Coroner delivers inquest findings into Bourke St attack
A coroner has found “deficiencies” within Victoria Police allowed James Gargasoulas to carry out the Bourke St massacre, which killed six people.
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Police trying to capture James Gargasoulas failed because of “deficiencies” within the force that allowed “a drug-fuelled, psychotic” offender to evade them.
Coroner Jacqui Hawkins is delivering her findings into the Bourke St massacre that killed six people at the Victoria Coroners Court this morning.
James Gargasoulas mowed down dozens of pedestrians on the packed strip in the central city on January 20, 2017 after evading police during a cat and mouse chase around Melbourne.
Police had been trying to capture him after the near fatal stabbing attack on his brother in Windsor.
Six people, including a three-month old child were killed, while a further 27 were injured at Bourke St Mall.
Coroner Hawkins said some police were “paralysed” in making serious decisions on the day of the tragedy, partly because they feared they wouldn’t be supported by police management if they rammed his car.
Gargasoulas had been on bail and went largely unchecked in the days before the incident, on January 20, 2017.
“It’s agonising that in the previous days a violent, drug-fuelled, psychotic, delusional perpetrator slipped through the cracks and evaded interception by police over several hours,” Coroner Hawkins said.
Systemic deficiencies within Victoria Police allowed Gargasoulas to manipulate the force.
“Poor planning, lack of leadership and resources, communication across radio units, a failure to follow guidelines, inflexible attitudes and a reluctance to act assertively for fear of recrimination … each of these factors led to a perfect storm.”
However, she said she could not say if such a “catastrophic event” could have been avoided if any of these outcomes had of been different.
The Coroner made nine recommendations, including that Victoria Police investigate the feasibility of body worn cameras being used for all out of sessions bail remand hearings.
Gargasoulas was freed on bail — despite police opposition — six days before the attack.
Police and the bail justice who freed Gargasoulas gave the inquest conflicting accounts of the controversial hearing.
All the recommendations relate to Victoria Police and the way they provide training to officers dealing with hostile vehicle and vehicle born attack simulations.
Coroner Hawkins said attempts to negotiate with Gargasoulas were doomed to fail because there was no clear arrest strategy.
She was scathing of the negotiation attempt by Detective Senior Constable Murray Gentner which consisted of “nothing more than two phone calls and bizarre text messages”.
“The strategy never had a chance to succeed. how could it, when they were negotiating with a delusional offender who was fixated on taunting police ... in particular Det Gentner.”
She criticised Port Phillip CIU for their actions in the hours leading up the Bourke St incident, saying it was clear a pursuit should have been formally called — which would have triggered proper oversight — and said it was clear there was no assertive leadership or “objective and strategic thinking” from senior CIU staff.
THE NINE RECOMMENDATIONS
1. That Victoria Police, in consultation with the Dept of Justice and Community Safety, investigates the feasibility of Victoria Police-issued body-worn cameras being used to record all out-of-sessions bail/remand hearings.
2. Victoria Police reviews its training and supervision of members involved in bail/remand proceedings to improve members’ skills and knowledge concerning:
3. That Victoria Police develops force-wide policies and procedures to ensure that notifications of failure to report on bail are forwarded to a Position-Based Email Account, such as the Officer-in-Charge of the police station, in addition to the informant; and provide guidance on the actions to be taken by the informant and Officer-in-Charge upon receipt of such notification.
4. That Victoria Police reviews its training, policies and procedures on bail and remand with respect to high risk recidivist offenders to ensure members:
5. That Victoria Police reviews its training, policies and procedures that govern the roles, responsibilities and coordination between the criminal investigation units and other supervisory units to eliminate role confusion and ambiguities concerning operational command in all areas, including criminal investigations, incident response and planned operations.
6. That Victoria Police conducts a review of its policies, procedures, training and infrastructure in respect of the management of critical incidents or emerging critical incidents and the proper and effective use of police communications, so that there is, to the maximum extent possible, continuity of command in planned operations and critical incidents, particularly in circumstances where:
The operation or incident crosses Divisional or Regional boundaries and may involve a change of radio channel;
The operation or incident may involve the use of dedicated (TAC) radio channels.
There is to the maximum extent possible, continuity of involvement of police
communications personnel performing the role of channel operator during a critical incident or emerging critical incident; and c. all police members that may be impacted or become involved in an operation or incident are afforded the best possible situational awareness and clarity of command, plans, roles and responsibilities.
