James Gargasoulas' girlfriend was held at a police station for two hours and only interviewed after he mowed down and killed six pedestrians, even though she knew about his plan to run people over.
Akiir Muo was kept in an interview room at St Kilda police station on the afternoon of January 20, 2017 but was only spoken to after Gargasoulas' rampage in Melbourne's Bourke Street Mall.
She was taken hostage by Gargasoulas that morning and was later forced out of the stolen car he was driving.
When police finally took Ms Muo's statement after 2pm that afternoon, she told them about Gargasoulas' chilling plan.
"He would drive to the city and run people over if police chased him," she said.
The inquest into the deaths had heard earlier this week that she claimed she told officers when they picked her up hours before the incident that Gargasoulas said: "I swear if they catch up to me I'm gonna run everyone down in the city".
The police officers who initially spoke to her have disputed this.
At the inquest, Coroner Jacqui Hawkins asked 维多利亚 Police Assistant Commissioner Stephen Fontana why Ms Muo was not interviewed sooner.
"When she was finally spoken to for the first time at 2.10pm, she did disclose what the offender's intentions were and what he was going to do and where he was going to do it," she said on Wednesday.
"There was the capacity to know that within minutes."
Mr Fontana replied: "I felt she should have been properly interviewed as a victim straight away and I can't explain why that didn't take place."
Mr Fontana, one of the force's most senior officers, authored an internal review into the massacre, which was made public by the coroner on Wednesday.
In it, Mr Fontana found there was no explanation about the "lack of police action in relation to Muo's disposition as a victim, witness or offender".
"A high priority should have been given to interviewing Muo much earlier," he wrote.
Ms Muo was scheduled to appear before the inquest on Monday but authorities have been unable to find her.
Mr Fontana told the inquest police dealt with dangerous drivers on a regular basis and did not expect Gargasoulas to be any different.
"It would have been a completely different approach to the operation all the way through if we had have known prior intent," he said.
"To then deliberately drive down Bourke Street killing lots of people and injuring people, it was a big step and no one expected that to happen."
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Even under the new policy, Gargasoulas' intent remained "ambiguous" until he turned onto Bourke St and an "unambiguous assault" was underway, Mr Fontana said.
Gargasoulas was jailed in February 2019 for at least 46 years for what was described by the sentencing judge as one of Australia's worst examples of mass murder.
© AAP 2020