Wednesday’s release of the massive coronial inquest report on the Sydney Lindt cafe siege was notably pre-empted twice this week – by the acting president of the Police Association of New South Wales, Tony King, and by the first part of an ABC Four Corners investigation that had significant access to the hostages and victims’ families. The two seemed diametrically opposed.

In a long piece published online, and circulated internally among NSW police, King condemned the inquest as an overly long and expensive “witch hunt” that had cruelly overlooked the valour and professionalism of the NSW force. “Instead of scrutiny,” King wrote, “police officers were subjected to what can only be described as a media circus. Instead of a sober inquisitorial process it descended into an adversarial attack and instead of a search for the truth we witnessed taxpayer-funded lawyers on a frolic, cross-examining police officers as if they were on trial.”

Four Corners, meanwhile, focused on the families’ belief that the police response was deeply flawed. Among other criticisms, they argued that the “contain and negotiate” tactic was inappropriate for a terrorist incident; that the threshold  for police entering the cafe was absurdly high, set as it was at death or serious injury; that there was an inexcusable delay of 10 minutes between Man Haron Monis first discharging his shotgun, and police storming the cafe; and that police negotiators had relied too heavily on a consultant psychiatrist who provided erroneous advice and spoke outside his expertise.

The coroner’s report would validate substantive elements of both. So long and complex has the inquest been, and so tortured are the various parties to this tragedy, that it has yielded conflicting interpretations. The 495-page report, though clear and considerable in its findings, will likely become a sort of Rorschach test. So it is important to state clearly some fundamental findings of the coroner: that the “vicious maniac” Man Haron Monis bore full responsibility for the tragedy and should be “the sole focus of our denunciation”; that the siege was an act of terrorism; that, believing Monis possessed a bomb, the tactical officers who stormed the cafe did so with a strong expectation that they would die; that despite this extraordinary courage, and the many other examples of police professionalism that day, the [broader] response was multiply flawed and the delay in triggering an emergency response too long; that legal error likely contributed to Monis being free on bail at the time of the siege; and that improvements must be made to the triaging and sharing of information by and between intelligence agencies.

Tony King was thinking of the tactical officers who called their loved ones before entering the cafe, believing it might be the last time they spoke, when he wrote his piece. But courage does not discount error, and King overstepped in describing the inquest as a “witch hunt”. He was wrong to criticise its length. As the coroner made clear, for an inquiry of this magnitude – 118 witnesses, almost 70,000 pages of evidence, 24,000 emails sent or received – 18 months was relatively swift. “As uncomfortable and distasteful as critiquing [police] might be, we cannot shy away from examining deficiencies.”

One of the most significant deficiencies, which the NSW Police Force accepted following the report’s publication, involved the 10 minutes between 2.03am and 2.13am on the morning of December 16, 2014. At 2.03am, having forced the cafe’s manager, Tori Johnson, to his knees, Monis fired his shotgun above Johnson’s head. This triggered the police’s “emergency response”, which was enacted 10 minutes later. But it was in that time that Monis fired his second shot to the back of Johnson’s head.

“The decision to send [Tactical Operations Unit] operatives into the cafe was unquestionably one no commander would want to face,” the report reads. “The risks for the officers and the hostages were immense. However, after a brief period to allow officers to gather relevant information, an Emergency Response ought to have been initiated following Monis’s first shot at 2.03am. That event made clear that negotiations had little or no chance of resolving the siege, and that the hostages remaining in the cafe were at extreme risk of harm. The 10 minutes that elapsed without decisive action by police was too long.”

The burden of command – of directing officers to their possible death – must be considered alongside an examination of why a decisive response was delayed. NSW Police Commissioner Mick Fuller, who was only promoted to the top position six weeks ago, said this week that “in hindsight, we should have gone in earlier. But I cannot accept that some people are trying to whitewash the fact that police believed there was an explosive device in the backpack. Some people have tried to dismiss this fact. Again, I will not accept any criticism that police did not have any reason not to believe there was a bomb in the backpack, which also had to be considered when making decisions.’’

