One of Victoria's most senior policemen blamed "well-intentioned" but unorganised rank-and-file officers for failing to stop the Bourke Street massacre.
Assistant Commissioner Stephen Fontana made the criticism at the inquest into the murders of six people by James Gargasoulas.
He was out on bail when he ploughed a stolen car into pedestrians on one of Melbourne's busiest streets on January 20, 2017.
Mr Fontana said the St Kilda police officers who laid charges against Gargasoulas in the days before the massacre didn't raise their concerns up the "chain of command" when he was bailed on January 14.
He said they had "no plan" to monitor Gargasoulas while on bail.
Police also failed the night before the massacre after Gargasoulas stabbed his brother Angelo and left him for dead in Windsor, Mr Fontana said.
He said the "well-intentioned" police seemed more focused on the crime scene than on finding and arresting Gargasoulas.
Mr Fontana authored a critical incident review into the rampage, which the police force sought to suppress before the inquest began.
Pages of the internal police document have been shown during the inquest, with coroner Jacqui Hawkins expected to release it in full on Wednesday.
In the review, Mr Fontana describes police at the scene of the stabbing as "uncoordinated and ineffective" with a "clear lack of leadership".
He also found Gargasoulas effectively controlled the events that day - a claim rebuffed by police.
"It's my view he wanted police to engage in a pursuit with him so that he could achieve his ultimate goal," Mr Fontana said in the report, which runs for 496 pages.
Mr Fontana began his evidence on Wednesday by apologising to the families of those killed and the 27 injured, noting the force had done "a lot of soul-searching" since the tragedy.
"I would like to on behalf of Victoria Police acknowledge the great harm and pain that this tragic incident has had on the families of the deceased and those that were injured," he said.
"It was an unprecedented event in Victoria that had a significant impact on all those involved.
"We're absolutely committed to learning from these incidents to ensure we're always improving our practices."
He also acknowledged he had the "benefit of hindsight" when writing the report.
Gargasoulas was jailed last February for at least 46 years for what was described by the sentencing judge as one of Australia's worst examples of mass murder.
His victims were three-month-old Zachary Bryant, 10-year-old Thalia Hakin, Jess Mudie, 22, Yosuke Kanno, 25, Matthew Si, 33, and Bhavita Patel, 33.
The inquest continues.
Australian Associated Press
