SPRINGFIELD, Ore. (AP) — Independent consultants say in a newly-released report that a sergeant’s 2019 fatal shooting of a woman with schizophrenia involved no efforts to de-escalate the situation and instead says officers “immediately resorted to force.”

The findings released Wednesday by the California-based OIR Group also highlights “significant gaps” in the investigations that followed the shooting of Stacy Kenny two years ago, The Register-Guard reported. It also questions whether the police department learned anything or made any changes.

The consultants’ review of the police shooting and tactics was required as a part of the city’s $4.5 million settlement agreement in the wrongful death suit brought by Kenny’s family.

Now-retired Sgt. R.A. Lewis shot Kenny March 31, 2019, after a traffic stop. Before the sergeant shot Kenny, officers broke her car windows, beat her and used a Taser on her multiple times.

Another officer had initially followed Kenny’s car and pulled her over. The officer stopped but never approached, so Kenny drove off. The officer pulled her over again, drawing his gun and yelling at her to put her hands out the window, according to the report.

She asked why she was being followed and drove away. Stopped for a third time, police approached as she was talking with a 911 dispatcher. Police escalated the encounter by breaking windows in her car to try to pull her out and punching her in the face, according to the report.

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Lewis broke the passenger window, entered the car and also struck Kenny in the face, the report said. While searching for the keys, the car lurched forward, struck the sergeant’s patrol car and continued around his car.

Lewis said he struggled to grab the steering wheel, pleaded with Kenny to stop the car and fired at her six times. The car then hit trees, crossed the road, struck a fence and crashed into a van. Kenny died from gunshot wounds to her head, the report said.

Two investigations — one by Lane County’s Interagency Deadly Force Investigation Team and the other by a city use-of-force review board — found Lewis’ use of deadly force was justified. The consultants found problems with both, and issued some three dozen recommendations related to investigation protocol and police department policy changes.

The police department also did no internal investigation of the officers actions in the incident even though a full-fledged review was particularly warranted, the consultants said.

Kenny’s mother, Barbara, and the family hope the city is “courageous enough to hold the department accountable” and follow the recommendations, The Register-Guard reported.

City spokeswoman Amber Fossen said in an email the city is continuing to work toward better transparency around use of force and that the police department has updated its use of force policy since Kenny’s death.

The report comes two days after a city official announced that the police chief had been placed on paid leave amid an investigation into administrative personnel.