Victoria Police were disorganised and "gung-ho" when apprehending a knife-wielding offender who was subsequently shot dead, the Coroner has found.
Craig Douglas was shot by two police officers after he came at one of them with a knife in St Kilda in May, 2011.
The "gung-ho" actions of an officer and inadequate police planning were highlighted by the Coroner Phillip Byrne in his findings in the Victorian Coroner's Court on Monday.
The court heard a few hours before he was fatally shot, Douglas, from Geelong North, had been at a St Kilda hotel where a woman was stabbed and cannabis stolen.
While police believed the suspects in the case were "long gone", police spotted a group that fitted their descriptions about two hours later still in St Kilda.
In his finding, Mr Byrne said police did not have a cohesive plan about what they would do prior to the confrontation with the 31-year-old and none of the officers knew what the other intended.
The first police officers on the scene, Constables Jason O'Donnell and Ryan Cross, were not given directions about what to do if they encountered the suspects, he said.
Const Ryan, who approached the scene on foot and was threatened by Douglas with a knife, was not criticised by Mr Byrne, but he said Const O'Donnell's actions, which included flashing police car lights and then coming to a screeching stop near the suspects, were "gung-ho".
The coroner said Const O'Donnell's engagement with the suspects were not directly in line with police safety principles and training, however, Douglas' "patently dangerous and precipitous" actions were the principle cause of his death.
Mr Byrne recommended the circumstances surrounding Douglas' death be used as a scenario in police training to focus on the importance of planning at the operational level.
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