A psychiatrist who treated the man responsible for the deadly stabbing rampage at a Sydney shopping centre will be referred to health regulators, after a coroner found she failed to act on warnings he may have been relapsing years before the attack.
The New South Wales coroner said Dr Andrea Boros-Lavack had provided long-term care to Joel Cauchi, who killed six people at Westfield Bondi Junction in April 2024, but did not respond adequately when concerns were raised by his family about his deteriorating mental health.
Cauchi, 40, who was first diagnosed with schizophrenia as a teenager, was unmedicated and homeless at the time of the attack. He stabbed 16 people in six minutes before being shot dead by police.
Handing down her findings, coroner Teresa O’Sullivan said Dr Boros-Lavack had delivered “personalised, consistent and compassionate treatment” over many years, but described it as a “major failing” that she did not take more active steps to urge Cauchi to resume medication when his mother raised concerns in late 2019.
The coroner said the lapse was one of several missed opportunities that contributed to the tragedy, alongside failures by police and shopping centre security.
Cauchi later moved interstate and came under the care of another doctor, but a discharge letter written by Dr Boros-Lavack did not sufficiently emphasise the seriousness of his condition or the need for urgent psychiatric review, Ms O’Sullivan said.
Six people were killed in the attack: Dawn Singleton, 25; Yixuan Cheng, 27; Jade Young, 47; Ashlee Good, 38; Faraz Tahir, 30; and Pikria Darchia, 55. Ten others were injured, including Good’s baby.
The inquest also heard that an email sent to police raising concerns about Cauchi’s mental health was not acted upon because of staff shortages. The officer involved “overlooked a single email amidst a significant workload”, the coroner said.
Security arrangements at Westfield Bondi Junction were also criticised, with Ms O’Sullivan finding that the guard monitoring CCTV at the time of the attack was not competent for the role. She said responsibility lay with the shopping centre, which has since changed its procedures.
Among 23 recommendations, the coroner called on the New South Wales government to strengthen mental health outreach services and provide short-term housing for people with serious mental illness. She also urged better coordination between emergency services and recommended a public awareness campaign promoting the message “escape, hide, tell” in armed-offender situations.
While praising the police and emergency response as “commendably rapid and extensive”, Ms O’Sullivan criticised some media coverage of the attack, saying it had exacerbated the trauma of victims and families. She said she would make recommendations to the Australian Press Council on reporting mass-casualty events.
Outside court, Noel McLaughlin, the husband of victim Jade Young, said the inquest had shown the attack was not a sudden or random act of violence but “the end point of a long story”.
Cauchi’s parents said they hoped the findings would help prevent similar tragedies in the future.
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