Delivering his inquest findings, coroner Terry Ryan said there were the hallmarks of an ambush before Maddison opened fire on police in the Lockyer Valley, west of Brisbane, on May 29, 2017.

Ryan on Tuesday said there were several systemic factors that may have contributed to 42-year-old Forte’s death and it was possible the fatal shooting may have been prevented.

Maddison, 40, was later shot dead after being warned to surrender more than 80 times during a 20-hour siege.

He had fired at police, including at a helicopter, 21 times.

Ryan described the absence of an overall tactical command during a police pursuit of Maddison as a missed opportunity and a “significant failure of leadership”.

He said it was not reasonable for Forte and his partner Sen Const Cath Nielsen to call off the pursuit of Maddison, but a tactical commander could have come up with an effective plan.

“Unfortunately the confrontation was left to evolve on Mr Maddison’s terms,” Ryan said.

“Snr Const Forte and Snr Const Nielsen were, as Snr Const Nielsen described, sitting ducks.”

Maddison had been on the run and hiding in a rural stronghold for more than two months, avoiding an arrest warrant for a domestic violence incident.

Police spotted his vehicle in Toowoomba and followed him on the Warrego Highway, before Maddison ambushed them on a dirt road.

“The events that transpired when Mr Maddison exited his vehicle following a marked change in the terrain along the roadway had the hallmarks of an ambush.”

He opened fire on police vehicles with automatic weapons, peppering Forte’s car with 27 bullets.

Forte urgently reversed but the vehicle rolled, trapping him and his partner inside.

He was hit at least twice and died within minutes.

Ryan said officers in pursuit would have known Maddison was “undoubtedly dangerous” but described someone opening fire on officers with a machine gun as unprecedented in Queensland.

He said officers could have been required to wear ballistic vests but noted that it may not have avoided Forte being killed.

The inquest that started in 2021 had heard the Toowoomba tactical crime squad had been looking for Maddison, while Gatton police had been investigating reports of automatic gunfire in the area prior to the shooting.

Ryan said reports of automatic gunfire in the area had not been treated with sufficient urgency by Gatton police before the fatal shooting.

He said a more proactive approach could have resulted in Maddison’s arrest before the shooting.

Gatton police had established the gunfire heard days before the fatal confrontation had come from a property owned by a family.

But police did not make the connection that the family was friends with Maddison, who was staying at the property.

Officers installed a camera with “Gatton police” on it near the property which Maddison located, increasing his hostility toward authorities.

No record of the Gatton officers’ activities was placed on the police database QPRIM.

The inquest also heard that a Toowoomba officer did not make a connection with a “Ricky Matterson” who was in the database for having a machine gun in 2007 before the shooting.

Ryan called for an overhaul of the way Queensland police search for intelligence information, saying the pursuit of Maddison may have been different if officers were aware of the automatic gunfire reports in the area.

Ryan extended his condolences to Forte’s widow, Susie Forte, who is also a police officer.

“Mrs Forte’s grief was undoubtedly amplified by the fact that she was on duty at the time of his death and heard the tragic events as they unfolded (on police radio),” he said.

He acknowledged her courage in participating in the inquest, saying she was “entitled to answers”.