The inflexibility of “contain and negotiate” tactics for terror sieges will, rightly, be reviewed. But as Commissioner Fuller suggests, the mistaken belief that Monis possessed an improvised explosive device narrowed the tactical possibilities for police. It was a belief that was held well after Monis’s death, when officers wondered if there might be a “dead man’s switch” on the assumed bomb. Regarding the police response, this belief might be the most significant aspect. The coroner said that officers “suspected he was carrying a bomb that could kill everyone inside the cafe unless they could kill him before he could detonate it. The bravery of these officers inspires awe and is difficult to fully appreciate or accurately describe.”

One of the successes of this report is coroner Michael Barnes’s deft balancing of respect and criticism.

The psychological profile of Monis that emerged this week is familiar. For years he gave off the stench of the mediocre narcissist – an abrasive man of few gifts who remained convinced of his own importance. He had tried “a wide variety of guises” and failed at all of them. By turns he was a failed poet, failed spy, failed cleric, failed businessman and failed outlaw bikie. In a book self-published in 1996, he expressed in poetry the repellent grandiosity that two decades later would be expressed in murder. He starts his collection of verse by telling the reader: “Do not think it’s understandable, you have to keep reading and not ask questions... [My poems] you cannot understand.” In other words: Do not question my authority. My heart is too tender, my mind too sharp for you to grasp. His poetry was dogmatic and sentimental slush, and rightly ignored.

Years later, in Sydney, Monis would make similar claims to his redoubtable spiritual authority. This time, it was to female clients of his “spiritual consultation” clinic who had approached him in various states of emotional despair. He promised enlightenment, and then he raped them.

The profile of Monis resembles that of Anders Breivik or Neil Prakash – grim and mediocre men whose hunger for recognition was transposed into murder. The charmless Breivik failed in distinguishing himself in either street art or liberal politics, and recast himself as an Aryan warrior. Prakash was a failed rapper who once dreamt of becoming Australia’s 50 Cent, and spat clumsy lyrics derogating women while telling us he “was reaching for the stars”. The Melbourne-born Prakash later moved to Syria, becoming
a prominent recruiter for Daesh.

Monis couldn’t possess authority without deception or duress, and failed at almost everything except destruction. “A narcissist could be a very dangerous specimen if his sense of self-importance is threatened,” a psychiatrist told police negotiators during the siege. Monis had faith in few things but himself, and his cynicism is obvious in his wildly varying religious and political poses. He wanted to be seen to be important. The vehicle for that – literature, spiritualism, criminality – hardly mattered. Monis was a dangerous loser.

An interesting part of the inquest’s report is its own recognition of contributing to Monis’s infamy. “The court is aware that this biographical outline will likely add to Monis’s notoriety and could make him a role model for other religious fanatics,” the report admitted. “However, the adage ‘know your enemy’ must be given weight. That said, the gaps in our knowledge of Monis are startling.”

Just as startling was Monis’s apparent fortune with the legal system. For years, Monis harassed the families of dead soldiers, raped dozens of women, and persuaded his partner to brutally murder his ex-wife. For each charge, he was bailed – he was on bail when he entered the Lindt cafe. Incapable of distinguishing himself constructively, he lied about his own persecution. In fact, he seemed to encourage it. Monis’s lawyer told the inquest that his client had once flown to New Zealand and back in a single day, “just to bamboozle customs. To make people believe he was doing something [illicit].” Monis established a Twitter account a month before the siege. His handle was @Sheik_Haron and his first post, published just weeks before he executed Tori Johnson, was: “Please connect to me.”

A forensic psychiatrist, asked by the inquest to review Monis’s history of mental health, distinguished between “categorical psychiatric” disorders and personality disorders. The first, he said, “causes the patient to suffer greatly, whereas a personality disorder causes others, rather than the person with the disorder, to suffer”. The suffering Monis inflicted, over many years, is incalculable. 

Importantly, the coroner found that Monis was not psychotic on the day of the siege. “Monis undertook the siege in a controlled, planned and quite methodical manner marked by deliberation and choice,” the report states. “He was not suffering from a diagnosable categorical psychiatric disorder that deprived him of the capacity to understand the nature of what he was doing.”

