Coroner Peter Morrison said police should have terminated the pursuit twice before the horrific smash in September 2015.

However, Coroner Peter Morrison has found that Timothy Smith-Brown, 24, died as a result of his own actions.

Mr Smith-Brown, of Oxley, had been attempting to evade police when he ran a red light and hit another car on Drakeford Drive about 5.45pm on September 4, 2015.

Police had called off the pursuit moments before the accident.

The crash killed Mr Smith-Brown, while his passenger and heavily pregnant girlfriend was rushed to hospital.

She gave birth to their son, Tim, later that day.

Two passengers of the other vehicle suffered serious injuries, while a third received a broken collarbone.

The Mitsubishi Magna, driven by Mr Smith-Brown, reached speeds up to 175 km/h, drove through a number of red lights, jumped a median strip, and drove in a bike line during the three-minute chase.

Post-mortem blood tests detected the presence of amphetamine, methylamphetamine, and tetrahydrocannabinol.

However, an expert found the drugs had been used days earlier and did not contribute to Mr Smith-Brown’s death.

ACT Policing's pursuit policy has been changed since Mr Smith-Brown's death.

Under the new "limited pursuit" regime, police are to initiate pursuits only when there is a serious risk to public safety that outweighs the risk of pursuit.

In his decision, Mr Morrison found police had not complied with the old pursuit policy and should have terminated the chase at two points before the eventual decision had been made.

The coroner found that information regarding the pursuit speeds should have been reported to police command earlier, as required by the pursuit policy of the time.

"I am satisfied, ... that, had the required communication been made earlier, and in particular at the point in time after the Athllon Drive intersection at which the Mitsubishi Magna reached the high speeds indicated previously, then [pursuit controller] Detective Sergeant Dean would have ordered that the pursuit be terminated," Mr Morrison wrote.

"I find that a matter of public safety arises because the continuation of the pursuit beyond that point
unjustifiably placed other users of Drakeford Drive and the intersecting carriageways in danger."

Mr Morrison also found that the conduct of Mr Smith-Brown had been "a strong indicator to the officers in pursuit of the dangerous lengths to which the deceased was prepared to go to avoid apprehension".

"Proper consideration of the danger to others demonstrated by that conduct, when weighed against the minor nature and comparative seriousness of the offence/matter as known to [the driver of the police vehicle] Senior Constable [Ben] Stone, ought to have resulted in him terminating the pursuit immediately after the Athllon Drive intersection.

"Proper application of the Old Pursuit Policy required him to do so.

"I find that a matter of public safety arises because the continuation of the pursuit beyond that point by Senior Constable Stone unjustifiably placed other users of Drakeford Drive and the intersecting carriageways in danger."

However, Mr Morrison said even if the chase had been terminated earlier, he could not find that it would have prevented the fatal crash.

"Any assessment of what the deceased would have done after that point is speculative.

"I have found that the direct cause of Timothy’s death was his own actions."

Outside court, Joanne Smith, Mr Smith-Brown's mother, agreed with Mr Morrison’s findings, which she said confirmed the accident had been avoidable.

Ms Smith said that her son might still be alive today if police had called off the pursuit earlier.

"I know he did the wrong thing, initially, but he did not deserve to die for being an unlicensed and unregistered driver," she said.

"His son does not deserve to grow up without a father and I do not deserve to spend the rest of my life grieving for my son.

"He was a beautiful, kind-hearted person. The world is a little bit darker place, in my life and the lives of the people that loved him there will also be an empty space."

Ms Smith said she believed the police involved should face disciplinary action.