A coroner has been scathing of police whose pursuit of a criminal led to a 17-month-old girl being crushed to death by a car in her own Sydney backyard.
Tateolena Tauaifaga died on January 8, 2015, when the car driven by Christopher Chandler careened through a fence into the Constitution Hill backyard where she was playing with her three sisters.
She was crushed and left lying motionless on the ground as two police vehicles followed Chandler through the backyard, the back fence and into a park where more children were playing.
"Her distraught mother and father could do little but watch as ... paramedics tried to save her," Deputy State Coroner Elizabeth Ryan said when handing down her findings into the girl's death on Wednesday.
Tateolena died of blunt head injuries, having suffered extensive skull fractures and abrasions to the right side of her face and body.
Chandler has since been jailed for taking Tateolena's life in a "senseless and violent way", Ms Ryan said, but the coronial inquiry also probed police actions.
Police had an opportunity to detain Chandler earlier in the day, when he had parked and left the stolen car he was driving, but instead fitted it with a tracking device in the hope of obtaining more information about his suspected involvement in other crimes, the inquest heard.
Ms Ryan found officers did not give appropriate consideration to the risk they were running in deferring his arrest.
"Had Mr Chandler been arrested earlier ... he could not have committed the terrible offence," she said.
"This knowledge remains a great source of pain for Tateolena's (family)."
The coroner was even more scathing of the officers' decision to follow Chandler into the Tauaifagas' yard.
"I have found those police officers took an appalling risk when they followed Mr Chandler through the fence ... they should never have done so.
"It is terrible to think of the danger to which these other little lives were exposed by this decision."
NSW Police Commissioner Karen Webb has decided to review the policies and training which contributed to all of the decisions on the day, with Ms Ryan saying the policies that apply to tactical operations unit officers in such circumstances are unclear and inconsistent.
Ms Ryan made a series of recommendations for improvements to police training and policies, including that Ms Webb investigate ways in which tactical operations unit vehicles could be fitted with audio visual recording devices and the unit's officers with body cameras.
Counsel representing Ms Webb opposed those recommendations being made.
Ms Webb should also consider whether the investigative strategy of using a stolen vehicle to obtain more information about a suspect's involvement in other crimes is a strategy that is appropriate.
In a statement on Wednesday afternoon, a NSW Police spokesperson said a comprehensive review of the findings is underway and all recommendations will be considered.
Addressing Tateolena's family, Ms Ryan said she was deeply saddened by the tragic loss of the beautiful and curious little girl.
"The grief that Tateolena's mother, father ... (and family) feel is still raw.
"They have a deep need to understand how her terrible death could have been allowed to happen.
"I hope that time will heal some of your pain and bring some peace of mind."
