The NSW coroner has praised police in the findings of his inquiry into the Lindt Cafe siege, but says officers took too long to respond and storm the building after the first shot was fired by gunman Man Haron Monis.
NSW coroner Michael Barnes concluded the 15 December, 2014, event was a terrorist incident in which two people died, barrister Katrina Dawson and cafe manager Tori Johnson, along with Monis.
And he found another crucial mistake occurred in the months leading up to the siege when police failed to arrest Monis over more than 40 sexual assault charges, which may have prevented him from getting bail when subsequently charged with being an accessory to the murder of his ex-wife.
Releasing the 495 page report following an 18-month inquest, Barnes criticised police for taking too long to respond once Monis fired his first shot, nearly 17 hours into the siege at 2.03am.
Another 10 minutes passed, by which time Johnson was killed.
“An emergency action should have been initiated following the first shot of Monis at 2:03am,” Barnes.
“That made it clear there was little to no chance of resolving the siege, and those within the cafe were at an extreme risk of harm.
“The 10 minutes that lapsed without decisive action by police was too long. Tori Johnson was executed in the meantime before the decision to entered the cafe was made.”
The inquest heard that Monis was released on bail three times in the year before the siege, despite facing serious charges, including being an accessory to the murder of his ex-wife, and 43 counts of sexual assault against women.
“Police made a mistake when they failed to arrest Monis,” Barnes said, when gunman faced the assault charges. Instead he was supplied with a court attendance notice.
The coroner’s first recommendation is that someone’s criminal history, including their bail status, is available to police and prosecutors across Australia.
“Barriers to the free exchange of criminal history information among national and state-based law enforcement and prosecuting authorities have the potential to adversely impact upon the effectiveness of those agencies, as occurred in this case,” Barnes.
Monis was given bail after being charged with being an accessory to murder his ex-wife because prosecutors did not know about the sexual assault charges.
Barnes labelled the submission opposing bail by the Department of Public Prosecutions (DPP) on the accessory change as “inadequate” and while police wanted to appeal granting it, they never did.
Barnes began by offering condolences to the families of Dawson and Johnson. He later said the families treated were insensitively by police, that facilities during the siege were inadequate, briefings were infrequent and the notification of the deaths of their loved ones were unnecessarily delayed.
He recommended NSW police develop better policies and procedures for family liaison during major incidents.
Barnes describing the events of the day as torture for the 18 hostages involved.
“Monis oscillated between feigning regard for their welfare and threatening to blow them apart,” he said.
“They had entered a familiar environment, only to find it transformed into a prison run by a vicious maniac. Public recognition of their suffering and the extraordinary courage some demonstrated is warranted.”
Barnes praised the police tactical officers who stormed the building shortly after 2.13am after Monis shot and killed Johnson at point blank range.
“The bravery of these officers inspires all. It is difficult to appreciate or even describe,” the coroner said.
“I cannot stress too heavily that the deaths and injuries that occurred as a result of the siege were not the fault of the police.
“All of the blame for those rests on the shoulders of Man Monis. He created the intensely dangerous situation. He maliciously executed Tori Johnson. He barricaded himself into a corner of the cafe and his actions forced police to enter the cafe in circumstances where the risk of hostages being wounded or killed was very high.”
Turning his attention to the senior officers in charge, he said: “No one could reasonably accuse them of shirking their duty. Those commanders must live with the outcome of their decisions, the likes of which their critics will never need to make.”
Monis took 18 hostages in the cafe in the name of the Islamic State, and police believed he had a bomb in his backpack. The gunman told authorities that three bombs had been placed around the city — a claim that was false.
The coroner said it was an extraordinary situation for all involved.
“Comments that the siege involved just one madman with a shotgun failed to appreciate the complexity of the situation that the police responders faced,” he said.
“An international expert told the inquest, this event would have challenged any police force in the world. I readily accept that view. It is appropriate to acknowledge the excellent police work that was done during the siege.”
The coroner said his report has 45 recommendations for state and federal ministers, police and the NSW DPP.
His findings look at the mental health of the gunman, the decision to grant him bail, whether it was a terrorist incident, the police response and negotiation attempts, when police stormed the building and family liaison.
He concluded that Monis was not psychotic during the incident.
The coroner was highly critical of the psychologist police relied upon for advice during the siege.
“The consultant psychiatrist’s role at the siege was suboptimal,” Barnes said.
“He was giving advice about tactics. He made erroneous and unrealistic assessments of what was occurring in the stronghold. He gave ambiguous advice. And he was permitted to go beyond his area of expertise to give advice about Islamic terrorism.”
Among his other findings, Barnes said the police strategy of “contain and negotiate” failed, and that suggestions the Australian Defence Force should have taken over the siege were “simplistic and unrealistic” for legal reasons.
He called for the “contain and negotiate” strategy, a standard procedure for domestic situations, to be reconsidered in the era of terrorism.
“I conclude that the commanders had insufficient guidance to help them assess whether the secondary, intangible trigger, the imminent risk of Monis’ killing or injuring a hostage, had escalated to a point where it outweighed the risk associated with a forced entry,” he said.
Barnes concluded that Tori Johnson died immediately after being shot in the back of the head by Monis.
The gunman died from multiple gunshot wounds from police as they stormed the cafe.
Katrina Dawson attempting to seek shelter on the floor as police entered, died from gunshot wounds after a bullet, or bullets, fired by police ricocheted and accidentally struck her.
The full report is here.
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