"It is a miracle that no more than four people died"
"Frankly, on the evidence before the inquiry, it is a miracle that no more than four people died," said Doogan in a statement before unveiling her report into the handling of the bushfires.
More than 430 people were injured.
Doogan said the Australian Capital Territory’s Emergency Services Bureau had not warned residents that the suburbs were threatened until less than 30 minutes before the first homes caught fire.
She said the bureau had "lulled themselves into a false sense of security", having handled brushfires a year earlier without losing a single building.
Doogan said that during the January 2003 firestorm emergency and park officials had failed to clear forest trails of debris that fuelled the fire’s path.
She said the bureau lacked sufficient plans to tackle fires that reached suburbs; as the firestorm swept over mountains and blackened whole suburbs fire-fighters were overwhelmed.
Peter Lucas-Smith, former chief fire control officer for the area, said additional efforts would not have altered the outcome much, given the intensity and speed of the fire.
Doogan conceded that extremely hot, dry and windy conditions and limited manpower exacerbated the situation.
But she said, her overall impression "was that senior personnel at the Emergency Services Bureau lacked competence and professionalism and that the bureau was disorganised and was functioning in a chaotic, unco-ordinated fashion."
"It seems the left hand did not know what the right hand was doing and neither hand was actually doing very much to deal with a crisis that was escalating, day-by-day, hour-by-hour."
The coroner's report came as fire-fighters in several areas of Australia battled widespread bushfires.
Bushfires commonly occur during Australian summers, but this year’s severe drought has made the fire danger more extreme than usual.