The fatal attack on beloved Melbourne identity Sisto Malaspina in Bourke Street three years ago was a premeditated act of terrorism.
Victorian State Coroner John Cain has handed down his findings into the horrifying 19-second attack by Hassan Khalif Shire Ali in November 2018, finding it was motivated by his adherence to Islamic extremism and ISIS.
While opportunities to prevent the attack may have been missed, Judge Cain was unable to conclude that Shire Ali's trajectory could have been averted if intelligence gaps had been filled, if a different threat assessment had been made or if Shire Ali had not been bailed weeks earlier.
Mr Malaspina, the co-owner of Pellegrini's Espresso Bar, was one of three people stabbed in a frenzied attack by Shire Ali who was a national security person of interest. He was regarded as a "very low risk".
The horror began just after 4pm on November 9 when hire Ali set fire to gas tanks in his car.
Bystander Rod Patterson believed he was running to help the driver when he was blindsided by Shire Ali and stabbed in the head with a 22cm hunting knife.
Shire Ali then overpowered Mr Malaspina, repeatedly stabbing him before chasing down security guard Shadi and stabbing him in the neck.
He turned then on police, who tried first to disarm him with their batons before one fired his weapon.
Shire Ali later died in hospital.
Judge Cain found Shire Ali's actions constituted a premeditated act of terrorism and an ISIS-inspired attack.
While his actions were intended to intimidate and harm, the acts of many others including civilian bystanders and off-duty police who stepped in without the benefit of tactical equipment demonstrated the opposite.
"These individuals acted with great courage and scant regard for the consequences to themselves in service to the Victorian community," he said, praising their selfless actions.
Judge Cain also found the use of lethal force by police was justified in the circumstances.
The two officers who first arrived on the scene, known as A1 and B2, believed they were responding to a car fire but instead found themselves confronted with an armed and determined assailant.
He commended their presence of mind, restraint and effective collaboration in a volatile and dangerous situation, noting one of the officers had graduated from the police academy five months earlier.
Judge Cain said there was evidence Shire Ali's criminal behaviour was escalating in the lead-up to the attack, including allegations he assaulted an acquaintance, damaged a vehicle with a sledgehammer, assaulted a person with a hammer, was involved in a hit-run and kicked a car door after an altercation with a stranger.
On October 12, 2018 Shire Ali was pulled over by police. He had five warrants outstanding and was bailed on the side of the road by a police sergeant, actions Judge Cain described as reasonable and appropriate.
The coroner found the absence of intelligence indicating Shire Ali was sympathetic toward Islamic extremism wasn't indicative that he no longer held those views, but it was regarded that way anyway.
The decision to manage Shire Ali as a low risk national security person of interest was premature given gaps in intelligence, he found.
He also said while there was insufficient evidence of mental illness it was not possible to rule out the possibility Shire Ali had a psychiatric illness at the time of his attack.
The inquest has resulted in a series of recommendations including that Victoria Police review and amend policy relating to national security person of interest warning flags, including around how notes might be tailored to address intelligence gaps.
Judge Cain also recommended Victoria Police develop and implement a review where an attempted or actual terrorist incident has occurred to identify opportunities for improvement in national security intelligence collation, analysis, assessment and management, and that they consider developing a joint review process with intelligence partners.
He said while politically motivated violence is a rare occurrence, the tragic outcome shows any potential for improvement should be identified, considered and pursued.
