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When a gunman entered the Masjid an-Nur on March 15, 2019, shooting dozens of worshippers in his path, the steroid-loaded terrorist was carrying out an attack that had taken months of diligent and intensive planning.
But there was no way police, the Security Intelligence Service or any other public sector agency could have been alerted about the imminent terrorist attack.
That is the finding of the Royal Commission of Inquiry into the Terrorist Attack on Christchurch Mosques, whose report was released to the public on Tuesday.
The 792-page report has found while - with the benefit of hindsight - there were clear events that could be linked to the terrorist's planning and preparation, the signs were "fragmentary" and could not be put together at the time.
"No single aspect of it could have alerted public sector agencies to an impending terrorist attack," the report said.
The report starts by setting out the horrific events of March 15 when 51 people were killed and dozens others gunned down at Masjid an-Nur and the Linwood Islamic Centre in Christchurch.
It details the terrorist's background, including his upbringing in Australia, his extensive international travel between 2014 and 2018, and the development of his terrorist ideology.
The report includes information on the terrorist's general life in New Zealand, events that happened as part of his planning and preparation, and a detailed look at how the gunman managed to get a New Zealand firearms licence.
The report found police had failed to meet required standards in the administration of the firearms licensing system, did not address whether the shooter's referees knew him well enough, and that there was a lack of training of staff.
Police were heavily criticised for an inadequate firearms licensing system, which they accepted was not robust enough to properly vet applicants.
Commissioner of police Andrew Coster apologised to families and survivors.
Also included in the report is the government's response after the terror attack, a look at legislation on hate crime and hate speech, and evaluation of Aoteoroa's counter-terrorism efforts.
Steroid abuse: 15 months before attack
On December 18, 2017, the gunman reported to the Dunedin South Medical Centre with abdominal pain around the liver area.
He told the doctor he had been taking non-prescribed oral steroids and injecting testosterone two to three times a week.
The doctor found the man presented with the "hallmarks of steroid overuse" including a rounded face also known as "moonface".
He warned the gunman the testosterone could have long-term consequences for his heart, but the terrorist was not interested in quitting the testosterone.
The gunman was referred to Dunedin Hospital's endocrinology service who sent a letter to the referring doctor with advice on treatment options and an offer to meet with the patient.
But an appointment was never scheduled due to "pressure on clinics" at the time and because the patient's condition could be managed by his doctor.
Police could not establish the source of the gunman's steroid and testosterone supply, but confirmed he had bought 500 hypodermic needles, 300 syringes and 200 alcohol swabs online in February 2018.
The Royal Commission said his use of these drugs were seen as part of his preparation for the attack as he was bulking up and possibly also imitating the preparation undertaken by the Oslo terrorist.
The commission said since the gunman's steroid and testosterone abuse did not spark concerns of criminal activity, they were satisfied that the case was properly seen as not warranting disclosure to police.
Shooting accident: Eight months before attack
On July 13, 2018, the terrorist injured his right eye and thigh in a firearms accident at his home in Dunedin.
He had been practising at home with his large capacity magazines - something he could not do where others were present - and a round got jammed in the chamber.
His attempts at freeing the round resulted in contact between the firing pin and the primer.
He had a decision to make - seek medical treatment and come to the attention of authorities, or stay away and hope for the best.
His concerns about his eyesight were outweighed by his need to avoid coming onto the police's radar.
He reported to Dunedin Hospital's emergency department where a metal fragment was removed from his eye, he was given intravenous antibiotics and an x-ray was done of his thigh.
Doctors decided to leave a metallic fragment that had entered his thigh as it was unlikely to cause any issues.
He was given an Accident Compensation Corporation claim form to fill out so that the Southern District Health Board could be reimbursed for his treatment costs.
About five and a half hours later, the terrorist was discharged.
The registrar who treated the gunman said although they considered the accident to have been "careless and a little unusual", the man had not acted in an agitated manner and they believed that the injury had been an accident and not a suicide attempt.
They therefore did not regard it necessary to report the injury to the police.
The Royal Commission's report found the Southern District Health Board was not remiss in not reporting the accident to the police as it was not uncommon to treat a person for a minor injury from an accidental discharge of a firearm.
Social media posts: The year prior to attack
An employee involved in the immediate post-attack investigation, claimed that sometime in 2018 they had seen a report containing images of social media posts made "Barry Harry Tarry", the name the gunman used on Facebook.
The employee says the posts included "broadly right-wing views and memes", but did not appear "inherently threatening or violent".
The employee claims they still reported seeing the posts to the external assessor carrying out the Arotake Review, but the material was considered as "not [warranting] escalation due to lack of internet, capability or imminence".
It was therefore not passed on to SIS's counter-terrorism unit.
Neither the SIS nor the external assessor were able to validate the employee's recollection, and no proof of this was found on SIS records.
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An internet address: Four months before attack
On November 12, 2018, the SIS received an intelligence report that identified four IP addresses that had accessed suspicious files of "possible national security interest".
One of these IP addresses had been accessing suspicious files containing content "that could facilitate actions that would result in threat and or attack activity".
This included files on Magpul-brand firearms parts and firearms tactics. It is now known the gunman later acquired Magpul parts.
The IP address also accessed content on the Oslo terrorist.
The Oslo terrorist's manifesto was recovered from the gunman SD card associated with his drone after the attack.
In November 2018, the IP address was assigned to a counter-terrorism investigator with the purpose of identifying the user of the address to assess their relevance to national security.
Efforts by the SIS to identify the user were fruitless and on December 12, 2018 the lead was closed after staff concluded there were no other options available for investigating the IP address.
The Royal Commission was unable to determine with certainty whether the March 15 gunman was the user of the IP address linked to the suspicious activity.
"If he was responsible for accessing the suspicious files, he did so in a way that prevented the activity being linked to him. It was therefore not information that could or should have alerted public sector agencies to the terrorist attack."
Findings and recommendations
In its findings, the commission notes that intelligence and security agencies have little social licence, which limits their capability and capacity.
"The idea that intelligence and security agencies engage in mass surveillance of New Zealand is a myth," it said.
"Given the operational security that the individual maintained, the legislative authorising environment in which the counter-terrorism effort operates and the limited capability and capacity of the counter-terrorism agencies, there was no plausible way he could have been detected except by chance."
Prime Minister Jacinda Ardern said the report identified many lessons to be learned and areas needing change.
She said the government will act quickly to implement some of the recommendations of the report, including the appointment of Andrew Little to coordinate the government response to the report.
The terrorist told the commission he was not a frequent commenter on extreme right-wing websites but rather used YouTube as a significant source of information and inspiration.
In response to this revelation, the prime minister said she will contact the leadership at YouTube - which is owned by Alphabet, the parent company of Google - to raise her concerns directly.