The NSW Coroner has ruled 2014's Lindt Cafe seige was a terrorist incident and Man Haron Monis was solely responsible for the deaths of hostages Tori Johnson and Katrina Dawson, not police.
Michael Barnes found that Monis "maliciously" executed Lindt worker Johnson and Dawson was killed by police bullet fragments, in what's been described as a "terrible accident."
"The death and injuries that occurred as a result of the siege were not the fault of police," said Mr Barnes.
"All of the blame for those rest on Monis."
Coroner Barnes said front line police officers who smashed their way into the cafe after 2am on December 16, knew Monis was armed and would almost certainly use the weapon against them. They also were under the assumption he had a bomb, which he did not, but police were concerned Monis would kill everyone in the cafe unless they could kill him first.
Whilst Barnes ruled police were not to blame for the deaths, he criticised how long it took them to storm the cafe.
"There was considerable controversy around what were the triggers for the initiation of an emergency action. I conclude the primary trigger was the death of a hostage and that there was a second trigger which had a lower threshold of immediate threat," Mr Barnes said.
"The EA was only activated after the primary trigger was reach, this raises the question of whether it should have occurred earlier. I conclude the commanders have insufficient guidance to help them assess whether the secondary intangible trigger had escalated to the point where it outweighed the risk associated with a forced entry."
"The bravery of these officers inspires all."
The findings have recommended that NSW police review their procedures to ensure their handovers between negotiation teams are staggered, so that a fully briefed officer is always available.
It was revealed that some hostage calls were never answered because of miscommunication before officers and negotiators.
"There was a significant failure in a basic component of siege management."