‘Major failing’ in psychiatric care before Joel Cauchi stabbed six people at Bondi Junction, coroner finds | Bondi Junction stabbings
Joel Cauchi’s former psychiatrist’s failure to recognize a relapse ahead of the Bondi Junction stabbings in 2024 was a “massive failure”, a coroner has found.
State coroner Teresa O’Sullivan presented her findings in an 837-page report on Thursday after delaying his release following the Bondi beach terror attack in December.
New South Wales has proposed changes to its mental health system.
Family members of the victims gathered in court to hear the coroner’s findings regarding the violent attack of 40-year-old Joel Cauchi at the Westfield mall.
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 being shot dead by police inspector Amy Scott.
O’Sullivan determined that all six people died from stab wounds.
“Whilst this inquiry can never change what happened, it is hoped that the recommendations provide an opportunity for reform that could save future lives,” O’Sullivan said in a statement on Thursday.
O’Sullivan said he would refer Cauchi’s former psychiatrist, Andrea Boros-Lavack, to the Queensland ombudsman for an investigation into his attention to Cauchi.
But O’Sullivan said it was “important to note” that Cauchi’s care was not a significant factor in why he killed six people. Assisting in the investigation is senior lawyer Dr. Peggy Dwyer SC said late last year: “No one could have foreseen the tragic events of April 13th. [2024] –Dr. It is not suggested that Boros-Lavack could have done this.”
The coroner’s office said Thursday that Boros-Lavack’s care for Cauchi from 2012 to 2019 was exemplary and compassionate, and that she did the right thing by listening to his requests to stop taking his medication.
However, O’Sullivan found that Lavack “failed” to assess the seriousness of “what was going on in front of him” when he deteriorated again.
“The care provided was one of many factors that led to this tragic outcome,” he said.
“Whilst this investigation will never be able to change what happened, it is hoped that the recommendations provide an opportunity for reform that could save future lives.”
He said the investigation was an opportunity to examine both Cauchi’s care and systemic problems in the state’s mental health system.
He recommended the NSW government establish and support short- and long-term accommodation for people experiencing mental health issues and people experiencing homelessness.
The coroner recommended the NSW government seek advice on the reduction of mental health outreach services over the next 12 months and set a “realistic timeline” for funding such services.
