Coroner Terry Ryan says there were missed opportunities before Queensland police officer Brett Forte was shot and killed by Ricky Maddison in 2017

A coroner has found there were ‘missed opportunities’ that could have prevented the death of a police officer gunned down in an ambush by a man on the run.

Police officer Senior Constable Brett Forte was shot and killed by gunman Ricky Maddison in 2017.

Lured down a dirt road, the police officers were ‘sitting ducks’ before Maddison fatally shot Snr Cnst Forte.

Coroner Terry Ryan said there were the hallmarks of an ambush before Maddison stepped out of his vehicle and opened fire with a machine gun following a police pursuit in the Lockyer Valley, west of Brisbane, on May 29, 2017.

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

Delivering his inquest findings on Tuesday, Mr Ryan said there was a ‘significant failure of leadership’ during the pursuit and missed opportunities to arrest Maddison before the shooting.

Coroner Terry Ryan says there were missed opportunities before Queensland police officer Brett Forte was shot and killed by Ricky Maddison in 2017

Coroner Terry Ryan says there were missed opportunities before Queensland police officer Brett Forte was shot and killed by Ricky Maddison in 2017

Coroner Terry Ryan says there were missed opportunities before Queensland police officer Brett Forte was shot and killed by Ricky Maddison in 2017 

Mr Ryan said there were several systemic factors that may have contributed to 42-year-old Sen Const Forte's death and it was possible the fatal shooting may have been prevented (pictured: Brett Forte's widow Susie Forte outside Brisbane Magistrates Court on Tuesday)

Mr Ryan said there were several systemic factors that may have contributed to 42-year-old Sen Const Forte's death and it was possible the fatal shooting may have been prevented (pictured: Brett Forte's widow Susie Forte outside Brisbane Magistrates Court on Tuesday)

Mr Ryan said there were several systemic factors that may have contributed to 42-year-old Sen Const Forte’s death and it was possible the fatal shooting may have been prevented (pictured: Brett Forte’s widow Susie Forte outside Brisbane Magistrates Court on Tuesday)

Maddison, 40, had been on the run and hiding in a rural stronghold for almost three 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 abruptly stopped 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,’ Mr Ryan said.

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

The officer urgently reversed but the vehicle rolled, trapping him and his partner Snr Cnst Cath Nielsen inside.

He died from gunshot and shrapnel wounds.

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

Ricky Maddison, 40, had been on the run and hiding in a rural stronghold for almost three months, avoiding an arrest warrant for a domestic violence incident at the time he shot and killed Mr Forte

Ricky Maddison, 40, had been on the run and hiding in a rural stronghold for almost three months, avoiding an arrest warrant for a domestic violence incident at the time he shot and killed Mr Forte

Ricky Maddison, 40, had been on the run and hiding in a rural stronghold for almost three months, avoiding an arrest warrant for a domestic violence incident at the time he shot and killed Mr Forte

Maddison opened fire on police vehicles with automatic weapons, peppering Snr Cnst Forte's car with 27 bullets. He died from gunshot and shrapnel wounds (pictured, Snr Cnst Forte's widow Susie Forte, left, with Snr Cnst Catherine Nielson)

Maddison opened fire on police vehicles with automatic weapons, peppering Snr Cnst Forte's car with 27 bullets. He died from gunshot and shrapnel wounds (pictured, Snr Cnst Forte's widow Susie Forte, left, with Snr Cnst Catherine Nielson)

Maddison opened fire on police vehicles with automatic weapons, peppering Snr Cnst Forte’s car with 27 bullets. He died from gunshot and shrapnel wounds (pictured, Snr Cnst Forte’s widow Susie Forte, left, with Snr Cnst Catherine Nielson)

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

Mr Ryan described the absence of an overall tactical command during the police pursuit of Maddison as a ‘significant failure of leadership’.

He said it was not reasonable for Snr Cnst Forte and his partner to call off the pursuit but a tactical commander could have come up with an effective plan.

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

‘Snr Cnst Forte and Snr Cnst Nielsen were, as Snr Cnst Nielsen described, sitting ducks.’

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

He said officers could have been required to wear ballistic vests but noted that it may not have avoided Snr Cnst Forte’s death.

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

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

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

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

But Mr Ryan said a more proactive approach by Gatton police could have led to 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.

Mr 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.

The coroner extended his condolences to Snr Cnst Forte’s widow Susie Forte, also a police officer, saying she was ‘entitled to answers’.

The coroner extended his condolences to Snr Cnst Forte's widow Susie Forte (pictured), also a police officer, saying she was 'entitled to answers'

The coroner extended his condolences to Snr Cnst Forte's widow Susie Forte (pictured), also a police officer, saying she was 'entitled to answers'

The coroner extended his condolences to Snr Cnst Forte’s widow Susie Forte (pictured), also a police officer, saying she was ‘entitled to answers’