Senior gardaí made 23 errors leading to death
The litany of failures led him to conclude: “I am satisfied that responsibility for his death rests primarily with the scene commanders and to a lesser extent with the ERU [Emergency Response Unit] tactical commander.”
The scene commanders were Superintendent Joe Shelly and Supt Michael Byrne, neither of whom, the report says, “had prior experience of dealing with any form of armed siege or with dangerous conduct which was motivated by mental illness”.