The police and ambulance response to a white supremacist terrorist attack on two mosques in Christchurch, New Zealand, is under public scrutiny for the first time as an inquest begins into the deaths of 51 worshipers in the 2019 mass shooting. The coroner, Brigitte Windley, opening the inquest at the high court in Christchurch on Tuesday, said: “This is an opportunity to consider if the response to such extraordinary events like this could be improved in the future, despite our strongest desire that we never again have to.” The attack during Friday prayers on 15 March 2019 by an Australian man who had been radicalised online before moving to New Zealand, where he legally amassed a cache of semi-automatic weapons and planned his assault, shocked the country. Most semi-automatic weapons were banned a month later. But the families of those killed, as well as the survivors and witnesses, said they still had questions about what had happened in the chaotic aftermath of the attack and whether lives could have been saved if the emergency response had unfolded differently. Two investigations of the attack did not explore such questions: a lengthy trial scheduled for Brenton Tarrant, the terrorist, was averted in March 2020 when he abruptly pleaded guilty to all charges, with evidence gathered in the case against him shelved. A royal commission of inquiry into the shooting was instructed to examine only the events before shots began to ring out at Masjid Al-Noor, the first the gunman struck. The commission of inquiry concluded that the attack could not have been prevented “except by chance”, while a police summary of its own response to the shooting, released in 2021, said all of those killed had sustained unsurvivable injuries, and none would have lived if treated sooner. The police drew public praise in the aftermath of the attack for their apprehension of Tarrant 19 minutes after his assault began. But lingering questions remained, at times compounded by the desire of New Zealand’s authorities to prevent further radicalisation or distress to the bereaved by drastically restricting access to what they knew. “They say that it wasn’t until this coronial inquiry was undertaken that they were able to get information on what exactly happened to their loved one from the moment that they arrived at the mosque until the moment they died,” Kathryn Dalziel, a lawyer for dozens of the families, told the detective senior sergeant Craig Farrant – the officer second in charge of the inquiry – when he took the witness box on Tuesday. The families “also say that they weren’t able to have medical information as to how they died”, Dalziel said. Communications between police and ambulance officers, response times to the mosques, and the triaging and treatment of the injured and dying are among the matters before the seven-week inquest. It will also examine whether Tarrant – who police say acted alone – had help from anyone else on the day of the attack, and why an emergency exit door at Masjid Al-Noor failed to work as desperate worshipers tried to flee the gunfire. Lawyers representing dozens of the bereaved families and survivors, as well as counsel for the police and other emergency services, are in court to question witnesses involved in the response. In New Zealand, however, coronial inquiries are inquisitorial and cannot generate fresh charges or directions for compensation. “It is about accountability for actions or inactions,” the coroner said. The inquest would “turn truth to power”, she added, employing evidence that has not been available publicly before. “We must take care not to let hindsight distort our assessment of decisions and actions taken at the time but nor to apply retrospective reason.” Lawyers for the bereaved families focused on the timing of the emergency response as the hearing began. The terrorist had modified his weapons to kill as many people as he could, as quickly as possible, said Nikki Pender, a lawyer representing dozens of the bereaved. “Would you agree with me that when the police are responding to an incident like this, when the intention is to save lives, that every minute matters?” she asked Farrant. “In fact that every second matters?” “Yes,” he replied. The inquest opened with a video tribute to each of those killed, whose families sat in the court’s public gallery, supporting each other as they wept. The contents of the video were suppressed by the coroner. An audio-visual timeline compiling an overview of what unfolded was played to the inquest on Tuesday. Its contents were also suppressed until each piece of evidence it referenced emerges in court; the coroner warned before its broadcast that it contained “confronting” footage from the terrorist’s own footage of the attack, which he streamed live on the internet – and which is legally banned in New Zealand. About 600 people are registered to watch the inquest online or in court, many of them relatives of those killed. It is the biggest coronial inquiry ever undertaken in New Zealand. The coroner is expected to release her findings from the inquest in 2024, before turning to the remaining issues her inquiry will scrutinise: the terrorist’s access to guns and his radicalisation on social media. It has not been decided whether public inquests will be held on those matters. Tarrant was sentenced in August 2020 to life in prison without the chance of parole on 51 counts of murder, 40 of attempted murder, and a terrorism charge.