Veteran Steven Richard Angus, a former Australian Army vehicle mechanic, died from a gunshot wound to the chest at his Kirwan home in Townsville on April 21, 2023.
An inquest heard Mr Angus was intoxicated and armed with two large knives when he ran at officers with the weapons raised, after refusing repeated commands to drop them.
Deputy State Coroner Stephanie Gallagher found it was more likely than not that Mr Angus, who had a long history of suicidal ideation, intended to make police shoot him.
"The unfortunate fact is that emergency departments are not equipped to deal with patients like Mr Angus outside of providing care for immediate trauma," Ms Gallagher said.
She found Mr Angus's death met the definition of "subject precipitated homicide", in which a suicidal person's actions effectively provoke a lethal police response.
The day before the fatal shooting, Mr Angus was involved in a siege while drunk and suicidal, and was taken to Townsville Hospital under an emergency examination authority before being released home.
Mr Angus, who had chronic back pain, major depressive disorder, generalised anxiety and severe alcohol use disorder, was medically discharged from the army in 2017.
He held a Department of Veterans' Affairs Gold Card which provides fully funded access to necessary healthcare.
The coroner found Mr Angus was receiving appropriate psychiatric care in the community, largely funded by the Veterans' Affairs Department, and had recently completed a voluntary stay at a private clinic for alcohol withdrawal.
A voluntary hospital admission on April 20 - the day before the fatal shooting - might have reduced his access to alcohol, but the coroner said it would not have changed the overall course of his discharge.
Ms Gallagher found no failure by Townsville Hospital and Health Service to provide appropriate care, and ruled that no aspect of the treatment Mr Angus actually received caused or hastened his death.
She also confirmed Queensland Police officers acted in accordance with policies and procedures in force at the time, and their actions were consistent with those guidelines.
"The case of Mr Angus is a powerful reminder of the need for better information sharing and co-ordinated responses for veterans in crisis," the coroner said.
The findings pointed to serious gaps in information sharing between emergency departments, private clinics, GPs, first responders and families, particularly for veterans in crisis.
Ms Gallagher recommended a working group of Queensland Health, ambulance and mental health leaders to improve after-hours links with private clinics, expand veterans liaison support into emergency departments and bolster crisis responses for veterans.
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