Todd McKenzie, who had been diagnosed with schizophrenia, was shot by police three times at his home on the NSW mid-north coast in 2019.
Police were initially called to the Taree property over concerns for his welfare but the situation devolved into a multi-hour siege that ended in Mr McKenzie's death.
After giving evidence to an inquest on Tuesday, an operations coordinator involved in the siege - known to the inquest as 'T10' - addressed Mr McKenzie's family.
"My sincere sympathies. It is a tragedy and I am so sorry for your loss," he said in front of the NSW State Coroners Court.
The officer said he knew on a personal level how people could slip through the gaps.
"When you've got doctors, psychiatrists, psychologists all trying to do the best they can - sometimes it's no one's fault - but the warning signs are missed," he said.
"People can slide from these treatments, drift out, and become involved with the police. As a parent, that's frightening and as a police officer that's concerning because I understand the ease and frequency that can occur."
Mr McKenzie's family and legal team acknowledged T10 was the first member of the police to offer an apology.
But Katrina Hawtrey, a solicitor at the National Justice Project which is representing Mr McKenzie's mother, says it showed police were not well-equipped to address mental health issues.
"His observations demonstrate the need to revisit the way we, as a society, respond to people suffering mental health crises," she told AAP.
"Instead of placing both community members and police in dangerous situations, we should be providing people experiencing mental heath crises with a medical response and a lifeline to their families."
Negotiators had called Mr McKenzie's parents to inform them of the situation, but kept them away from the scene to avoid putting them in danger, the inquest was told.
Mr McKenzie's step-father Neil Wilkins wishes the police consulted his family so they could draw from their experience with Todd's schizophrenia.
"They missed an opportunity because they didn't allow us to come near the siege," he told AAP.
"We had information about his psychiatrist, the medical services, how to approach him. There were small windows of opportunity and they were ignored."
Mr McKenzie's family attended the court in matching shirts that paid tribute to their loved one.
On the back was printed, "nobody deserves to die just because they're unable to comply".
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