7. That Victoria Police reviews its criminal investigator and investigator management training program with a view to incorporating a curriculum on risk evaluation, transition to incident management, and the identification and management of critical incidents.
Such training should incorporate an immersive, interactive training environment to support decision-making in critical incidents and emerging critical incidents.
8. That Victoria Police Professional Development Command develops and implements appropriate operational safety training on hostile vehicles and vehicle-borne attacks
that incorporates simulation or Hydra experience training to enhance the skills and operational decision-making of frontline operational members (including uniform, criminal investigation units and the Critical Incident Response Teams) who may be called upon to act in response to a hostile vehicle or vehicle-borne attack.
9. That Victoria Police Professional Development Command incorporates regular annual or biennial refresher training on the Victoria Police Manual Hostile Vehicle Policy and on vehicle-borne attacks to ensure member’s knowledge and skills remain up-to-date.
The inquest ran for 31 days and heard from 60 witnesses. It began late last year and continued in 2020 before final submissions were heard in May.
Only some family members of the victims were able to attend the inquest in person due to coronavirus restrictions.
FAMILIES SLAM HANDLING OF ATTACK
The families of those killed in the Bourke Street attack have lashed a “persisting disconnect” between the police who handled the lead up to the incident and force command.
But they’ve expressed hope today’s coronial finding will not become another missed opportunity in the tragic saga.
Lawyer Genna Angelowitsch, from Adviceline Injury Lawyers, this afternoon read a statement on behalf of five of the six victim’s relatives.
“Over the course of 31 separate sitting days, Her Honour Coroner Hawkins heard evidence from over 50 witnesses about what happened in the lead-up to and on the day of 20 January 2017, as well as changes that have been implemented by Victoria Police and other organisations since that time,” it said.
“During the course of the evidence, a number of witnesses extended genuine condolences for those who lost their lives as a result of the events on 20 January 2017. These condolences were gratefully received and were deeply appreciated.
“The majority of the witnesses who gave evidence during the inquest were current serving members of the Victoria Police Force. During the course of their evidence, criticisms were put to a number of these officers about decisions that were made or actions that were or were not taken in the lead up to the Bourke Street attack. It was difficult to hear these officers reject any criticisms that were made of their actions, even when these criticisms had been levelled by senior members of the Victoria Police command. This suggests a persisting disconnect between serving members of the Force and senior members of the Victoria Police Force command.
“The findings delivered this morning by Her Honour Coroner Hawkins seek to ensure that similar atrocities never occur again in the future. With this purpose in mind, it is expected that the recommendations will be adopted in full, and their implementation will be undertaken with transparency and accountability.
“Over the course of this particular inquest, evidence was given about missed opportunities for earlier intervention and apprehension. It is imperative that Victoria Police see this inquest as a catalyst for real, meaningful cultural change within the force, lest this investigation be added to the list of opportunities missed.”
Matthew Si’s widow Melinda Tan released an additional statement which Ms Angelowitsch read out, telling how Ms Tan hoped new leadership at Victoria Police would prompt change and that the couple’s daughter had a heartbreaking Christmas wish to see her beloved “Papa”.
“As we approach the fourth anniversary of the tragic day in Bourke Street, my family are constantly reminded of the lives lost on 20 January 2017,” the statement read.
“This year in particular has been especially difficult for us as our families remain separated by different State and country borders due to the COVID situation. As a result, some family members who wanted to attend today’s hearing are unable to do so.
“Reflecting on the evidence and oral submissions by the various interested parties, it is clear to me that no one will accept any responsibility on their part for the events on that day or the lead up to it. There is no dispute that the offender himself drove the vehicle that injured and killed innocent lives. However, how and why did we enable him to do so?
“I felt that counsels assisting the Coroner finally voiced the families’ feelings and concerns with their closing and oral submissions. It is based on hard evidence and facts rather than one’s self-interest to protect their reputation.
“Her Honour Coroner Hawkins has instilled hope that this inquest will not be wasted and to remember the main reason why we were all gathered here in the first place. It is for the safety of the community – the young and old, local Victorians, interstate visitors and even foreigners. We place our trust in Victoria Police to protect our lives and take decisive action in the face of danger; and we will have your back when you do. With the change in leadership at Victoria Police, I hope that the new Police Commissioner will listen to the victims’ voices in this tragedy and provide us with some comfort that our loved ones were not sacrificed in vain.
