violence is recurrent, avoidable and frequently used against the vulnerable. There is real concern that such violence has been occurring in Victoria. In its 2005 report, the OPI warned that the broader community ‘may experience an erosion of trust in Victoria police, which in turn affects the way Victoria Police is regarded by the community’.

Are Police a Health Risk for the Mentally Ill?

In Victoria, police are frequently coming into contact with people who have a mental illness.35,37 This contact can involve offenders, suspects, victims, vulnerable or at-risk people, and people in need of assistance. Police have become ‘gatekeepers’, not only to the criminal justice system but also to mental health services.38 However, if members of a vulnerable community experience an erosion of trust in their police, due to frequent or excessive use of force against that community, it can adversely impact levels of trust in and cooperation with police.

Policing organisations internationally are increasingly recognising their role in the public health arena, and many have developed formal partnerships with health services. In Victoria, new partnerships between police departments and local health services through the Police, Ambulance and Clinical Early Response (PACER) model, for example, offer the prospect of a streamlined response to people experiencing mental health problems, and assist police in connecting people with mental illness to appropriate treatment and services. By this view, police are in a position to contribute to the health of the mentally ill and to the safety of the wider community.

However, the question that must be addressed is whether the history of police use of force against people with a mental illness in Victoria is hindering attempts to provide new tailored services. Citizens are more willing to cooperate with police when they perceive police as fair, competent and reliable, and this perception impacts on the decision to call on police in times of need.39,40 Police are often the first service called when a person is experiencing a serious mental health crisis.21 Family, friends, carers or mentally ill persons may all be hesitant to call on police for assistance when they perceive police as untrustworthy or likely to resort to use of force. The unhappy truth is that in Victoria, and indeed in other Australian states, a fear of police which might be dismissed as paranoid for most in the community, has genuine foundation for the mentally ill. The number of mentally ill civilians shot dead by police within minutes or seconds of police arriving at a crisis scene is sufficient, in our view, to make the risk of police violence a significant health hazard for the mentally ill in Victoria’s urban communities. For friends and family of a mentally ill person undergoing a crisis, the decision not to call police could be considered a rational assessment of risk.

This perception has the potential to undermine new models of policing which focus on improving responses to people with mental illness. Erosion of trust in police among the mentally ill, and those close to them, can be considered a health risk for that population. It is therefore important, when considering new models of policing aimed to better respond to mental illness, to acknowledge the history of the relationship between police and the mentally ill. Project Beacon has shown that it is possible to make positive changes to police philosophy and training and that these changes can reduce the number of mentally ill civilians killed by police. However, it is also clear that without vigilance and continual reinforcement from police management, a drift away from safety-first policing will occur.


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Articles from Journal of Urban Health : Bulletin of the New York Academy of Medicine are provided here courtesy of New York Academy of Medicine