If New Zealand's "lax" gun laws that were "open to easy exploitation" had been addressed earlier, it's likely the Christchurch mosque attacks may never have happened.
That's according to the Royal Commission's inquiry, publicly released on Tuesday, that details the "failings" that led up to the March 15, 2019 shooting.
The report found many police errors led to granting the gunman a firearms licence, including the referees he submitted. Two referees are needed to get a gun licence, one of which is supposed to be a spouse, partner, or next of kin.
The gunman's licence application forms show a gaming friend and their parent as the referees. The friend indicates he's known the terrorist for 10 years and that their relationship is "good" - but they'd only spent 21 days in each other's company.
The terrorist applied for a licence 15 days after arriving in New Zealand and described himself as responsible and with no enemies. His gamer referee was also aware of his racist and Islamophobic views, but the police didn't probe enough to find that out.
The report then shows the terrorist legally collected semi-automatics and ammunition after being granted his gun licence to do so by police - which he shouldn't have been.
The regulation of semi-automatics was "lax", "open to easy exploitation", and it was a "known risk" that a terrorist could take advantage of it, according to the report.
The Government was warned in 2011 - a month after a white supremacist attack in Oslo - that the country's gun laws were exploitable.
"Those laws were inadequate for a long time," Prime Minister Jacinda Ardern said on Tuesday.
The Royal Commission found: "If the known risk that a terrorist could take advantage of the lax laws had been addressed earlier, it is likely that there would have been no terrorist attack on March 15."
Ardern said the current and past governments need to take responsibility for not changing gun laws.
"We must take collective responsibility for the fact that over successive governments over successive years, gun laws were not changed despite significant evidence to suggest they needed to be."
Police Commissioner Andrew Coster apologised for the police's failings over its licencing process.
"We've unreservedly apologised that our licensing processes were not at the level the public would expect."
The former head of gun control says the gun licence application questions were crafted in a particular way.
"We designed the questions so they're intentionally open-ended. They're the beginning of the conversation, not the end," Joe Green said.
Coster said the vetting form now specifically includes a question about violent extremism or views connected with that.
Another red flag missed by authorities was the terrorist visiting hospital after he accidentally shot himself. He was never reported to police since it isn't mandatory - but the Royal Commission now recommends it should be.
Continual tweaks to a systematic failure that ended in tragedy.
