lindt cafe findings-and-recommendations

Contributing factors

• Monis' initiation of siege with claimed explosives and Islamic State affiliation
• Reluctance to initiate deliberate action despite indications it should be considered
• Delayed approval and development of deliberate action plan
• Failure to adequately reassess negotiation progress
• Negotiation team staffing and training deficiencies
• Communication failures between tactical, negotiation, and command units
• Suboptimal advice from consultant psychiatrist
• Inadequate risk assessment by commanders
• Media engagement by hostages undermining negotiation strategy
• Monis' execution of Tori Johnson triggering emergency action

Coroner's recommendations

1. ODPP to review file management training to ensure retention of important documents
2. Commissioner to issue guidelines on arrest versus court attendance notice decisions
3. Law, Crime and Community Safety Council to develop mechanism for ready access to criminal history across jurisdictions
4. Director of Public Prosecutions to develop policy overseeing bail concession decisions
5. Review TOU Management Operational Guidelines for consistency with counterterrorism protocols
6. Develop integrated intelligence system with secure access and command decision recording
7. Establish procedures for expeditious transfer of 000 calls in high-risk situations
8. Review logging systems for command decisions and dissemination
9. Develop guidance on State Protection Group officer interaction with Police Forward Commander
10. Review scope of Police Forward Commander duties to focus on incident resolution
11. Conduct general review of negotiator training, particularly progress measurement and information recording
12. Develop comprehensive policy describing role of psychological advisers in high-risk situations
13. Expand panel of psychological advisers and range of disciplines consulted
14. Review Australia–New Zealand Guidelines to provide commanders guidance on assessing imminent and immediate risk
15. Reform guidelines for deliberate action planning and approval
16. Review training for deliberate action planning and approval
17. Reconsider police response to terrorist incidents through Australasian policing alliance consultation
18. Develop policy regarding use and training for distraction devices
19. Evaluate noise-attenuation devices for use during emergency actions
20. Undertake formal assessment of alternative ammunition for tactical operations
21. Develop comprehensive family liaison policy and procedures for high-risk situations
22. Review casualty identification policies and death notice delivery procedures
23. Review ADF call-out arrangements and criteria
24. Amend Australia–New Zealand Counter-Terrorism Committee protocols for consistency with Defence Act
25. Examine procedures for obtaining ADF assistance in absence of call-out
26. Review information-sharing arrangements between federal, state and territory agencies
27. Review Australian Psychological Society disclosure rules affecting information sharing
28. Review privacy legislation constraints on information sharing with security agencies
29. Develop policy for forwarding relevant correspondence to ASIO
30. Establish Fixated Threat Assessment Centre
31. Establish liaison between proposed FTAC and ASIO
32. Law Enforcement Conduct Commission to facilitate urgent debriefs and internal reviews of critical incidents
33. Update ANZCTC documents regarding concessions to terrorists
34. Develop cadre of counterterrorist negotiators with specialist training
35. Develop policies requiring recording of negotiation positions, tactics, and progress
36. Commissioner to seek agreement with news media on protocol for alerting to incident-compromising material
37. Minister for Police to consider amending Terrorism (Police Powers) Act 2002 regarding use of force
38. Develop pro-forma debriefing sheets for hostage interviews in high-risk situations
39. Acquire audio surveillance technology for Police Forward Command Post and Operations Centre
40. Review personnel arrangements and structures for surveillance device monitoring
41. Ensure clear communication channels for reporting surveillance data through integrated intelligence platforms