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

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:

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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More to come.