“This Christmas, Matt’s Daughter, Arya, said “I wish that Papa is still here.”
The family of Sydney woman Jess Mudie, 22, did not take part in the statement.
POLICE ASSOCIATION RESPONDS TO FINDINGS
Police Association Victoria secretary Wayne Gatt said the Coroner’s recommendations rang true and the union had long advocated for officers to have greater flexibility in how they dealt with pursuits, resulting in Victoria Police’s new hostile vehicle policy introduced in 2019.
“As a result of its implementation, the operating environment for police today is significantly
different to what it was at the time of the Bourke Street tragedy. Many of the barriers that may have inhibited police from considering alternate options at Bourke Street, have been removed,’’ Mr Gatt said.
“We accept that there is more work that must be done to best prepare our members to deal with the critical task of trying to stop or reduce the trauma caused by criminals in dynamic, real-time situations like this in the future.
“While we will need time to digest the entire coronial report, the Police Association welcomes the recommendations made by the Coroner today. They make sense, and they align with many of the views our members have conveyed to us, and through us, following the Bourke Street tragedy”.
But Mr Gatt said police would always face difficulties and complexities in their duties which forced them to make decisions with risk attached no matter what the pathway.
“We acknowledge the efforts of all of our members who, in extraordinary circumstances, acted in good faith and with the primary intent of reducing harm and saving lives,’’ he said.
“There can never be policies and procedures in place to confront every eventuality that police will confront in their work. Notwithstanding that, police require flexibility and support through policy, so that they can better adapt to critical situations as they arise.”
Gargasoulas was jailed for life in February 2019. He will be 75 before he is eligible for parole after being sentenced in February to a minimum of 46 years behind bars.
The coronial inquest attempted to learn if system failures – including the way police responded on the day of the incident – contributed to the tragedy.
The inquest heard evidence from police officers who said they feared they would lose their jobs if they rammed Gargasoulas’ car, and they told of not having enough training, or being unclear if they were allowed to box Gargasoulas in as he tore through several suburbs before arriving in the central city.
A report by Assistant Commissioner Stephen Fontana singled officers out for failing to take ownership, making basic errors, lack of communication and being “ill-prepared” for their duties.
The inquest also heard accusations of errors made by those who were at the out of sessions bail hearing at St Kilda Police Station when Gargasoulas got bail – despite police opposition – six days before the attack.
Bail justice Christos Pantelios allowed Dimitrious Gargasoulas free six days before the massacre. He said he wasn’t given a copy of Gargasoulas’ criminal history at that hearing and accused police of sloppy presentation that was rushed and lacking in detail.
But his role also came under intense scrutiny. He was accused of reconstructing evidence and admitted his recollection of events might have been “polluted” in the aftermath of the tragedy.
It emerged during the inquest that basic errors had been made on the bail application form that was handed to Mr Pantelios.
The officer in charge, Senior Constable Jake Semmel, said he didn’t know he could ask to have a hearing delayed, and conceded more training was required.
“Yes. For all police officers, not just detectives,” he said, when asked if specific training would benefit officers.
The victims were three-month-old Zachary Bryant; 10-year-old Thalia Hakin; Jess Mudie, 22; Yosuke Kanno, 25; Matthew Si, 33; and Bhavita Patel, 33.
TOP COP WISHES GARGASOULAS PULLED OVER
Victoria Police Chief Commissioner Shane Patton said he wished “more than anything” the Bourke St attack didn’t happen and Gargasoulas had stopped after repeated requests for him to pull over.
“I know the community rely on police to keep them safe when an incident like this occurs” he said.
“What transpired that day was and still is absolutely devastating to everyone in our organisation...The tragedy was not what members wanted to see happen.”
Mr Patton said the inquest findings showed all police acted in good faith.
“No one could have predicted the outcomes of that day, (but), with the benefit of hindsight, there were shortcomings in our response .”
“I’m aware some (officers) felt they would not be supported if they actively tried to stop the vehicle.That was of significant concern to us, do not want them second guessing themselves.”
“Significant changes had been made since then, including a new hostile vehicle attack policy.”
He insisted any ambiguity had now been removed.
“They all know what they must do.”
Mr Patton couldnt say if changes would have stopped the attack.
“We are doing everything we can to stop an incident like this ever happening again.”
On bail issues, he said work was under way on upskilling officers about what they could do better convey their positions during bail hearings.
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