The inquest was presided over by the New South Wales State Coroner, Michael Barnes, and its task was "to determine how the [three] deaths occurred, the factors that contributed to them and whether they could have been prevented".
[2][3][4] Two unusual features of the inquest were its detailed opening which provided an account of events in order to dispel speculation[5] and its focus on social media, believed to be merited by police because of its significant role.
Coroner Barnes said that a central question is, "Was Monis a so-called lone wolf prosecuting an ISIS-style terror attack, or a deranged individual pursuing a personal private grievance in a public manner?"
Hostage Ms Ma said that Man Haron Monis was becoming increasingly agitated as the siege entered the early hours of the morning.
Catherine Wood of Amnesty International then testified that after interviewing Monis in 2010, "It was very much like he was standing on a soap box, he was painting himself as a noble victim ... it was a story of victimhood and persecution.
Senior constable Murray Northey then testified that he had spent several months examining Monis's digital trail but found no evidence of contact with ISIS.
[15] Conversely, lawyer Chris Murphy told the court he thought Monis was "not very intelligent" and a "broken man" who "cried like a baby" when recounting alleged mistreatment in Silverwater jail.
[16] At the end of the first week, a picture has emerged of "a complex, disturbed individual desperate for recognition and status but completely lacking the skills or achievements to bring that dream to life".
When Monis married Noleen Pal in 2002, he had been "quite westernised", but around 2007, he became more strict, demanding that she wear a veil and imposing corporal punishment on their children.
Under the new act, the granting of bail was on the basis of risk assessment that an accused would fail to appear, commit another offence, or interfere with a witness or evidence.
Stek accused Monis of being an instigator of the Lakemba protests after counter-terrorism police raided several roads, but upon questioning by Gormly admitted that there was no evidence for this.
Melanie Staples from the homicide squad said the court should not have granted bail for the murder charge because the DPP did not present evidence of a discredited alibi.
Kate Barelle, a forensic psychologist, regarded Monis as atypical for a radicalised person, saying that he acted like "someone who had backed himself into a corner" during the siege.
[33] News organisations have applied to the coroner to release the names of the two unnamed DPP officers who handled Monis' bail in December 2013 and October 2014.
[34] Prof Greg Barton and Dr Clarke Jones said that it would have been extremely difficult to predict that Monis would undertake the siege as he was a loner, had mental health problems, and was desperate to attach himself to something.
[44] ASIO received a number of calls about the contents of Monis' Facebook page on 9 December 2014, at the time considering him a "serial pest".
[45] On the anniversary of the siege, State Coroner Barnes released a statement, describing the inquest as "one of the largest and most complex" undertaken in Australia, highlighting the implications for national security and for public confidence in the police.
In particular, Peter found out about Monis's demand for the ABC to broadcast that Australia was under attack only after a Facebook post from one of the hostages was read out on radio 2GB(!)
Hostage Selina Win Pe told him they had made the request two or three hours ago and Monis wanted to know why it hadn't happened.
[64] Upon application from Gormly, Coroner Barnes reduced the number of remaining witnesses to be heard from 40 to 17 in order to be able to be able to release a finding more quickly.
[65] At about 11 am Operational Commander Mick Fuller approved negotiations for the release of half of the 18 hostages in return for Monis being allowed to talk on ABC radio, and to "Look for concessions/reciprocity."
[68] Police Commissioner Andrew Scipione and Premier Mike Baird gave a press conference during the siege at 8:15 pm without first consulting the negotiators.
[71] "There should have been a strategy to engage him more forcefully, to actually meet some inane demand and use that as a foot in the door, to utilise someone with the standing of a Grand Mufti to tell him bluntly he is on the wrong track … nothing was happening.
[73] The psychiatrist said that ISIS had been calling for violent lone wolf attacks, but that "certainly didn't involve putting people in a stronghold and talking for hours."
"[77] The psychiatrist also said that it was the escape of six hostages at 2:03 am on December 16 that prompted the murder of cafe manager Tori Johnson, rather than the fact that none of his demands were acceded to.
The psychiatrist said that, feeling defeat and humiliation, Monis spent the next 10 minutes steeling himself to kill the cafe manager — who he saw as the authority figure.
[77] "Darren" said that about 1:50 am one of the hostages had called the ABC (not the police) to say that pregnant lawyer Julie Taylor was about to be set free from the Lindt cafe.
[90] [91] The TOU Forward Commander accepted responsibility for the three deaths, stating that he did not send police into the building before someone was killed due to the belief that Monis had a bomb.
It is unclear how long it took Monis to fall to the ground after being hit in the head nor how the officer managed to fire so many rounds in such a short period of time.
British terrorism expert Detective Senior Constable Simon Chesterman said "The harsh reality is that lives may be lost", and that he would have "screamed" to assault the cafe before Monis shot Johnson.