A coroner has found “systemic deficiencies” by Victoria Police allowed driver James Gargasoulas to kill six victims along Bourke Street in 2017.

Coroner Jacqui Hawkins has made nine recommendations after a six-week inquest.

Gargasoulas was released on bail six days before the tragedy.

The coroner found poor planning and a lack of leadership and resources and inflexible attitudes were among the failures which allowed Gargasoulas to manipulate the police force.

Chief Commissioner Shane Patton released the following statement in response to the recommendations being made public.

The Bourke Street tragedy on 20 January 2017 is an incident that will never be forgotten. Sadly, six innocent victims lost their lives, while the lives of many more people forever changed.

First and foremost, I want to offer my continued and heartfelt condolences to the families and friends of those who lost their lives. To lose someone because of such a callous act is unthinkable. I can’t even begin to imagine the heartache and anger they must still be feeling.

I want to assure them that our entire organisation will never forget what happened on 20 January 2017. Nor will we forget the names Matthew Poh Chuan Si, Thalia Hakin, Yosuke Kanno, Jess Mudie, Zachary Matthew Bryant and Bhavita Patel.

Just as importantly, our hearts continue to go out to the 27 innocent people who were injured that day. The vast majority of these victims were hospitalised and many of them are still receiving treatment for their injuries. This incident will have lifelong consequences for them, not to mention for all those who saw the tragedy unfold and for Melburnians more broadly.

As with any crime, I wish more than anything that what occurred on 20 January 2017 never happened. That the offender would have stopped his vehicle when he was repeatedly requested to do so by police and that he never would have entered the city or used his vehicle as a weapon. Most of all, I wish there were no victims and that our community would never have been exposed to such a horrendous crime.

As the Chief Commissioner of Victoria Police, I know the community relies on police to keep them safe when incidents like this occur. This is no different to what the victims and their loved ones would have expected from us that day.

That is why what transpired that day was – and still is – absolutely devastating to our entire police force, particularly the police officers involved. This was not the outcome our police officers wanted, nor what they anticipated, when they set out to apprehend the offender.

It’s why in the days that followed we commenced a thorough review of our actions leading up to and on the day of the incident. When a critical incident occurs, we prioritise this review to ensure our operational response is looked at from every angle.

This is an integral part of our operating procedures as we need to understand exactly what happened and if there are lessons that can be learnt. We started this work as soon as possible because we did not want to delay the opportunity to implement any improvements identified through the review.

Having read the internal report and closely followed the Coronial Inquest, it is my firm belief the police officers responding to this incident acted in good faith based on the information available to them.

The reality is, no one could have predicted the outcome. There had never been a hostile vehicle attack in Australia and our members had never dealt with a similar situation.

However, with the benefit of hindsight, it is clear there were some shortcomings in our operational response.

Based on interviews conducted internally and at the Inquest, I am aware some police officers felt they would not be supported if they actively tried to stop the offender’s vehicle. Regardless of whether the vehicle could have been stopped before coming into the city, the fact is some of our members felt uncertain if they would be supported in taking more forceful and decisive action.

This is not how we want our police officers to feel. Community safety is our number one priority, which is why it was so important that we addressed this issue as soon as possible.

Over the past four years we have introduced a number of new response teams and policies to directly deal with critical incidents like this. This includes SOG’s Quick Response Force (September 2017), the CIRT security teams (December 2017) and a new hostile vehicle attack policy (October 2019).

While it is impossible to speculate whether any of these changes would have stopped the devastating outcome on 20 January 2017, the community should know we are committed to doing everything we can to prevent an incident like this from occurring again.

Now the Coronial Inquest findings have been released, we will take the time to read this report in detail and consider the nine recommendations for Victoria Police.