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Sydney siege inquest: police should have stormed Lindt cafe sooner, coroner finds

Hostages flee the Lindt cafe at the end of the Sydney siege
Hostages flee the Lindt cafe at the end of the Sydney siege. The state coroner says the siege should have been ended by police after Man Haron Monis’s first shot at 2.03am. Photograph: Getty Images

Police should have stormed the Lindt cafe as soon as Man Haron Monis began shooting, state coroner Michael Barnes has found in his inquiry into the Sydney siege: in the 10 minutes they delayed, hostage Tori Johnson was forced to kneel on the floor and was murdered by the gunman.

Islamist extremist Man Monis, brandishing a shotgun and claiming he was an Isis operative with explosives in his backpack, took 18 people hostage inside the Lindt cafe on the morning of 15 December 2014.

Seventeen hours later, just after 2am, with negotiations having foundered and his behaviour growing increasingly erratic, Monis fired his first shot, in the direction of escaping hostages.

The coroner said that action should have been the cue to police to forcibly end the siege, which the new New South Wales commissioner of police agreed with.

Delivering his findings from the 18-month inquest into the siege deaths, Barnes said: “I conclude that after a brief period to allow officers to gather information, an emergency action should have been initiated following the first shot of Monis at 2.03am.

“That made it clear there was little to no chance of resolving the siege and those within the cafe were at an extreme risk of harm. The 10 minutes that lapsed without decisive action by police was too long.

“Tori Johnson was executed in the meantime, before the decision to entered the cafe was made.”

Police ultimately stormed the cafe after Monis shot Johnson. Police killed Monis but fragments of police bullets also hit Katrina Dawson, who was seeking safety lying on the floor. She later died in hospital.

In his 472-page formal findings, Barnes comprehensively details Monis’s criminal and psychological history, the chronology of the siege and the police response to the terrorist act.

Barnes said Monis knew what he was doing and was not incapacitated by a psychiatric condition.

“The inquest had all of Monis’s medical records reviewed by an eminent psychiatrist. I accept his evidence that Monis was not suffering from a diagnosable, categorical psychiatric disorder that deprived him of the capacity to understand the nature of what he was doing when he staged the siege.

“He was not psychotic, although he almost certainly had a severe personality disorder. Monis undertook the siege in a controlled, planned and methodical manner, marked by deliberation and choice.”

He said responsibility for the deaths in the siege lay solely with Monis, not with police or any other responders.

But Barnes was critical of NSW police’s decision to enact an “emergency action” plan – an action taken in response to a particular action by the terrorist – instead of a “direct action” plan, whereby police would enter the siege stronghold at their own instigation and at a time of their choosing.

In the case of the Lindt cafe siege, the police emergency action plan insisted tactical operations unit officers would respond only when Monis killed or seriously injured a hostage.

Barnes said stronger consideration should have been given by police to a direct action plan before anybody was hurt or killed.

“By entering the stronghold at a time of their choosing, tactical police increased their chances of surprising the hostage taker and reducing the risk to hostages,” he said. “This approach is safer for the tactical police and safer for the hostages. That said, it bears repeating, all forced entries entail very considerable risk.”

Barnes acknowledged initiating a deliberate action plan to storm the cafe before Monis made clear his intent to kill anybody would have posed risks to police.

“But the fact a deliberate action would have involved risk does not necessarily mean it should not have been approved, authorised and initiated.”

The new NSW police commissioner, Mick Fuller, conceded armed officers should have been sent in earlier to rescue the hostages.

“In hindsight, as with everything, we know we should have gone in earlier,” he told ABC’s Four Corners in a pre-recorded interview released after Barnes delivered his findings. “It does not guarantee there will not be a loss of life ... but clearly a deliberate action is a much more professional action and a lower risk in terms of emergency action.”

The coroner also found the police’s strategy to “contain and negotiate” failed, that police negotiators were inadequately trained, underresourced and failed to explore all options for making contact and establishing a dialogue with the gunman.

A consultant psychiatrist brought in to assist with negotiations played a “sub-optimal” role, the coroner found. The psychiatrist’s advice was ambiguous and he made erroneous and unrealistic assessments of what was occurring within the siege stronghold.

Barnes also found hostages weren’t able to talk to police negotiators when they needed to.

“Eight calls by hostages to a number they had been told would connect them with a negotiator were not answered,” he said. “An unknown number of calls were also diverted to other telephones within the police forward command post. This was a significant failure in a basic component of siege management, the maintenance of open communications between hostages and negotiators.”

At one stage, four calls went unanswered when all the negotiators went to a briefing.

During the siege, two police snipers set up positions across Martin Place from the stronghold. However, their legal authority to kill Monis was unclear to them.

“Throughout the siege, the snipers and the police commanders believed that police did not have lawful authority to shoot Monis because they conceded he did not pose an imminent or immediate danger to the hostages. That was, in my opinion, an unduly restrictive view of their powers and an underestimation of the risk the hostages face.”

For a period of 10 minutes – between 7.38pm and 7.48pm – a part of a head, believed to be Monis’s, was visible from one sniper position. However, it was not certain the person was Monis and, because of the obstruction of a flag, the sniper could not see if hostages were behind him.

“In those circumstances, the sniper’s decision not to fire was entirely reasonable.”

Barnes made no criticism of the snipers’ decision not to fire.

Thomas Zinn, the partner of Tori Johnson, said during the course of the 18-month coronial inquest “one shocking discovery followed the next”.

“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, at times, were confused, ill-informed, unprepared and under resourced to deal with Monis.

“While we have been shocked by these failures, I would like to make clear that our family has high regard and respect for the officers who put their lives at risk after waiting so long for orders to act, and we acknowledge the grief and trauma that they have experienced.”

Speaking outside the coronial inquest, Zinn said “the pain deep in our hearts from losing Tori is as strong now as it was in December 2014”.

“Everyone who knew Tori would agree that we lost a guardian angel that night.”

Following the coroner’s findings, the NSW premier, Gladys Berejiklian, acknowledged the bravery of the police and first responders in the incident she said “devastated” the state.

“We will also never forget the ordeal suffered by the surviving hostages,” she said on Wednesday. “The outpouring of grief that saw a sea of flowers grow in Martin Place is still palpable.”

Berejiklian said the state government would “take the lessons learned” and thoroughly review the findings.