A Victorian coroner has recommended sweeping changes to policies surrounding high-speed police pursuits.
The findings are part of a coronial inquest into the 2017 death of Gunnai, Gunditjmara and Wiradjuri man Raymond Noel, who died while being chased by police.
Raymond Noel (the family's preferred name) whose car was flagged as unregistered, was killed just 21 seconds after Victorian police began their pursuit.
"The horrific accident unfolded and Sergeant John Sybenga radioed 'He's come to grief'... The pursuit, from the point it was called to the radio transmission, lasted 21 seconds," Coroner John Olle told the court.
Raymond Noel died instantly from the impact after he was thrown from his car.
The coroner found that speeds exceeded 150 kilometres per hour during the chase, and that police admitted they were going so fast they were unable to check their speeds.
The court also heard that contrary to Victorian police procedures, the vehicle's lights and sirens were not activated during the chase.
"Frankly I consider this practice should cease. A police vehicle traveling at speeds without lights or sirens poses an unacceptably high risk - be (it to) drivers, cyclists, or pedestrians," he said.
Policy changes needed to prevent deaths
Mr Olle said authorities must adequately assess risks before deciding to instigate a police pursuit, and that the perceived harm must be greater than the risks of a police pursuit.
In some instances, he stated it was the pursuit itself that created the jeopardy.
"In other words were it not for police involvement, the danger would not exist."
He said that threshold was not justified during the case of Raymond Noel, but acknowledged risk assessments in the field are challenging.
Policies related to police pursuits were changed in 2016, which Mr Olle said had the 'unintended consequence' of lowering the risk threshold.
"It unintentionally minimised the extreme danger of pursuits."
The coroner also recommended easily visible speed odometers be placed in all police vehicles so they can clearly see how fast they are traveling during high risk situations.
The family of Raymond Noel were present for the proceedings. They said nothing would bring their son back but they hoped changes could prevent another death.
Raymond Noel's father Uncle Ray is calling for police chases to be outlawed, saying the risks were too high.
"I'd like to see all pursuits banned so no other family has to go through this," Uncle Ray said.
Uncle Ray described his son as a 'gentle giant', whose fear of the police began when he was still in primary school.
"He and his cousins were innocently playing in the docklands and the police came along and decided to handcuff them on the gutter and one of the police officers said 'If you move, I'll shoot you,'" he told NITV News.
"He was only 10 or 11 at the time and (it was) his first interaction with the police, so you have to understand the fear," Mr Tomas said.
Mr Thomas's mother Auntie Debbie said the inquest was distressing, but the family hope it will lead to policy changes to prevent unnecessary deaths.
"We begun this without Raymond, and we've walked away without Raymond," Aunty Debbie said.