“I have formed the view that once Gargasoulas arrived at the intersection of Flinders and Swanston Street, there was very little [police officers] could do from here on in terms of decisive action to stop him, without endangering the lives of many people,” Mr Fontana wrote. “A deliberate full-frontal collision with Gargasoulas’ vehicle as he proceeded along Swanston Street was the only real option left for police to stop him from this point onwards.” The report also shows Victoria Police’s vehicle pursuit policy at the time of the incident was a mess of sometimes contradictory instructions and inflexible regulations that were interpreted differently by command and uniform officers. Uncertainty about the policy led to officers being extremely risk-adverse about engaging in pursuits. Assistant Police Commissioner Steve Fontana arrives at the Bourke Street massacre inquiry on Wednesday. Credit:Simon Schluter “This was demonstrated at various times in events leading up to the Bourke Street tragedy where dynamic and decisive decision making was stifled at critical times, creating an opportunity for Gargasoulas to avoid apprehension,” Mr Fontana wrote.

“Police members were not prepared to take a risk in what they perceived to be a breach of policy due to fear of repercussions and lack of confidence in their management to support them.” On Wednesday, Mr Fontana told the inquest into the tragedy that police officers who had charged Gargasoulas in the days before the massacre failed to create an adequate arrest plan or raise their concerns about his "extreme" risk of further offending up the “chain of command”. Loading Replay Replay video Play video Play video Gargasoulas' criminal history records 253 charges dating back to his childhood, including numerous offences for dishonesty, violence, escaping from custody, weapons offences, assaulting police and drug use. He is also listed as a perpetrator in 10 family violence incidents and has a history of breaching intervention orders, the report says. “[The officers] had no real plan around bail management,” Mr Fontana told the inquest.

“There were things that could've been done to make sure he was complying with his conditions. "The biggest failing [though] was no one was tasked to look at where [Gargasoulas' mobile phone] pings were. It wasn't that hard to ask." Mr Fontana said no one was given ownership over a plan to arrest Gargasoulas in the hours after he stabbed his brother, Angelo, at Windsor – an incident that preceded the Bourke Street attack. He said despite concerns being raised by one detective, no one seemed to show any “interest” in arresting Gargasoulas, which resulted in a “lack of ownership, thought or planning”. Police race to stop James Gargasoulas on the day of the massacre.

Mr Fontana's report also criticises the decision by supervisors of the police's Critical Incident Response Team to refuse a request to arrest Gargasoulas when he was believed to be parked in St Kilda, then Elsternwick, hours before the incident. “There was no reason why the CIRT could not have deployed to the area to assist in a search for Gargasoulas or the stolen vehicle that he was driving.” Officers from the Port Phillip Crime Investigation Unit are also heavily criticised for their failure to arrest Gargasoulas after he committed a series of escalating offences in the lead-up to the vehicle attack. About two hours before his stolen maroon Commodore reached the CBD, two officers were ordered to terminate a pursuit of Gargasoulas after following him across several suburbs to Moray Street in South Melbourne. The report finds the failed pursuit should have signalled that it was “time to regroup” and review the planned operation, including the level of command and control and operational support needed to safely arrest Gargasoulas.

“This did not happen and I am of the view that this is a failing of Port Phillip CIU management,” Mr Fontana wrote. People leave tributes in Bourke Street Mall in January 2017. Credit:Jason South “In my view, what should have been a well-planned operation to resolve this evolving situation, unwittingly turned into a poorly coordinated, unplanned response.” The report lambasts Port Phillip officers for failing to share critical information with other units, including the air wing, despite knowing Gargasoulas’ criminal history and being in contact with him by text message asking him to surrender. “In fact, Port Phillip CIU on air communication with operational units was almost non-existent – their silence was deafening,” Mr Fontana wrote.

Detective Sergeant Adam Vohmann, the officer who nominated himself as the incident controller of the operation to stop Gargasoulas, was “ill-prepared” to be in charge because he was at another crime scene, the report finds. “In fact, other than issuing a few initial instructions before directing units to change channels, he effectively exercised no control of the ongoing pursuit,” Mr Fontana wrote. As part of his testimony, Mr Fontana said the force had done “a lot of soul searching” since the tragedy. “I would like to, on behalf of Victoria Police, acknowledge the great harm and pain that this tragic incident has had on the families of the deceased and those that were injured,” he said. “We’re absolutely committed to learning from these incidents to ensure we’re always improving our practices.”

The report noted that more than a thousand police employees had sought help from welfare services following their involvement in the Bourke Street attack. The Critical Incident Review was launched by Mr Fontana in February 2017 and details blow by blow criticisms of numerous police officers involved in Gargasoulas’ failed arrest and how they handled the incident. Victoria Police Chief Commissioner Graham Ashton sought to stop Assistant Commissioner Steve Fontana's scathing report from being released publicly. Credit:AAP Chief Commissioner Graham Ashton had sought to prevent the public airing of the report, but the families of those killed, along with media organisations including The Age, fought for its release because it was ‘‘inextricably linked and inextricably intertwined’’ with attempts to understand events leading up to the massacre. It enabled the internal review to be referred to in full during the inquest.