The Coroners Court has handed down three recommendations to Victoria Police over the death of a 16-year-old girl during a police chase in 2017.
Sixteen-year-old Jacqueline Vodden died after being flung from a stolen van on the Western Highway near Ballan.
Coroner Sarah Gebert told the court this morning that police conducting the pursuit were not fully equipped to judge the speeds of the fleeing van.
She said two civilian eyewitnesses had judged the van to be travelling at 100 kilometres per hour in the township of Ballan, where the speed limit was 60kph.
Coroner Gebert said police would have called off the chase if they had an accurate speed reading, even though police did not agree with the speed assessment at the time.
Her first recommendation was fitting all police vehicles with appropriate equipment to gauge the speed of other vehicles.
Her second was that Victoria Police look into ways to improve radio communications during chases.
Finally, she recommended police receive training to give greater weight to the passengers in the vehicle, the age of the driver, and the likelihood of success of a pursuit.
She also told the court the driver of the van drove around a roundabout in the wrong direction, avoiding a crash with a truck.
"It was generally acknowledged that the risks of the pursuit itself tended to fall in the higher end of the spectrum," she said.
The 17-year-old offender at the time, given the pseudonym Dale Cairns, was last year sentenced to six years in prison after pleading guilty to culpable driving and other charges.
"The human cost is immense," Coroner Gebert said.