NSW Coroner Michael Barnes is handing down his report into the 2014 Sydney Lindt cafe siege, which left cafe manager Tori Johnson and Sydney barrister Katrina Dawson dead.
After an hour and fifteen minutes State Coroner Michael Barnes has concluded the summary of his findings.
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He has made 45 recommendations in his 600 page report which has now been made publicly available.
"I am acutely conscious that systemic improvements will do nothing to alleviate the grieving for Katrina and Tori that their loved ones will continue to suffer," he said in conclusion.
"I am powerless in that regard."
He found that Tori Johnson died immediately after he was shot in the back of the head by Man Haron Monis. Monis died when police stormed the cafe and the officers who shot him did so because they reasonably believed it was necessary to protect themselves and others in the cafe.
Katrina Dawson died from gunshot wounds from a bullet, or bullets, fired at Monis by police that ricocheted and accidentally struck Ms Dawson as she lay on the floor.
"Those are my findings. I authorise the publication of the report that I have prepared," Mr Barnes said.
"I close this inquest."
Police Commissioner concedes they were wrong
Newly-appointed Commissioner Mick Fuller has made a stunning about face, saying that they should have stormed the cafe earlier.
ABC has just played an excerpt from an upcoming Four Corners interview with Mr Fuller in which he says the police were "getting poor advice from people" and it led to them taking the wrong strategy.
Q: Are you saying that was a mistake?
A: In hindsight, as with everything, we know we should have gone in earlier. The challenge with that is 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, I guess, in terms of emergency action.
Q: Tori Johnson was placed on his knees in a position of execution. Why did not police go in at that time?
A: At that time I can only assume they felt they were in a cycle of contained negotiation and were hoping that was their best outcome... They were getting poor advice from people that lead them to commit to something which turned out to be the wrong strategy at the time. Again, a deliberate action at an earlier would have been safer, while not guaranteeing no loss of life.
Premier says thoughts are with hostages and the victims's families
Premier Gladys Berejiklian has released a statement following Coroner Michael Barnes handing down his findings.
Ms Berejiklian says the government will do "all we can to take the lessons learned from this tragedy".
"We will thoroughly review the findings and respond as quickly as possible," she said.
Ms Berejiklian says that her thoughts are with the Dawson and Johnson families and that no one will ever forget the ordeal suffered by the surviving hostages.
"I acknowledge the bravery of the police and first responders who put their lives on the line during this act of terror," she said.
"The people of NSW were devastated by the events of 15 and 16 December 2014. The outpouring of grief that saw a sea of flowers grow in Martin Place is still palpable.
"The completion of the NSW Coroner's Inquest into the deaths arising from the Lindt cafe siege today is an important step along the path to recovery."
Ms Berejiklian has also thanked Mr Barnes for his "comprehensive and extensive inquest".
Families of victims treated ‘insensitively’
Another recommendation: NSW Police need to develop comprehensive policies and procedures for family liaison during major events.
Coroner Barnes said the families of Tori Johnson and Katrina Dawson were "treated insensitively" during the siege.
They were kept in a family reception room that was badly situated and ill-equipped, they received infrequent briefings or updates and there was undue delay in being given the news of the deaths.