Finding into death of Thalia Hakin
Deceased
Matthew Poh Chuan Si, Thalia Hakin, Yosuke Kanno, Jess Mudie, Zachary Matthew Bryant, Bhavita Patel
Date of death
2017-01-20
Finding date
2020-11-19
Cause of death
Traumatic injuries from motor vehicle strike
AI-generated summary
On 20 January 2017, James Gargasoulas deliberately drove a stolen vehicle into crowds on Bourke Street in Melbourne's CBD, killing six people: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25), Jess Mudie (22), Zachary Matthew Bryant (3 months), and Bhavita Patel (33). He struck 33 pedestrians total; six died from traumatic injuries. The coroner found critical systemic failures in Victoria Police's response from 14-20 January 2017. Police failed to adequately monitor bail conditions, coordinate between units, use phone intelligence, establish clear incident command, develop contingency plans, or implement tactical options. Police reluctance to breach policy also hindered response. The coroner made nine recommendations addressing police training, bail procedures, incident management, command and control protocols, and hostile vehicle policy. She noted that better coordination and planning might have aided apprehension.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Inadequate bail monitoring and enforcement
- Poor police unit coordination and communication
- Failure to act on phone intelligence
- Inadequate incident command and control
- Absence of contingency planning
- Excessive reliance on negotiation strategy
- Inadequate information sharing between divisions
- Role confusion and ambiguous responsibilities
- Inflexible policy attitudes limiting tactical options
- Multiple uncoordinated radio channel changes
Coroner's recommendations
- Victoria Police, in consultation with DJCS, to investigate feasibility of body-worn cameras recording all out-of-sessions bail/remand hearings
- Victoria Police to review training and supervision of members involved in bail/remand proceedings regarding preparation, identification of grounds, presentation of evidence, and appeal procedures
- Victoria Police to develop force-wide policies for notifications of failure to report on bail and guidance on actions to be taken
- Victoria Police to review training, policies and procedures on bail and remand regarding high-risk recidivist offenders, using risk analysis tools and implementation of oversight plans
- Victoria Police to review training, policies and procedures governing roles, responsibilities and coordination between criminal investigation units to eliminate role confusion
- Victoria Police to review policies, procedures, training and infrastructure for management of critical incidents to ensure continuity of command and communication
- Victoria Police to review criminal investigator training to incorporate curriculum on risk evaluation, incident management and identification of critical incidents with immersive training
- Victoria Police Professional Development Command to develop operational safety training on hostile vehicles and vehicle-borne attacks incorporating simulation or Hydra training
- Victoria Police Professional Development Command to incorporate annual or biennial refresher training on Hostile Vehicle Policy and vehicle-borne attacks
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