James Gargasoulas’s murderous Bourke street rampage was helped by a “perfect storm” of police deficiencies and led to a “confluence of events” that worked in the killer’s favour, a Victorian coroner has found.

Gargasoulas is currently serving at least 46 years in jail for murdering six people and injuring 27 others by driving a Holden Commodore through the Bourke Street Mall on January 20, 2017.

Delivering her findings following an inquest into the deaths, coroner Jacqui Hawkins said “poor planning, a lack of assertive leadership [and a] lack of adequate resources”, combined with “inflexible attitudes”, allowed Gargasoulas to roam across Melbourne before speeding through the lunchtime crowds in Melbourne’s CBD.

Ms Hawkins said a plan to persuade Gargasoulas to surrender was destined to fail.

She said a formal pursuit should have been called, and a failure to do so led to a lack of oversight.

But the coroner said she was unable to determine if the murders would have been prevented if any circumstance had been different, saying stopping moving offenders was “incredibly difficult”.

Out of respect for the families of the dead, Ms Hawkins did not use Gargasoulas’s name when delivering her findings.

-more to come