The NSW Coroner has identified numerous inadequacies in the handling of the Lindt cafe siege that ended with the deaths of two hostages.
Man Haron Monis walked into the Lindt chocolate cafe in Martin Place at 8:30am on December 15, 2014. Seventeen hours later, cafe manager Tori Johnson, 34, barrister and mother-of-three, Katrina Dawson, 38 and Monis were all dead.
The Coroner, Michael Barnes, was particularly critical of the Department of Public Prosecution for failing to secure Man Monis' bail in the weeks leading up to the siege, and the police psychiatrist who advised police negotiators for overstepping his role. This comes despite him commending the "great courage" of police in the highly dangerous situation.
"Against what standards does one charge a man demanded to stand -- to stare down death to save strangers? Who would dare say they could do better?" he told the inquiry on Wednesday.
Barnes said that the unusual circumstances of the siege would have challenged "any police force in the world".
"Even if every aspect of the response adopted had been executed to the highest possible standard, there is no certainty the outcome would have been any better."
Nevertheless, the Coroner found that the police response was inadequate in several respects:
- The Office of the Director of Public Prosecutions (ODPP) did not take sufficient action to oppose Man Monis' bail for 40 counts of sexual assault and the solicitor responsible failed to keep on file important documents relating to Monis' previous charges
- Police negotiators' approach in dealing with gunman Man Monis "lacked sophistication" to come up with other options when negotiations failed;
- The psychiatrist advising police negotiators during the siege "overstepped" his role, gave "ambiguous" advice and made "erroneous and unrealistic assessments" of what was happening in the cafe;
- The NSW Police should have entered the Lindt cafe when Monis first fired at escaping hostages at 2:03am. During the ten minute delay, Tori Johnson was shot by Monis;
- The excessive use of distraction devices during the late-night police raid on the cafe was counterproductive;
- The families of hostages were given "infrequent and inadequate" information and the news of Katrina Dawson's death to her family was "unduly delayed".
The findings have now been released in a 600-page report.
Shortly after the findings were handed down, NSW Police Commissioner Mick Fuller told media that authorities will act quickly to respond to the Coroner's recommendations and admitted that police "should have gone in earlier" on the night of the siege.
"In acknowledging the 28 recommendations, the NSW Police will respond quickly to the Coroner, but again, I want to give the community some real assurance that we haven't been sitting on our hands in the last two and a half years," he said.
"If there was a terrorist attack today, similar to Lindt Cafe, then we would respond with the same highly trained police, but with a different philosophy based on the fact that terrorism has changed [in the last three years].
"I've said it before and I'll say it again - in hindsight, knowing everything weknow now, New South Wales Police should have gone in earlier. But again, hindsight is a wonderful thing."
Fuller also announced a commitment to a new police intelligence agency aimed at streamlining flows of information across agencies within law enforcement bodies.
"We will, for the first time, have a single intelligence agency before this year is out, to ensure that information flow is as smooth as possible and when we filter information, the most important information is getting to the operational commanders.
"It will be the Assistant Commissioner in charge of intelligence and they will take control of intelligence within the NSW Police Force to ensure the flow of information across the silos in the organisation is not lost and to make sure that we are communicating at the highest level with national and other partners across Australia."
'We Lost A Guardian Angel'
Tori Johnson's long-time partner, Thomas Zinn, spoke outside the courthouse of his ongoing anguish at the loss of his partner of 14 years.
"The pain we have deep in our hearts for losing Tory is as strong now as it was in December 2014.
"Everyone who knew Tori would agree we lost a guardian angel that night."
While acknowledging his "high regard and respect" for police officers who put their lives at risk, he was critical of the "systematic failures" made before and during the siege.
"Throughout the inquest, one shocking discovery followed the next," he told reporters.
"Soon it became apparent that we were not simply fighting for the truth of the circumstances of Tori and Katrina's deaths. Rather, we were confronted with systematic failures of various authorities who were at times confused, ill-informed, unprepared and under-resourced to deal with Monis throughout the bail process and later on during the siege."
The inquiry was told that just after 2am on December 16, Johnson was forced to his knees by Monis. Johnson was executed at point-blank range at 2:13am. Dawson died a short time later as specialist NSW police officers stormed the building. She had been hit by six fragments of bullets from their high-powered rifles, which ricocheted off the walls.
Monis was killed by officers during the operation, and three other hostages and one police officer were also wounded.
The exhaustive 18-month inquest into the siege has investigated whether authorities could handle the situation differently in the event of a future hostage situation.
The families of Johnson and Dawson have been regular fixtures at the inquest, hopeful that the findings will lead to changes that will save lives in the future.
They have expressed anger at the police handling of siege -- especially the tactical decision to "contain and negotiate", the end result of which meant police would wait for a hostage to be killed or seriously injured before storming the cafe.
In a Four Corners expose on Monday night, Dawson's mother, Jane, called the strategy "outrageous", while her brother Angus said it was "staggering".
"These are people they should be protecting -- they shouldn't wait for them to be impacted on in any way. They should be saving them from death or serious injury," Dawson's mother said.
Johnson's mother Rosie Connellan told Four Corners she "can't forgive people for that trigger".
"I'll never be able to understand how you make a calculated decision to wait for someone to die. It's just beyond me."
'Erroneous And Unrealistic Assessments'
The Coroner found that while the police were following established protocol in sticking to the "contain and negotiate" strategy, the strategy was "too entrenched" and by late on Monday night it should have been clear that negotiations had failed.
"The 'contain and negotiate' approach may not be the best ongoing response to a terrorist incident if the offenders believe, whether or not they survive, their cause will benefit from the publicity generated by a protracted siege," the Coroner said.
He recommended police considering developing new strategies for responding to terrorist incidents.
The Coroner was also critical of the psychiatrist who advised police negotiators during the seige, saying he lead the negotiators to underestimate the threat Monis posed.
"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," the Coroner said in the damning findings.
The Coroner recommended that multiple psychiatrists be used in the future to stop any one individual assuming too much control.
Other recommendations made by Coroner Michael Barnes included:
- The sharing of criminal bail histories among all Australian jurisdictions;
- The revision of the Terrorism (Police Powers) Act to give police more powers in responding to terror attacks;
- A clarification of snipers' legal powers to shoot;
- Staggering of handovers between police negotiators during hostage situations, so one fully briefed officer is always available;
- Establishing a way for media organisations to confidentially determine with police what information should be suppressed, so as not to compromise negotiations;
- Developing a "comprehensive policy" for providing information to family members in high-risk situations;
- Better communications between the ADF and the NSW Police be established.
'Only One Person To Blame'
The NSW Police Association had earlier spoken out in defence of police officers in anticipation of the Coroner's findings.
Acting President Tony King said the inquest had turned into a "witch-hunt", which has "tarnished" the reputation of the police force.
"There is one person to blame -- that is Man Monis," King told the Today show.
"Man Monis was out on bail, despite serious charges. He had possession of a shotgun and he was believed to be armed with a bomb. Those are the facts -- that is what really has been lost in all of this."
In handing down his findings, the NSW Coroner agreed with this assessment, saying "the deaths and injuries that occurred as a result of the siege were not the fault of the police -- all the blame for those rests on the shoulders of Man Monis."
The NSW Police Association was also critical of the bail laws and the actions of lawyers in the lead up to the siege, which allowed Monis to be out on bail -- despite being charged with more than 40 counts of sexual assault and the attempted murder of his ex-wife.
In August 2015, NSW bail laws were tightened by then-Premier Mike Baird in response to the siege, making it more difficult for those with links to violent extremism to be granted bail.
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