Damning report slams Victoria Police's failure to stop crazed killer rampaging through central Melbourne - killing six and injuring 27 in one of Australia's most-ever criminal massacres

James Gargasoulas was jailed in February for at least 46 years

Victoria Police committed a series of monumental blunders that allowed James Gargasoulas to enter Melbourne and commit the Bourke Street massacre. 

Gargasoulas mowed down 33 pedestrians on the packed strip in the central city on January 20, 2017 after evading police over a two-day period.

Among the dead was three-month-old Zachary Bryant; 10-year-old Thalia Hakin; Jess Mudie, 22; Yosuke Kanno, 25; Matthew Si, 33; and Bhavita Patel, 33.

Baby Zac was being pushed in his pram by his mum when Gargasoulas ploughed into them, sending Zac 68 metres into the air to his death. 

The inquest began last year and ran for 31 days and heard from 60 witnesses. 

In handing down her 300 page findings on Thursday, Coroner Jacqui Hawkins provided a scathing assessment of how police had mishandled Gargasoulas leading up to the atrocity. 

Police had been trying to capture him after the near fatal stabbing attack on his brother in Windsor. 

On the day he would kill six people, police allowed Gargasoulas to drive into Melbourne's CBD while they slowly trailed behind him in a convoy. 

Ms Hawkins claimed Victoria Police's bungling contributed to the 'perfect storm'.

'I find that once the offender was driving recklessly around the intersection of Swanson and Flinders Street and then headed west along Bourke Street ... there was nothing further the operational police could have done safely,' Ms Hawkins said. 

The coroner said Victoria Police allowed all of the cards to fall in Gargasoulas' favour. 

'Including a set of systemic deficiencies in the response of Victoria Police, that permitted manipulation by a single, dangerous and unpredictable offender,' she said. 

The pram of three-month-old Zachary Bryant lays empty on Bourke Street after being flung 68 metres by the vehicle of James Gargasoulas

Gargasoulas fled in a stolen car after stabbing his brother, police tailing him across several suburbs

James Gargasoulas performs doughnuts outside Flinders Street Station. Police stood by and watched him drive down Swanson Street and onto Bourke Street where he killed six people

Road Trip To Murder: What The Coroner Said

'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 perpetrator was able to slip through the cracks and evade interception by police over several hours on 20 January 2017.'

'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.'

 

Ms Hawkins lashed out at force command over a range of deficiencies, one of which saw police afraid to take down Gargasoulas out of fear of reprisals from their own bosses. 

'I agree with Assistant Commissioner  Fontana’s opinion that the fear of being disciplined paralysed some police members from taking more assertive action on the day. This issue has hopefully, in part, been addressed with the implementation of the new Hostile Vehicle Policy,' she said.  

Despite the findings, the coroner was unable to conclude the outcome might have ended differently had things been done differently. 

'I am unable to conclude that had any of these responses been different, that the catastrophic outcome could have been avoided,' Ms Hawkins said. 

'My investigation starkly exposed the significant practical challenges of stopping a moving vehicle. Finding an appropriate means to neutralise offenders who use their vehicles, as a weapon, is incredibly difficult and options are limited.'

The court heard police had worked hard since the tragedy to rectify the clear errors of their previous ways. 

'Victoria Police has done much soul searching to ensure it is better equipped, and to provide individual officers with the support of the police command to be more decisive and able to respond differently if this kind of incident were to present itself again,' Ms Hawkins said. 

She has made nine recommendations aimed at preventing a similar rampage.

These include changes relating to the granting of bail.

People attend to a victim on Bourke Street in 2017

James Gargasoulas was jailed for life in 2019

'It is agonising ... such a violent drug-fuelled, psychotic and delusional perpetrator was allowed to slip through the cracks,'she said.

The coroner was poured specific scorn on the way police had handled what they described as a 'extended follow' in the lead-up to the atrocity. 

'I find that the extended follow from Yarraville to Port Melbourne was a pursuit and should have been called as such,' she said. 

'Not calling a pursuit meant that proper oversight was not initiated, as no pursuit controller was allocated.

'This meant that no one had responsibility to conduct the appropriate and necessary risk assessments to manage the risk. This was a clear breach of the Pursuit Policy.' 

It was well known at the time that rank and file police had been terrified of initiating pursuits for fear of reprisals from force command. 

'Had a pursuit been called by Port Phillip 508 and/or any to the other units in the convoy of police, following at the time and given the preceding events, I have no doubt a pursuit controller would have recognised the futility of "chasing" this offender again and would have appropriately terminated the pursuit,' Ms Hawkins said.

Gargasoulas on Swanson Street taunted police, who stood back and did nothing. By then, it was all too late and six people would die, including a baby

Three-months old Zachary Bryant and his two-year-old sister Zara. Baby Zac was murdered on Bourke Street while being pushed in a pram by his mother 

Jess Mudie, Matthew Si, Bhavita Patel and Thalia Hakin were all killed on Bourke Street during the rampage

The coroner further chastised attempts by police to negotiate with Gargasoulas. 

'When all the facts are objectively considered, the negotiated surrender plan really amounted to nothing more than two phone calls and a series of bizarre text messages.,' Ms Hawkins told the court. 

'There was no actual negotiation. There were no plans made, nor agreement reached. The strategy never had a chance of succeeding.'

Ms Hawkins was scathing of senior officers who had headed the doomed intercept of Gargasoulas. 

'What was needed was a disciplined, calculated and objective approach from senior officers so that decisions and alternative strategies could be evaluated and formulated as the events unfolded and to assist in managing the dynamic situation and the operational police officers in the field,' she said.  

Gargasoulas was jailed for life in 2019  

He will be 75 before he is eligible for parole after being sentenced in February to a minimum of 46 years behind bars.