The police officers who chased James Gargasoulas in the hours before he went on a murderous rampage treated the pursuit as a "routine investigation" and failed to consider what would happen if they couldn't catch up to the now-convicted killer, a stinging internal review has found.
Key points:
- Assistant Commissioner Stephen Fontana's review found officers "failed to consider" what would happen if attempts to negotiate Gargasoulas's surrender failed
- His report said police should have "regrouped and rethought their strategies" after an initial pursuit
- But he said officers had few low-risk options to safely stop Gargasoulas once he had reached the CBD
The 496-page report by Assistant Commissioner Stephen Fontana, one of the force's most senior officers, also found rank and file members were too focused on negotiating Gargasoulas's surrender and failed to pass on critical information that would have helped key decision-makers.
But Assistant Commissioner Fontana acknowledged officers had few options available to them once Gargasoulas arrived at the intersection of Flinders and Swanston streets in Melbourne's CBD, where he did doughnuts in a stolen Commodore before embarking on his rampage.
"There was very little they could do from here on in terms of decisive action to stop him, without endangering the lives of many people," he said.
"A deliberate full-frontal collision with Gargasoulas's vehicle as he proceeded along Swanston Street was the only real option left for police to stop him from this point onwards."
The review into the force's policies, procedures and response to the massacre was released this afternoon after being tendered to the Bourke Street coronial inquest, which is probing the actions of Victoria Police in the lead-up to the rampage and how Gargasoulas was on bail at the time.
But it almost did not see the light of day, with Victoria Police opposing its release.
Bourke Street victims:
- Yosuke Kanno: 25-year-old student from Japan. He had just been to lunch with a friend when he was struck
- Jessica Mudie: 22-year-old insurance consultant from Sydney who was in Melbourne for a business meeting. She was returning from lunch with colleagues.
- Matthew Poh Chuan Si: 33-year-old architect and father of an 18-month-old daughter. He had just been to lunch with his wife.
- Bhavita Patel: 33-year-old accountant. She had been to lunch with colleagues.
- Thalia Hakin: 10-year-old primary school student. She was on her way to a circus show with her mother and sister.
- Zachary Matthew-Bryant: The 3-month-old was in a pram with his sister when he was struck.
Police could not have predicted 'big step' in offending
In his review, and on the witness stand today, Assistant Commissioner Fontana stressed his findings were made with the benefit of hindsight and that officers were "well-intentioned".
"Any commentary made in this report regarding failings identified, does not mean that if other action had been taken a different and better outcome would have been achieved," he wrote.
He also said there was nothing to forewarn police that Gargasoulas was any different from other reckless and dangerous drivers, before he drove into the city.
"Police did not have prior knowledge that he had expressed intent to run everyone down in the city 'if the cops came to find him'," the report said.
"They did not know of his murderous intent and so from their experience, they would not have expected Gargasoulas to deliberately drive into a crowd of pedestrians along Bourke Street.
"It is a big step for anyone to progress from offending and behaviour such as that displayed by Gargasoulas."
Officers had 'no alternative plan or strategy'
But he also noted that the police plan to intercept Gargasoulas "was never going to succeed" without the help of specialist officers.
"It seems that they were so focused on negotiating surrender that they failed to have awareness of a dynamically changing situation," Assistant Commissioner Fontana wrote.
"When they did try to intercept him, a pursuit eventuated but was almost immediately terminated.
"Despite this, they continued to adopt the same strategy but failed to consider what would happen if he failed to stop for them again, or if their attempts to negotiate a surrender failed.
"They had no alternative plan or strategy … It was treated as a routine investigation when it should have been prioritised as an active ongoing investigation."
Assistant Commissioner Fontana said police failed to be decisive at critical moments, which in turn allowed Gargasoulas to evade their clutches.
"Police members were not prepared to take a risk in what they perceived to be a breach of policy, due to fear of repercussions and lack of confidence in their management to support them," he said.
He also said it was clear Gargasoulas wanted to get the police's attention.
"Police would have been better prepared to re-engage with him again if they had regrouped and rethought their strategies following the pursuit," he said.
"In my view, what should have been a well-planned operation to resolve this evolving situation, unwittingly turned into a poorly coordinated, unplanned response.
"I am of the view that this is a failing of Port Phillip CIU management."
His report also contained some praise for officers.
"Once systems and processes were in place, Victoria Police employees performed in a way the community would expect," he said.
"Whilst responding units were initially unable to identify who was in control, they acted immediately to arrest Gargasoulas, treat victims and to identify triage areas for victims and witnesses."
Assistant Commissioner Fontana is expected to continue giving evidence until Friday.
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