Bourke St rampage was ‘perfect storm’

The plan to make a Bourke Street rampage driver surrender via texts, along with poor planning and a lack of leadership by police led to a "perfect storm" on the fatal day but the tragedy not have been prevented, a coroner has found.

Nine months after the 31 day inquest into the Bourke Street massacre Coroner Jacqui Hawkins handed down 300-pages of findings into the deadly attack.

Six people died and another 27 were injured when James Gargasoulas mowed down pedestrians in the busy shopping strip in Melbourne's CBD on January 20, 2017.

Deficiencies including poor police planning, a lack of assertive leadership, lack of adequate resources, inadequate communications between units and a staunch belief in negotiating with the driver led to a "confluence of events," Ms Hawkins found.

"Each of these factors contributed to the perfect storm," she found.

But despite this the catastrophic event couldn't have been prevented.

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

Victims killed in the rampage were three-month old Zachary Bryant; 10-year-old Thalia Hakin, Jess Muddie, 22, Yosuke Kanno, 25, Matthew Si, 33 and Bhavita Patel, 33.

Moments before the carnage on Bourke Street, the driver was filmed doing burnouts at the busy Flinders Street intersection. Picture, Tony Gough
Moments before the carnage on Bourke Street, the driver was filmed doing burnouts at the busy Flinders Street intersection. Picture, Tony Gough

"The negotiated surrender plan really amounted to nothing more than two phone calls and a series of bizarre texts," Ms Hawkins said when handing down her finding on Thursday.

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

During the inquest more than 60 witnesses gave evidence into what happened the day of the fatal attack and heard from the family of victims who were left to pick up the pieces.

Melinda Tan, wife of slain architect Matthew Si lashed police for their handling of the tragedy and the events before.

Architect Matthew Poh Chuan Si, 33, one of the victims of the Bourke Street massacre.
Architect Matthew Poh Chuan Si, 33, one of the victims of the Bourke Street massacre.


"Our families had to be sacrificed on that day. If this is the best that Victoria Police can offer, then we are better off protecting ourselves," she told Coroner Jacqui Hawkins during the inquest.

She criticised police for texting Gargasoulas to get him to surrender.

"You cannot negotiate with a psychopath via text messages," she said.

One of Victoria Police's most senior officers, Assistant Commissioner Stephen Fontana held an internal review into the massacre.

The force tried to stop the 496 page document from being released but Coroner Jacqui Hawkins made the critical incident report public earlier this year.

Mr Fontana found the operation to stop the deadly driver was "poorly co-ordinated" and officers had "tunnel vision" because they believed they could convince him to surrender.

"Once Gargasoulas arrived at the intersection of Flinders and Swanston Street 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 wrote in the internal report.

Gargasoulas was jailed for life in February last year and will only be eligible for parole after serving 46 years behind bars.

Originally published as Bourke St rampage was 'perfect storm'

Zachary Bryant
Zachary Bryant


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