What is distressing to the families of the victims – and to detectives who had investigated his previous crimes – was the fact that Monis was on bail for charges of sexual assault and for being an accessory to the murder of his ex-wife. The coroner found a mixture of inexperience and poor record management may have contributed to his freedom, a finding that blends the banal with the catastrophic. “The oral submission of the ODPP solicitor who appeared for the prosecution to oppose Monis’s application for bail [on the accessory to murder charge] on 12 December 2013 was inadequate,” the report states, and, regarding the sexual assault charges, “there were deficiencies in the way prosecutors dealt with the question of bail”.

The coroner said that, while it’s impossible to be definitive, had all of Monis’s criminal history and behaviour been examined when considering bail – rather than each charge considered in isolation – “it is far less likely that Monis would have been at large on bail on 15 December 2014”.

It is a particularly emotional aspect of the tragedy, and the source of considerable public anger. But the coroner cautions against condemnation. “There is no evidence that any of the police officers or prosecutors involved recklessly disregarded their onerous responsibilities,” the report notes. “Indeed, all of the evidence supports the opposite conclusion … Those involved in his bail applications bear no responsibility for what Monis subsequently did. He alone was to blame for the deaths investigated by the inquest.”

It’s important to attempt some profile of Monis, but we fixate on monsters at the risk of obscuring their victims. An integral part of the inquest was allowing the families of the victims an opportunity to legally question NSW police, but also to share tender remembrance. A section of the inquest’s report includes testimonials to Katrina Dawson – killed by fragmentations of police bullets – and Tori Johnson. What is noticeable are their achievements. Dawson was a young, bright barrister, and to read her résumé is to reflect upon the great potential Monis extinguished. A superb student, Dawson was offered a scholarship to the prestigious Sorbonne, in Paris, where she completed her final year of law. She was a qualified ski instructor, and had a long history of volunteer work. “There is much to say about Katrina,” her family wrote. “She never said it herself though. She was a quiet achiever. She was modest and subtle, understated and dignified.”

Tori Johnson was the Lindt cafe’s manager. His name came from the Japanese Shinto torii archway, signifying the gateway between the physical and spiritual realms. He was curious and well travelled, had studied in Italy and Switzerland, and dreamt of becoming an architect. He met his long-term partner, Thomas, in 2000, and the next year they were living just outside New York City when the planes hit the towers. “Luckily we were not directly affected by the attacks,” Thomas wrote, “although many of our friends lost their loved ones back then. Little did we know how the world would change in the years to come nor how 13 years later it would mean the end of our life together as we knew it … Our love grew each day over the 14 years, and we could both feel this.”  

The profile of Monis – despite the shadowiness of his past – is clearer now than it was to police negotiators at the time. And it was their negotiations that are the subject of some of the coroner’s strongest criticism. Monis’s murderous potential was simply not seen until he demonstrated it.

The standard police tactic for siege situations is “contain and negotiate”. The tactic emerged following two separate NSW police shootings – the fatal shooting of David Gundy in 1989, and the non-lethal shooting of Darren Brennan the following year. Both shootings occurred in the men’s homes after police executed search warrants and stormed the premises. Both incidents drew vociferous condemnation, publicly and via multiple inquests. A NSW police review of tactics, which had previously preferred the storming of strongholds, “identified that best practice internationally was to contain a stronghold and then negotiate with the occupant. It therefore adopted containment and negotiation as the principal police operating strategy for resolving high-risk situations.”

While this remains the principal strategy of NSW police – and other jurisdictions – it is a tactic mostly applied, effectively, to domestic sieges. This is by far the most common type of these situations – there were two other sieges in NSW on the day of the Lindt cafe tragedy – and, having had no precedent in Australia, the Sydney siege was the first time the tactic had been applied to a terror situation in this country. As it is, the coroner brokered concerns about the tactic’s suitability for terrorist sieges. “The experience of international law enforcement agencies in recent years has shown that sieges motivated by terrorism are less likely to be resolved by negotiation alone,” his report says.

