Police breached their guidelines during a fatal pursuit through residential Sydney streets that ended with the dead man's car split in two, a coroner says.
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Disqualified driver Andrew Ngo, 35, was high on methamphetamine and had ingested morphine when he failed to stop at a random breath test site in western Sydney on December 9, 2017.
The parolee led police on a chase through Lapstone, at the foot of the Blue Mountains, before driving the wrong way down the Great Western Highway and smashing into a tree.
Deputy state coroner Elizabeth Ryan said police were right to begin pursuing Mr Ngo but repeatedly failed to inform each other what they were doing.
At times Senior Constable Barry Thurling exceeded 100 km/h on residential roads lined with parked cars.
The experienced highway patrol officer eventually crashed into a highway off-ramp when Mr Ngo made a sudden turn.
In findings delivered on Tuesday, Ms Ryan said Sen Const Thurling's supervisor was clear he would have terminated the pursuit if he'd had a fuller picture.
"Communication is critical to the effective management of a police pursuit," she noted.
Pursuing police were unaware Mr Ngo - also known as Giang Dinh Tran and Andrew Tran - was behind the wheel, and pursued based on his failure to stop for the RBT.
During the inquest, Sen Const Thurling said it had been difficult to pursue Mr Ngo while communicating his speed and driving behaviour with supervisors.
Ms Ryan said it was an issue NSW Police should examine further, but stopped short of formally recommending police introduce real-time tracking for their cars.
Ms Ryan said the practical implementation of the pursuit policy had issues.
She concluded Mr Ngo faced a strong possibility of a fatal crash regardless of police involvement given the impact his drug-induced state had on his driving and decision-making skills.
Australian Associated Press