Miscommunication between emergency providers who responded to the Bondi stabbing tragedy has been labelled as a "near miss" by medical experts.
Joel Cauchi was experiencing psychotic symptoms when he went on a stabbing spree at Sydney's Bondi Junction Westfield on April 13, 2024.
The 40-year-old killed six people and injured 10 others before he was shot dead by NSW Police Inspector Amy Scott.
Confusion and miscommunication about a potential second offender led NSW Ambulance assistant commissioner Brent Armitage to declare the mall a "hot zone" about 4.30pm.
This meant paramedics were barred from entering the complex.
Mr Armitage was acting on flawed information that was not provided in a timely manner, a NSW Ambulance medical executive told the Bondi stabbings' inquest on Friday.
"It does represent a near miss and is therefore an important learning opportunity," Thomas Evens said.
All victims had already been removed from the mall so the declaration did not affect any medical outcomes.
But Dr Evens and other emergency doctors on an expert panel said miscommunication between providers can delay victims' care.
The panel put forward a framework developed in the United Kingdom called JESIP, focusing on how emergency providers can best work together to respond to emergencies.
They were careful to acknowledge their suggestions were made in hindsight and their report included critiques, not criticism.
While describing the "exceptionally high standard" of care, physician Phillip Cowburn called the zoning system a dogmatic approach.
"The zones are always too big, they are left in place for too long and patients come into harm as a result," he said.
All emergency service providers should be trained in the "10 Second Triage" system, where they can quickly identify patients who need support in a rapidly unfolding incident, the panel said.
Meanwhile, the identity of the private psychiatrist who treated Cauchi for almost a decade has been revealed after a court order protecting her identity was lifted.
Andrea Boros-Lavack formed a plan to wean Cauchi off medication that he had successfully used since being diagnosed with chronic schizophrenia as a teen.
Cauchi was not taking any more medication by mid-2019 and stopped seeing a psychiatrist regularly after moving from Toowoomba to Brisbane in early 2020.
Around this time, his mother raised concerns about Cauchi expressing feelings of "being under satanic control" and other behavioural changes.
An expert panel of psychiatrists agreed he displayed concerning behaviour in the years leading up to the incident.
"They suggest he is having relapse," Professor Anthony Harris said on Thursday.
"There are several red flags and the most important ones are the ones concerned by his mother who knows most about his condition," Professor Merete Nordentoft said.
The inquest continues.
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