It was a “major failing” for Joel Cauchi’s former psychiatrist not to recognise he had relapsed in the lead-up to the Bondi Junction stabbings in 2024, a coroner has found.
The state coroner, Teresa O’Sullivan, handed down her findings in a 837-page report on Thursday, having delayed its release after the Bondi beach terror attack in December.
She recommended changes to the New South Wales mental health system.
Family members of the victims gathered in court to hear the coroner’s findings regarding 40-year-old Joel Cauchi’s attack at a Westfield shopping centre.
Cauchi, who lived with schizophrenia, killed Ashley Good, 38, Jade Young, 47, Yixuan Cheng, 27, Pikria Darchia, 55, Dawn Singleton, 25, and Faraz Tahir, 30, and injured 10 others before he was shot and killed by police Insp Amy Scott.
O’Sullivan determined that all six people died of stab wounds.
“While this inquest cannot ever change what happened, it is hoped the recommendations can provide an opportunity for reform which could save future lives,” O’Sullivan said on Thursday.
O’Sullivan said she would be referring Cauchi’s former psychiatrist, Andrea Boros-Lavack, to the Queensland ombudsman to examine her care of him.
“It was a major failing that Dr Boros-Lavack revised her view with respect to early warning signs and did not more proactively agitate for resumption of medication,” she said.
But O’Sullivan added that it was “important to note” that her care was not a major factor that led Cauchi to murder six people.
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Senior counsel assisting the inquest, Dr Peggy Dwyer SC, said late last year that “no one could have foreseen the tragic events of 13 April [2024] – it’s not suggested that Dr Boros-Lavack could have”.
The coroner said on Thursday that Boros-Lavack’s care of Cauchi from 2012 to 2019 was exemplary and compassionate, and she did the right thing in listening to his wishes to wean off his medication.
However, O’Sullivan found that Boros-Lavack “failed” to assess the seriousness of “what was unfolding before her” when he relapsed. She discharged him to his GP in 2020, O’Sullivan said.
“The care that was provided was one of the many factors that led to this tragic outcome.”
She said the inquest was both an opportunity to examine Cauchi’s care, but also the systemic issues in the state’s mental health system.
The coroner recommended the NSW government establish and support short- and long-term accommodation for people experiencing mental health issues and homelessness. She said the government should, over the next 12 months, obtain advice about the decline of mental health outreach services and determine a “realistic timeline” to resource them.
The tragedy was the ‘end point of a long story’
Outside the court, Jade Young’s husband, Noel McLaughlin, said she was “the person I shared life with for more than two decades, her absence has left a vast and permanent space, one that can’t be filled, only carried”.
“While the inquest can’t undo our loss, it has mattered. It has helped us understand what happened, and it has examined these events with seriousness, care and dignity,” he said.
“The evidence has shown that what first appeared to be a sudden and random act of violence was, in fact, the end point of a long story.”
Three family members of Faraz Tahir – a security guard who died on his first day on the job – spoke of his bravery.
A major concern raised within the inquest was whether earlier activation of the shopping mall’s security alerts could have saved lives. However, the coroner found it wouldn’t have.
“Based on the evidence available to me, I did not consider it was realistically possible for the public to have been informed of an active armed offender event by making a PA announcement or activating the centre management emergency override before Mr Cauchi had completed his fatal attacks,” she said.
Cauchi was in a psychotic state and armed with a 30cm hunting knife when he went to the shopping centre. In three minutes, Cauchi moved through three levels of the centre, stabbing 16 people.
O’Sullivan found that the policies of the mall’s security firm, Scentre Group, to deal with an active armed offender event “can only be described as excellent”, despite failures on the day.
She said that one of the CCTV control room operators, known as CR1 due to a suppression order over her identity, was not competent and should not have been left unsupervised. She said the finding was not a personal criticism.
“[It was] a deliberate managerial decision by Scentre Group and Glad Group who would have been aware she did not have the skills necessary,” O’Sullivan said.
O’Sullivan commended emergency services for their “rapid and extensive response”. However, she found issues with how the police and ambulance service worked together. She recommended that the state’s emergency services convene and develop a framework to deal with this issue.
She recommended the state government roll out a campaign to educate the public regarding the active offender messaging of “escape, hide, tell”.
The NSW government said it would carefully consider the 12 of the 23 recommendations directed at it.
“This will be a difficult day for many, particularly for the families who lost loved ones, those who were injured, first responders, and everyone in the Bondi community whose lives were changed forever,” the premier, Chris Minns, said.
“We will now carefully consider the coroner’s recommendations and work to implement measures that strengthen our mental health system and community safety.”
