A handful of cops, who will probably never forgive themselves, seem likely to carry the can. The report is a massive 496 pages. It reviews the case from the moment Gargasoulas was bailed six days earlier, his near-fatal knife attack on his brother and that final, deadly drive that took less than a minute before he was rammed and arrested. But to understand what went on we need to go back further - not a few days but more than 25 years. The failure to stop Gargasoulas is not a failure of a few officers but the result of training that has encouraged a generation of police to be risk-averse. To begin with we should look at a coronial inquest - not the one headed by Jacqui Hawkins into Bourke Street but the police shootings inquiry by Hal Hallenstein. Coroner Hal Hallenstein (left) found Victoria Police in the grip of a "culture of bravery". Credit:The Age

In 10 years from 1984 Victoria Police shot and killed 31 people - each was considered lawful on the grounds of self-defence, but Hallenstein wanted to know if they were avoidable. Hallenstein held a “super-inquest” into seven deaths and found police had developed a “culture of bravery’’ where they felt compelled to take action no matter what the risk. He found police often made the situation worse by confronting offenders, resulting in an escalation of danger. A better strategy, he found, was to cordon and contain rather than just race in. In 1994 then chief commissioner Neil Comrie ordered a new training program called Project Beacon where safety became the first priority of any police operation. Every operational police officer was trained in conflict resolution and had to complete a refresher course every six months to remain on the street. The Beacon principles stated: “The success of an operation will be primarily judged by the extent to which the use of force is avoided or minimised.” It worked, as the number of shootings dropped. It also meant every police officer in Victoria was trained that doing nothing may be the best option.

In the Gargasoulas inquest the question was asked why the offender wasn’t rammed before he entered the CBD. The reason is simple. There was a very good chance the police who took that initiative would be charged with disciplinary or criminal offences. A leading senior constable was charged with reckless conduct endangering serious injury and dangerous and careless driving in 2012 after he rammed a fleeing vehicle driven by some knucklehead (see below). The policeman was rightly acquitted in the County Court. A series of inquests into police chase fatalities criticised pursuit policies and a succession of coroners urged a rethink on chase procedures. In 2014, coroner John Ollie found: "Having considered a range of material and evidence on this matter ... I cannot conceive of many situations where a police pursuit would be justified, as the risks are too high to members of the community." He said pursuits should only be authorised when the driver is wanted for a serious crime or when someone had been harmed or was about to be.

As a result, in 2015 police announced a new safety-first pursuit policy to reduce chases and on one level it worked, with the number of police pursuits dropping from 1700 a year to around 60. However the crooks discovered they would not be chased and so the number of drivers prepared to flee increased to 300 a month. It actually increased the risk, as speeding idiots knew if they ran a red light or drove on the wrong side of the road police would stop chasing. Instilled with bravado they took to ramming police who tried to block them, until there was one vehicle being smashed every three days. Another crucial problem for police is the number of days lost to work-related injuries. Desperate to lower WorkCover claims and increase productivity (there are around 2300 assaults on police per year), a series of rules were put in place requiring every operation to be designed to minimise the risk to police. This is entirely sensible, but the middle ranks say they drown in paperwork if a member is injured, resulting in a desire to avoid confrontation. One told me: “Like it or not policing is a contact sport and people get hurt.” There is layer after layer of rules and training designed to make policing safer, but the unintended consequence is to encourage police to be slow to make hard decisions. At a recent race meeting they milled about near an ugly incident, leaving it to private security to move in and eject the offenders.

There is always a disconnect between street police and bosses, with the doers thinking the shakers are out of touch. Many years ago, the troops referred to the then police HQ at William Street as “Marijuana House” because “the harder you suck the higher you get”. Just recently the pendulum has begun to swing back. The threat of terrorism and the increase in armed crooks prepared to shoot has resulted in a change of thinking. We now have an Active Shooter policy, where the first police on the scene are expected take immediate action rather than cordon the area and wait for heavily-armed specialists. Elite Special Operations Group snipers have been given more freedom to use lethal force in terror/hostage incidents. In October last year police introduced the Hostile Vehicle Policy, which spells out that doing nothing is no longer an option. Deputy Commissioner Shane Patton told us at the time: ‘‘It is saying that they will be supported if they need to take action and states clearly that they must take action.’’ Deputy Commissioner Shane Patton: wants the troops to act. Credit:Jason South “We will not wait for offenders to plough into people. The instructions are that you must do something, that you must stop these attacks and that the response must be proportionate and justified.” Options include ramming the vehicle or shooting the driver dead. It is a major shift.

Clearly senior police are trying to get out a message that they will support reasonable, decisive action. The question is not whether the police action was right or wrong. It is not even whether there was a better alternative. It is simply: was the action reasonable? James Gargasoulas leaving the Supreme Court in January 2019. Credit:Jason South Was it reasonable to believe Gargasoulas would drive through the city and not turn left into Bourke Street? That you could have grabbed him in a less populated area? Would it have been reasonable to confront him when he was doing burnouts in Flinders Street, knowing you may have to shoot him as he was suspected to be carrying a knife? The fact police did not stop Gargasoulas is rightly the subject of coronial scrutiny. A few years earlier in the very same court they were blasted for taking decisive action in remarkably similar circumstances. On February 2, 2005, Wayne Joannou walked into a St Albans flat and shot criminal associate Brian Bottomley, 32, in the neck in front of two witnesses. He then made them help him dismember the body in the bath, using an angle grinder and a circular saw.

Joannou made it clear he would shoot police rather than surrender and so the arrest was handed to the Special Operations Group. Just after 7pm on February 18, Joannou pulled up in a green Camry in Bank Street, South Melbourne, to smoke heroin. The SOG rammed him and when he raised his shotgun they opened fire, killing him instantly. The coroner sent the file to the Office of Public Prosecutions to examine whether charges should be laid against the four shooters (they weren’t). John Noonan, then head of the SOG, remains filthy that their actions were subject to criticism: ‘‘We had no other options and made a split-second decision. If we had let him go and lost him in traffic he could have killed someone else.’’ Francis Adams, left, the veteran police officer who was off duty but compelled to act during the December 2017 car attack. Sound familiar? No wonder cops make themselves small targets.

To truly support the troops it will take more than just words from Police Command. Sergeant Francis Adams, an off-duty sergeant, was about to go Christmas shopping in late December 2017 when a driver in Flinders Street deliberately ploughed into 17 pedestrians, killing one. Adams could have walked away but he didn't. He dragged the offender from the car and even though he thought the man was wearing a suicide vest, he choked him until he surrendered. Adams suffered serious shoulder, hand and ankle injuries that ended his career. In the Police Headquarters foyer is the Honour Board that carries the names of police recipients of the Valour Award. Francis Adams’ name is not there. It should be. When police take decisive action to protect the community, they should be publicly supported - after all, isn't that what we want from our first responders?