{"id":279798,"date":"2026-02-08T00:40:18","date_gmt":"2026-02-08T00:40:18","guid":{"rendered":"https:\/\/www.newsbeep.com\/il\/279798\/"},"modified":"2026-02-08T00:40:18","modified_gmt":"2026-02-08T00:40:18","slug":"major-failing-in-psychiatric-care-before-joel-cauchi-stabbed-six-people-at-bondi-junction-coroner-finds-bondi-junction-stabbings","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/il\/279798\/","title":{"rendered":"\u2018Major failing\u2019 in psychiatric care before Joel Cauchi stabbed six people at Bondi Junction, coroner finds | Bondi Junction stabbings"},"content":{"rendered":"

It was a \u201cmajor failing\u201d for Joel Cauchi\u2019s former psychiatrist not to recognise he had relapsed in the lead-up to the Bondi Junction stabbings<\/a> in 2024, a coroner has found.<\/p>\n

The state coroner, Teresa O\u2019Sullivan, handed down her findings in a 837-page report on Thursday, having delayed its release after the Bondi beach terror attack<\/a> in December.<\/p>\n

She recommended changes to the New South Wales<\/a> mental health system.<\/p>\n

Family members of the victims gathered in court to hear the coroner\u2019s findings regarding 40-year-old Joel Cauchi\u2019s attack at a Westfield shopping centre.<\/p>\n

Cauchi<\/a>, 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<\/a>.<\/p>\n

O\u2019Sullivan determined that all six people died of stab wounds.<\/p>\n

\u201cWhile this inquest cannot ever change what happened, it is hoped the recommendations can provide an opportunity for reform which could save future lives,\u201d O\u2019Sullivan said on Thursday.<\/p>\n

O\u2019Sullivan said she would be referring Cauchi\u2019s former psychiatrist, Andrea Boros-Lavack<\/a>, to the Queensland ombudsman to examine her care of him.<\/p>\n

\u201cIt 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,\u201d she said.<\/p>\n

But O\u2019Sullivan added that it was \u201cimportant to note\u201d that her care was not a major factor that led Cauchi to murder six people.<\/p>\n

Sign up: AU Breaking News email<\/a><\/p>\n

Senior counsel assisting the inquest, Dr Peggy Dwyer SC, said late last year that \u201cno one could have foreseen the tragic events of 13 April [2024] \u2013 it\u2019s not suggested that Dr Boros-Lavack could have\u201d.<\/p>\n

The coroner said on Thursday that Boros-Lavack\u2019s 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.<\/p>\n

However, O\u2019Sullivan found that Boros-Lavack \u201cfailed\u201d to assess the seriousness of \u201cwhat was unfolding before her\u201d when he relapsed. She discharged him to his GP in 2020, O\u2019Sullivan said.<\/p>\n

\u201cThe care that was provided was one of the many factors that led to this tragic outcome.\u201d<\/p>\n

\"FootageFootage shows Joel Cauchi interviewed by police 15 months before Bondi Junction stabbings \u2013 video<\/p>\n

She said the inquest was both an opportunity to examine Cauchi\u2019s care, but also the systemic issues in the state\u2019s mental health system.<\/p>\n

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 \u201crealistic timeline\u201d to resource them.<\/p>\n

The tragedy was the \u2018end point of a long story\u2019<\/p>\n

Outside the court, Jade Young\u2019s husband, Noel McLaughlin, said she was \u201cthe person I shared life with for more than two decades, her absence has left a vast and permanent space, one that can\u2019t be filled, only carried\u201d.<\/p>\n

\u201cWhile the inquest can\u2019t undo our loss, it has mattered. It has helped us understand what happened, and it has examined these events with seriousness, care and dignity,\u201d he said.<\/p>\n

\u201cThe 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.\u201d<\/p>\n

Three family members of Faraz Tahir \u2013 a security guard who died on his first day on the job \u2013 spoke of his bravery.<\/p>\n

A major concern raised within the inquest was whether earlier activation of the shopping mall\u2019s security alerts could have saved lives. However, the coroner found it wouldn\u2019t have.<\/p>\n

\u201cBased 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,\u201d she said.<\/p>\n

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.<\/p>\n

O\u2019Sullivan found that the policies of the mall\u2019s security firm, Scentre Group, to deal with an active armed offender event \u201ccan only be described as excellent\u201d, despite failures on the day. <\/p>\n

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.<\/p>\n

\u201c[It was] a deliberate managerial decision by Scentre Group and Glad Group who would have been aware she did not have the skills necessary,\u201d O\u2019Sullivan said.<\/p>\n

O\u2019Sullivan commended emergency services for their \u201crapid and extensive response\u201d. However, she found issues with how the police and ambulance service worked together. She recommended that the state\u2019s emergency services convene and develop a framework to deal with this issue.<\/p>\n

She recommended the state government roll out a campaign to educate the public regarding the active offender messaging of \u201cescape, hide, tell\u201d.<\/p>\n

The NSW government said it would carefully consider the 12 of the 23 recommendations directed at it.<\/p>\n

\u201cThis 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<\/a> community whose lives were changed forever,\u201d the premier, Chris Minns, said.<\/p>\n

\u201cWe will now carefully consider the coroner\u2019s recommendations and work to implement measures that strengthen our mental health system and community safety.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"It was a \u201cmajor failing\u201d for Joel Cauchi\u2019s former psychiatrist not to recognise he had relapsed in the…\n","protected":false},"author":2,"featured_media":279799,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[163,85,46,522,523],"class_list":["post-279798","post","type-post","status-publish","format-standard","has-post-thumbnail","category-mental-health","tag-health","tag-il","tag-israel","tag-mental-health","tag-mentalhealth"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts\/279798","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/comments?post=279798"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/posts\/279798\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/media\/279799"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/media?parent=279798"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/categories?post=279798"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/il\/wp-json\/wp\/v2\/tags?post=279798"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}