Finding into death of Sestilio Malaspina
Deceased
Sestilio Malaspina; Hassan Khalif Shire Ali
Demographics
74; 30y, male; male
Coroner
State Coroner Judge John Cain
Date of death
2018-11-09
Finding date
2021-06-28
Cause of death
Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wound to the chest
AI-generated summary
On 9 November 2018, Hassan Khalif Shire Ali committed a premeditated ISIS-inspired terrorist attack in Bourke Street, Melbourne, using an improvised explosive device in his vehicle followed by a knife assault. He fatally stabbed 74-year-old Sestilio Malaspina, and injured two others. Police responded appropriately with restraint and tactical options; Police Officer A1 shot Hassan, who died from the gunshot wound. The coroner found that while the SIU and CVE Unit had opportunities to better assess and manage Hassan's risk between 2015-2018, it cannot be established that different outcomes would have prevented the attack. Deficiencies in SIU procedures, intelligence gaps, delayed CVE referral, and premature risk downgrading were identified. Mental health concerns were noted but not conclusively linked to the attack. The police response was appropriate and justified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- delayed Security Intelligence Unit assessment procedures
- intelligence gaps in NSPOI management
- deficient communication between SIU and CVE Unit
- delayed CVE referral (nine-month delay)
- premature risk downgrading despite ANZCTC tool indicators
- inadequate address information on LEAP system
- mental health issues not addressed
- psychological distress unmanaged
- social isolation and paranoia
- extremist ideology and religious adherence to ISIS
- premeditated planning from 5 November 2018
Coroner's recommendations
- Victoria Police review and amend SIU Standard Operating Procedures to include: timeframes for task completion, procedures for follow-up of outstanding tasks, regular review intervals for active NSPOI files, guidance on when fresh ANZCTC assessments should occur, procedures for ASNET information circulation, process for ASNET documentation of classified information, process for CVE Unit referral, senior management consideration of threat downgrading, and consultation expectations with partner agencies
- Victoria Police deliver training to all SIU staff about SOPs and awareness of CTC partner procedures, particularly CVE Unit
- Victoria Police develop and deliver training/policy to ensure disputed address details are recorded on LEAP and easily accessible
- Victoria Police review and amend policy relating to annotations on NSPOI and warning flags to address specific intelligence gaps
- Victoria Police develop and implement a review process where an actual or attempted terrorist incident has occurred to identify opportunities for improvement in national security intelligence collation, analysis and assessment, and NSPOI management
- Victoria Police and national security intelligence partners consider developing a joint review process where an actual or attempted terrorist incident has occurred to identify opportunities for improvement
Full text
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