‘The perfect storm’: Bourke Street coroner delivers scathing findings against Victoria Police

A Victorian coroner has delivered scathing findings against Victoria Police and their futile attempts to negotiate with Bourke Street killer James Gargasoulas as he drove through Melbourne's inner-city nearly four years ago.

Coroner Jacqui Hawkins, who is delivering her findings following a six-week inquest into the deadly rampage, said attempts to negotiate with Gargasoulas 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 at Port Phillip area to police on the ground 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 the six and injured dozens more when he sped through the heart of Melbourne's CBD in a stolen 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.

Ms Hawkins acknowledged the fear of being disciplined stopped some officers being more assertive on the day. "The fear of being disciplined paralysed them from taking action," she said.

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 on the previous days … such a violent, drug-fuelled, psychotic and delusional perpetrator was able to slip between the cracks and evade police for several hours," she said.

Police began searching for Gargasoulas at 2.20am on January 20, 2017, about an hour after he allegedly 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 for change there is to help prevent similar tragedies in future.

Bombshell evidence included revelations:

  • Of failed 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.

The inquest also scrutinised Victoria Police's pursuit policy and procedures, including the hostile vehicle policy introduced in late 2019.

In her findings on Thursday, Ms Hawkins was highly critical of officers' failure to call their attempts to stop and arrest Gargasoulas on January 20 a "pursuit".

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

The Age previously revealed the specialised unit CIRT ignored repeated requests from local police to help contain and arrest Gargasoulas in St Kilda and Elsternwick almost nine hours before the tragedy. Instead, Gargasoulas was tailed by police for hours after critically injuring his brother with a knife in Windsor before driving across Melbourne and ultimately through the CBD.

Audio from the police radio as Gargasoulas tore through the CBD revealed senior officers had pleaded for someone to “take the vehicle out before he kills someone”.

One of the two CIRT officers who eventually shot the killer, Senior Constable Roland Jones, told the inquest he believed he could have done more to stop the driver, but admitted that when he tried to block traffic with his van and stop Gargasoulas near the West Gate Freeway, he would’ve been breaking force policy.

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