James Gargasoulas's murderous Bourke street rampage was helped by a "perfect storm" of police deficiencies, which led to a "confluence of events" that worked in the killer's favour, a Victorian coroner has found.
Gargasoulas is currently serving at least 46 years in jail for murdering six people and injuring 27 others by driving a Holden Commodore through the Bourke Street Mall on January 20, 2017.
Delivering her findings following an inquest into the deaths, coroner Jacqui Hawkins said "poor planning, a lack of assertive leadership [and a] lack of adequate resources", combined with "inflexible attitudes", allowed Gargasoulas to roam across Melbourne before speeding through the lunchtime crowds in Melbourne's CBD.
Ms Hawkins said a plan to persuade Gargasoulas to surrender was destined to fail.
She said a formal pursuit should have been called, and a failure to do so led to a lack of oversight.
But the coroner said she was unable to determine if the murders would have been prevented if any circumstance had been different, saying stopping moving offenders was "incredibly difficult".
'Strategy never had a chance of succeeding'
Gargasoulas had been pursued by police since the early hours of the morning of January 20 after he stabbed his brother Angelo.
A search for him began about an hour after the stabbing, but police failed to stop him until after his deadly attacks at about 1:30pm.
About half an hour before the killings, Detective Murray Gentner, who had several previous interactions with Gargasoulas including at his bail hearing six days earlier, tried to negotiate for Gargasoulas to surrender.
"The negotiated surrender plan really amounted to nothing more than two phone calls and a series of bizarre text messages," Ms Hawkins said.
"There was no actual negotiation.
"The strategy never had a chance of succeeding."
The coroner noted police came agonisingly close to stopping Gargasoulas as he drove towards the city, but said police were fearful of the consequences of ramming his car.
She said that once Gargasoulas had reached the CBD, police could not plausibly stop him.
"Due to the very populated area and the extreme dangers involved, there was nothing further the operational police could have done," she said.
Ms Hawkins said, with hindsight, it was clear the only police squad that may have been able to stop Gargasoulas was the State Surveillance Unit or the Special Operations Group.
She said police had done much "soul searching", and that a number of changes to policy on pursuits had already been made, limiting the need to make drastic findings.
"The fear of being disciplined paralysed some police members from taking more assertive action on the day," Ms Hawkins said.
"This issue has hopefully, in part, been addressed with the implementation of the new Hostile Vehicle Policy."
Attack 'struck at the heart of Melbourne'
Ms Hawkins paid tribute to the first responders to the tragedy and, out of respect for the families of the dead, did not use Gargasoulas's name when delivering her findings.
She said many of the victims of the rampage had their backs to the oncoming car and didn't see the vehicle until they were struck by it.
"To simply describe these events does not capture [the victims'] horror, occurring as they did in the midst of crowds of shoppers, tourists and office workers enjoying the height of summer," she said.
"Numerous witnesses likened it to a nightmare.
"The moments they witnessed were simply beyond their comprehension.
"The offender's actions are both unthinkable and repellent.
"They struck at the heart of Melbourne."
More to come.
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2020-11-19 00:29:00Z
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