The containment of Monis was immediately established – at no point could Monis have exited the cafe. That left negotiation, a process marred by flawed assumptions, incomplete information, and, shockingly, eight missed phone calls from hostages ringing on behalf of Monis. This last point is a spectacular breach of a cardinal rule of police negotiation, which stipulates that lines of communication are always open. Critically, direct conversation with Monis was never established – negotiations were conducted via his hostages.

“The negotiators failed to pursue opportunities to attempt to engage with Monis because of a lack of experience in terrorist negotiations, a lack of flexibility in approach and a lack of initiative,” the coroner found.

These deficiencies included a stunning failure to consider how public statements – press releases, conferences, media commentary – might be used to leverage Monis. During the siege, Monis was listening to the radio and following news stories online – a fact known to police at the time. “The [NSW Police] submitted that the benefit of involving negotiators in crafting media releases and statements can be seen only with hindsight,” the report states. “However, given that police knew Monis was following media coverage of the siege, anxious to have his true motivations broadcast, and keen to take part in some form of broadcast himself, I am satisfied that the negotiators should have identified and raised with the Forward Commander the potential advantages of their helping to craft media releases and media statements by senior police officers and politicians.”

The coroner stated that there was a similar lack of initiative regarding the possible use of third parties – the grand mufti, for instance, had offered to speak with Monis – and the deployment of a long-range acoustic device, a megaphone, once it was clear that direct contact with Monis was unlikely. “It is not suggested that the negotiators failed to adequately pursue opportunities to engage with Monis because of any lack of diligence or commitment. Rather, it appears that their practice lacked the sophistication necessary to generate options, probably because that had never been necessary in their previous work dealing with domestic sieges.”

It is one of large themes of this report: police commanders, negotiators and consultant psychiatrists deploying tactics – and making assumptions – based upon domestic sieges. Revisions must be made.  

The coroner spoke of “considerable” public speculation as to why the Australian Defence Force was not employed during the siege – speculation he described as “simplistic” during his summary of findings. There were, he said, considerable constitutional and statutory limitations to the deployment of the ADF in domestic situations, and added that this should be reviewed. The prime minister quickly accepted the recommendation.

There was equal public speculation about the presumed failure of police snipers to take a shot. During the siege, six police snipers assumed three separate positions – in the buildings of the Seven Network, Westpac and the Reserve Bank. Per protocol, positions were chosen that provided a line of sight with the stronghold, but offered the snipers concealment. A problem with this, though, was that snipers were faced with two sheets of glass to penetrate – the windows of the building they occupied, and those of the Lindt cafe – obstructions that would alter the trajectory of a bullet. The immediate windows could be broken with a special shotgun blast, but loudly and at the risk of alerting Monis before a sniper shot was taken. Additionally, the windows of the Seven Network offices were largely bulletproofed. There were also doubts about legal justification. Most significant was the fact that there was “only one opportunity to shoot Monis before he killed Tori”, the coroner stated. “[This opportunity] arose between about 7.38pm and 7.48pm. During that time, only part of the back of the head of a person thought to be Monis was visible through White Window 4. The snipers in the Westpac building were not certain that person was Monis. Because most of the window was obscured by a flag, they could not see whether there were any hostages immediately behind or beside the individual in question. Therefore, they could not discount the risk that any hostages who were nearby might be killed or injured if they tried to shoot him. In those circumstances, the snipers’ decision not to fire was entirely reasonable.”

The coroner’s report contains evidence of both institutional efficacy and deficiency. As it does of human viciousness, compassion and courage. Its comprehensive analysis – and the implementation of its recommendations – will take some time. For those left suffering, there have likely been enough words. Perhaps the last here should be theirs. “If there is one thing above all that we can learn from Katrina’s example,” a colleague of Dawson’s wrote, “it is how to love, to show love, to use love, and by loving to make other people and places better. I believe Katrina’s greatest achievement was to make sure that those she loved knew that she loved them.”

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