A psychiatrist who treated the man behind a fatal stabbing rampage at a crowded Sydney shopping centre will be referred to health investigators after a coronial inquiry.
Joel Cauchi, first diagnosed with schizophrenia in his teens, was unmedicated and homeless when he stabbed 16 people inside Westfield Bondi Junction in 2024, killing six.
The New South Wales coroner said Andrea Boros-Lavack had provided 40-year-old Cauchi 'exemplary' care over a long period, but failed to heed warnings from family that he may be relapsing, years before the attack.
This mistake was one of many that led to the tragedy, the coroner said, also pointing to a series of actions by police and shopping centre security.
Six people - Dawn Singleton, 25; Yixuan Cheng, 27; Jade Young, 47; Ashlee Good, 38; Faraz Tahir, 30; and Pikria Darchia, 55 - died during the attack in April 2024. Ten others, including Good's baby, were injured in the three minutes before Cauchi - who was suffering a psychotic episode - was shot dead by New South Wales (NSW) police inspector Amy Scott.
During a five-week coronial inquest that finished last May, the coroner heard from dozens of witnesses including doctors, police, survivors, and the families of victims in a bid to unearth the events leading up to the attack and prevent such a tragedy occurring again.
The inquest revealed that Boros-Lavack had worked closely with Cauchi to manage his condition but failed to respond adequately to emerging warning signs that he may be relapsing in late 2019.
In her recommendations to Queensland health authorities, the coroner also listed 23 recommendations aimed at improving mental health services and police response protocols, underscoring the systemic failures that contributed to the tragedy.
