Police attempts to stop James Gargasoulas before he murdered six pedestrians and injured 27 others along Melbourne's Bourke Street Mall were doomed to fail.
That's the finding of coroner Jacqui Hawkins into the car rampage that struck the city to its core during the lunchtime rush on January 20, 2017.
Systemic failures by Victoria Police contributed to the perfect storm that allowed Gargasoulas to manipulate the situation, findings handed down in Victoria's Coroners Court on Thursday revealed.
These "agonising" failures culminated in the murders of three-month-old Zachary Bryant and 10-year-old Thalia Hakin.
Also killed were 22-year-old Jess Mudie, Yosuke Kanno, 25, and 33-year-olds Matthew Si and Bhavita Patel.
"It is agonising that despite the escalating events of the previous days and the scores of police members actively engaged in attempting to stop him, such a violent, drug-fuelled, psychotic and delusional perpetrator was able to slip through the cracks," Ms Hawkins said.
Six days before, Gargasoulas had been released from custody on a string of charges including dangerous and careless driving, assault, failing to answer bail, and reckless conduct endangering life and serious injury.
His behaviour escalated and on the morning of the rampage, he stabbed his brother and went on the run.
Detective Senior Constable Murray Gentner tried and failed to get Gargasoulas to surrender via phone and text messages, as officers tracked him across suburbs.
"The negotiated surrender plan really amounted to nothing more than two phone calls and a series of bizarre text messages," Ms Hawkins said.
"There was no actual negotiation. There were no plans made, nor agreement reached. The strategy never had a chance of succeeding."
Ms Hawkins found the force didn't follow its own policy for police pursuits and that it was simply too late to stop Gargasoulas by the time he reached the CBD.
Some officers were paralysed by the fear they'd be reprimanded if they took more aggressive action outside police rules.
The situation was exacerbated by poor planning, communication, coordination and "a staunch belief that negotiating with a delusional person was the best chance of bringing the incident to a conclusion".
"A remarkable confluence of events emerged in favour of the offender, including a set of systemic deficiencies in the response of Victoria Police, that permitted manipulation by a single, dangerous and unpredictable offender," Ms Hawkins said.
Despite this, she was unable to find the catastrophic outcome would have been prevented if police did things differently.
Ms Hawkins made nine recommendations including that Victoria Police review how it manages critical incidents, and its bail procedures for high-risk and repeat offenders.
She also called for better training for officers involved in bail hearings, and suggested that they look at recording after-hours bail and remand hearings on their body-worn cameras.
Bail justice Christos Pantelios agreed to release Gargasoulas from custody during one such hearing, despite police opposition.
Ms Hawkins said it would be inappropriate for her to comment on whether that was the correct decision.
But she found Mr Pantelios defensive and eager to blame police during the inquest.
Gargasoulas was simply referred to as "the offender" in the findings.
"To simply describe these events does not capture their horror, occurring as they did in the midst of crowds of shoppers, tourists and office workers enjoying the height of summer," Ms Hawkins said.
"Numerous witnesses likened it to a nightmare ... simply beyond their comprehension.
"The offender's actions are both unthinkable and repellent. They struck at the heart of Melbourne."
Gargasoulas is serving a life sentence, with a non-parole period of 46 years, for what was described as one of Australia's worst examples of mass murder.
Victoria Police Chief Commissioner Shane Patton said while no one could have predicted the rampage, mistakes were made.
He said the force had implemented changes including an overhaul of how it responded to hostile vehicle attacks.
The victims' families urged police not to waste the chance for "real, meaningful cultural change, lest this investigation be added to the list of opportunities missed".