Monis 'solely to blame' but 'police took too long' to enter Lindt Cafe siege: NSW Coroner

The NSW Coroner has concluded that gunman Man Haron Monis was "solely to blame" for the deaths in the 2014 Lindt Cafe siege, but has criticised police timing during the incident.

In an almost 90-minute delivery of his findings, NSW Coroner Michael Barnes said "all of the blame for those rest on Man Monis".

Key points:

• Coroner made 45 recommendations.

• Man Haron Monis is "solely to blame" for the Lindt cafe siege.

• Siege classed as terrorist incident.

• Incident not police officers' fault.

• Monis shouldn't have been out on bail

"I cannot stress too heavily that the deaths and injuries that occurred as a result of the siege were not the fault of the police," he said.

"All of the blame for those rest on Man Monis. He created the intensely dangerous situation, he maliciously executed Tori Johnson, he barricaded himself into a corner of the cafe and his actions for police to enter the cafe in circumstances where the risk of hostages being wounded or killed was very high."

Man Haron Monis was 'to blame' for the entire Lindt cafe siege, the NSW Coroner said. Photo: AAP

Gunman Monis had walked into the Lindt Cafe in Sydney's Martin Place on the morning of Monday December 15 with an ageing sawn-off shotgun and an Islamic flag and took 18 people hostage.

Two hostages, Tori Johnson and Katrina Dawson, were killed as the Martin Place stand-off came to a horrific end after 17 hours.

Katrina Dawson and Tori Johnson were killed in the tragedy. Photos: AAP

Monis was shot by specialist police who stormed the stronghold 17 hours after Monis sent the area into lockdown.

Mr Barnes concluded the siege was a terrorist incident.

The Coroner commended the bravery of NSW Police officers and said "the bravery of these officers inspires all".

"The commanding officers who ordered the storming of the cafe came under intense scrutiny during the inquest," he said.

"It is appropriate to acknowledge the burden of command they carry."

He did criticise police on their response times however, explaining that waiting 10 minutes after Monis fired his first gun shot was too long.

"The 10 minutes that lapsed without decisive action by police was too long," Mr Barnes said.

"Tori Johnson was executed in the meantime before the decision to enter the cafe was made."

In reviewing the police response Mr Barnes highlighted a problem of the negotiation handovers.

He said four calls made between 12.30am and 1am from hostages to police went unanswered while police were in a negotiation handover.

"I recommend the negotiation handovers are staggered so a fully briefed officer is always available," he said.

Hostage survivor John O'Brien reacts to Coroner's inquest findings

Mr Barnes did say he believed there was no real chance for police to enter the Martin Place building earlier than they did, knowing the risk it would pose to hostages.

He said the only possible opportunity to contain Monis before he killed cafe manager Tori Johnson arose in a 10 minute period commencing at about 7.38pm.

Pictured: Paramedics act quickly to help the injured. Photo: AAP

"During that time, only part of the back and side of the head of a person thought to be Man Monis, was visible through one of the windows overlooking Martin Place.

"The snipers in the Westpac building are not certain that the person was Man Monis.

"Further, because most of the windows were obscured by a flag, they could not see whether there were any hostages immediately behind or beside the individual in question. And so, they could not discount the risk that any hostages who were nearby might be killed or injured if they tried to shoot him."

The report was handed down after a 23-week inquest into the siege.

Thousands of people paid their respects after the siege ended. Photo: AAP

Ms Dawson's parents Sandy and Jane Dawson and brother Angus Dawson, and Mr Johnson's partner Thomas Zinn, mother Rosie Connellan and father Ken Johnson were in attendance on Wednesday.

At least one of the siege survivors, Paolo Vassallo, also attended.

NSW premier Gladys Berejiklian says the government will learn from the tragedy of the Lindt Cafe siege that killed two people who will "never be forgotten".

"The inquest has been a difficult process for the families and surviving victims, and our thoughts are with them," she said.

She acknowledged the bravery of the police and first responders in the incident she says "devastated" the state.

"We will also never forget the ordeal suffered by the surviving hostages," she said in a statement on Wednesday.

"The outpouring of grief that saw a sea of flowers grow in Martin Place is still palpable."