When Cauchi moved to another city and and came under the care of a different doctor, a discharge letter from Boros-Lavack also failed to provide enough information to prompt intervention, the coroner said. It didn’t emphasise the need for Cauchi to see a psychiatrist or that an urgent review of his case should be a priority.
O’Sullivan’s recommendation that Boros-Lavack be investigated by Queensland health authorities followed calls by some of the victim’s families for such action.
She also found there was a missed opportunity for police intervention after an email raising concerns about Cauchi’s mental health was not acted upon due to staff shortages .
The officer “overlooked a single email amidst a significant workload”, O’Sullivan said.
The inquest heard a security guard who was the sole person in the CCTV control room at the Westfield when Cauchi attacked his first victim was “not competent” for that role. However, O’Sullivan said this was the fault of the shopping centre, which has since improved its processes.
Among her 23 recommendations, O’Sullivan also called on the NSW government to improve its mental health outreach services and provide short-term housing for people with mental health issues.
The coroner praised the police and emergency services response to the stabbings, describing them as “commendably rapid and extensive” but said there were issues with the “inter-operability” between various agencies that could be improved.
She also recommended a public awareness campaign with the message of “escape, hide, tell” when there is a situation with an armed offender.
O’Sullivan, though, did criticise some media coverage, which she said “exacerbated the trauma already being suffered” by victims and families affected, and said she would be making recommendations to the Australian Press Council on how reporters should cover incidents that involve mass casualties.
The coroner also recommended bravery awards for the police officer who shot Cauchi, two Frenchmen who tried to stop Cauchi during the attack, the husband of victim Jade Young, and Ashlee Good, who died while trying to shield her baby.
Outside the court, Noel McLaughlin – Young’s husband – said the inquest mattered greatly.
“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,” he said.
Earlier, Cauchi’s parents released a statement, saying they hoped the coroner’s findings would prevent such a tragedy happening again.