Self-declared Muslim cleric Man Haron Monis took customers and staff at the upmarket Lindt cafe hostage on December 15, 2014, bringing the Martin Place financial district in Australia's largest city to a standstill.
As the siege dragged on into the early hours of December 16, he became more erratic. When six hostages ran for a door he fired his shotgun, an act which was seen as a warning shot at the time.
"The fact that he missed by some margin is consistent with him having limited experience with guns and with the difficulty of aiming his sawn-off shotgun, plus the suddenness of the escape."
The inquest was told that police had hoped to "contain and negotiate" with Monis, who was armed with the gun and thought to have a bomb in his backpack. It was later discovered to be fake.
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Monis, who had asked police for an Islamic State flag but was refused, held the hostages for some 17 hours -- over which time five escaped, including two without his notice.
But not long afterwards, he ordered cafe manager Tori Johnson, 34, to get on to his knees and put his hands on his head. Minutes later he shot him dead.
The shooting prompted tactical police to storm the building. Monis and hostage Katrina Dawson, a 38-year-old barrister and mother-of-three, were killed in the firing.
Australia raised its terror threat alert level to high in 2014 amid concerns of attacks by individuals inspired by organisations such as the Islamic State group.