Families hope coroner's scathing Bourke St report 'will not be wasted'

Almost four years after the Bourke Street massacre left six people dead and dozens more injured, the victims' families say a coroner's scathing findings against Victoria Police should be used as a catalyst for change.

Coroner Jacqui Hawkins, who delivered her findings following a six-week inquest into the deadly rampage, said attempts to negotiate with James Gargasoulas as he drove through Melbourne's inner city amounted to "nothing more than two phone calls and bizarre text messages".

"The strategy never had a chance to succeed," Ms Hawkins said. "How could it when the person they were trying to negotiate with was a ... delusional offender fixated on taunting police?"

She said "objective and strategic" thinking by officers was absent and there was a lack of assertive leadership from senior detectives in the hours leading up to the January 2017 massacre that claimed six lives.

Gargasoulas, who is serving life in prison with a non-parole period of 46 years, killed six and injured dozens more when he sped through the heart of Melbourne's CBD in a stolen maroon Holden Commodore.

Those who died were: three-month-old Zachary Bryant; Matthew Si, 33; Thalia Hakin, 10; Jess Mudie, 23; Bhavita Patel, 33; and Yosuke Kanno, 25.

The makeshift floral tribute to the Bourke Street victims on January 30, 2017.Credit: Jason South

Ms Hawkins acknowledged the fear of being disciplined stopped some officers from being more assertive on the day and "paralysed them from taking action". She said she was hopeful Victoria Police's new hostile vehicle policy, introduced late last year, would ameliorate that fear in the future.

She found poor planning, the lack of assertive leadership and command control, a lack of adequate resources, inadequate communication on police radios, inflexible policies and misguided attempts to negotiate with Gargasoulas created a "perfect storm" in favour of a violent offender.

"It is agonising that, despite the escalating events of the previous days and the scores of police members actively engaged in attempting to stop him, such a violent, drug-fuelled, psychotic and delusional criminal was able to slip through the cracks and evade interception by police over several hours," she said.

Once Gargasoulas reached Swanston Street that day and headed towards Bourke Street, "due to the very populated area … there was nothing further the operational police could have done".

Coroner Jacqui Hawkins

"A remarkable confluence of events emerged in favour of the offender, including a set of systemic deficiencies in the response of Victoria Police, that permitted manipulation by a single, dangerous and unpredictable offender.

These deficiencies included poor planning; a lack of assertive leadership, supervision and coordinated command and control; lack of adequate resources; inadequate communications between units across police radio channels; failure to follow up and action essential inquiries and resources, inflexible attitudes and policies; loss of objectivity; a staunch belief that negotiating with a delusional person was the best chance of bringing the incident to a conclusion; and, ultimately a reluctance to act assertively for fear of recrimination.

Each of these factors contributed to the perfect storm."

In her findings on Thursday, Ms Hawkins was highly critical of officers who failed to call their chase a "pursuit", saying it highlighted the challenges of police "losing perspective in the heat of the moment".

"This meant that no one had responsibility," she said.

"While I am unable to say whether the offender would have been located and arrested had a planned strategy been in place, the failure to develop such a plan and the lack of a co-ordinated response meant that this opportunity was lost," she said.

However, Ms Hawkins said she was unable to conclude the catastrophic attack, which "struck at the very heart of Melbourne", could have been avoided.

She made nine recommendations, including further training for police in hostile vehicle attacks; a review of Victoria Police's training, policies and procedures on bail and remand with respect to high-risk, recidivist offenders; a review of co-ordination policies between different police units; and a review of critical incident communication procedures, particularly where the use of a dedicated radio channel is appropriate.

The coroner also recommended police investigate the feasibility of officers using body-worn cameras to record all out-of-session bail and remand hearings.

While admitting "operational shortcomings" occurred in the hunt for Gargasoulas, Chief Commissioner Shane Patton backed the actions of his officers on the day and said he believed they had all acted in good faith.

He said changes had now been made in how police manage the arrests of high-risk offenders with investigators no longer left "holding the ball".

Coroner Jacqui Hawkins delivers her findings.

Instead, he said, more senior officers – potentially ranking as high as assistant commissioner – would be called in to oversee an arrest plan, particularly when offenders crossed divisional boundaries.

"We will take the time to read this report in detail and consider the nine recommendations," he said.

"I wish more than anything that this had never happened."

Families call for change

The families of those killed have since urged Victoria Police to adopt all nine recommendation.

In a statement released to the press, they said it was “imperative” that police see the inquest as a catalyst for real, meaningful cultural change within the force.

Melinda Tan, widow of Matthew Si, she said she felt no one had ever accepted any responsibility for their part in events on that day or in the lead up to it.

“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,” Ms Tan wrote.

“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’.”

Premier Daniel Andrews said he had not yet been briefed on the details of the coroner's report, but again offered his support to the families of the victims.

Victorian Police Association secretary Wayne Gatt.Credit: Paul Rovere

"They are just amazing people. Their dignity, their bravery, the courage, but the grief that they carry with them every day is absolutely profound and we should think of them today," Mr Andrews said.

Police Association Victoria secretary Wayne Gatt said the findings provide an account of the difficulties and complexities that confront police when they are "forced to make decisions in which every potential pathway has risk attached".

"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,” Mr Gatt 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."

Bombshell revelations

Police began searching for Gargasoulas at 2.20am on January 20, 2017, about an hour after he stabbed his brother, Angelo, multiple times in the face, neck and chest outside a housing commission flat in Windsor.

The wanted man had been on a two-month crime spree after returning from South Australia and eluded police – who at times were following him from the road and sky – for 11 hours that day before he careered down Bourke Street at 1.30pm. He was shot and arrested at the scene.

In December 2019, Ms Hawkins began a six-week inquest into the deaths to explore how they could occur in the way they did and what, if any, potential there is for changes that could help prevent similar tragedies in future.

Bombshell evidence included revelations:

• There were opportunities to arrest Gargasoulas in the hours before the tragedy.
• That lives were put at risk by a "poorly co-ordinated, unplanned response" to his escalating offending.
• Senior police, such as inspectors and superintendents, should have provided "active supervision" to "coalface" officers attempting the arrest.
• The deluded driver may have decided to carry out his murderous rampage at the last moment.
• Only Victoria's elite Special Operations Group stood a chance of stopping him once in Melbourne's CBD.
• Elite officers didn't box in or ram Gargasoulas' car, fearing a "proverbial butt-kicking" for smashing the car.
• The bail justice who freed Gargasoulas six days before the rampage claims police fabricated evidence to shift responsibility for the fateful decision to grant him bail.

If you or anyone you know needs support call Lifeline 131 114, or beyondblue 1300 224 636.

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