Frank Vitkovic, a former tennis player and law school withdrawee, entered the building on the pretext of visiting a friend, and opened fire on office workers at random with an illegally modified M1 carbine, killing eight and injuring five.

He was also a keen tennis player, winning a number of local club competitions, but his career was derailed by an ongoing knee injury.

He started a law degree course at Melbourne University in 1984 but, due to poor grades, had voluntarily discontinued that course in early 1987.

[2] On 8 December 1987 at around 4:20 p.m., Vitkovic entered the building at 191 Queen Street, Melbourne, carrying a sawn-off M1 carbine in a brown paper bag.

[3] Vitkovic went to the 5th floor office of the Telecom Employees Credit Co-operative where a former friend (and the primary target), Con Margelis, worked.

The weapon jammed, and Margelis ducked behind a counter; Vitkovic then began shooting, killing a young female office worker, Judith Morris.

A robbery alarm was activated by a staff member at 4:22 p.m. Margelis escaped the office unharmed, and hid in the women's restroom.

Marianne Van Ewyk, Catherine Dowling, and Rodney Brown were fatally shot in that area, some while hiding under their desks.

After the killer's fall, police and members of the special operations group searched the building for accomplices.

A former secretary of the club where Vitkovic played tennis said he often threw on-court tantrums and did not easily accept losses.

[9] The coronial enquiry in September 1988 heard that there was chaos during and immediately after the shooting and there was uncertainty over which of the police officers present was in charge.

Fyfe criticised this officer's "appalling" lack of knowledge of "police command structure" for not realising who was in charge until 5:00 p.m., 40 minutes after his arrival.

Knowing that Vitkovic could not move quickly due to a bad knee, Margelis jumped over the counter and hid in the women's toilets on the 5th floor.

Margelis said Vitkovic had become depressed and embittered after injuring his leg playing tennis, followed by a failed operation to repair the damage.

[13] Another employee in the 5th floor office said that their colleague Judith Morris was shot as Margelis attempted to leap over the counter: "He was after Con and Judy was in the way."

[13] Officer worker Tony Gioia told the inquest he tackled Vitkovic, having just witnessed a co-worker being shot dead at point-blank range.

Vitkovic linked those to an incident when he was eight years old and was forced to undress in a school locker room and friends made fun of his uncircumcised penis.

"[15] At the coroner's hearing on 4 October 1988, Joe Dickson, counsel assisting the court, said that the police response was "satisfactory, and no complaints could be made about it."

He said the police officer who sent people back into the building truly believed he advised them to go to the top floor, despite evidence that he did not.

He said the 5th floor Telecom Credit Union security measures were "adequate for all purposes except the visit of a maniac."

Forensic psychologist Dr Alan Bartholomew told the coroner's court that Vitkovic would have been eligible at the time to be certified insane under the Mental Health Act.

After studying Vitkovic's diaries, Bartholomew concluded he was a paranoid schizophrenic and that there was no doubt the personality test worsened his depression and might have contributed to the decline in his mental state.

[16] After hearing representations by counsel representing the building tenants directly affected, the families of those killed, and news media organisations, the coroner Hal Hallenstein refused to suppress publication of photographs taken from a 5th-floor security video that showed Vitkovic.

[21] The doctor who performed several of the autopsies told the inquest that even had Brown been taken to a neurological unit within 15 minutes of being shot, his chances for survival would have been "very slight".