An inquest into the 2024 mass stabbing at the Westfield Bondi Junction shopping centre has found killer Joel Cauchi was schizophrenic, likely psychotic, and had been smoking cannabis for days before he stabbed six people to death and injured 10 others.
Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and Faraz Tahir, 30, were killed by Cauchi in April 2024.
Cauchi, 40, was later fatally wounded by police.
According to the report, there can only be speculation over whether Cauchi purposely targeted women and young girls—the majority of his victims—and also to the “content of his delusion” as there was no logical motivation for his actions.
Tahir, Cauchi’s only male victim, was a security guard who attempted to intervene in the attacks.
The inquest’s findings revealed the opinion of experts who believe Cauchi’s cannabis use had likely exacerbated his psychotic symptoms and potentially even prompted him to relapse.
It was also found that Cauchi’s psychiatrist, Andrea Boros-Lavack, did not err in taking him off medication in 2019 for treatment purposes, but failed to adequately monitor him as his condition deteriorated.
Specifically, the inquest said Boros-Lavack failed to realise that Cauchi’s mental health was declining, despite his mother expressing concerns her son was unfit to live independently, was “very unwell” off his medication, heard voices, and also penned notes about “satanic control.”
At an appointment in 2020, Boros-Lavack described Cauchi in her notes as “totally well” and continued a plan to keep him off medication.
“It 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,” NSW state coroner Teresa O'Sullivan said.
Regarding the management of the Westfield shopping centre, it was found that the security operator in charge of the CCTV room was not competent in the role and her employers at Scentre Group and Glad Group should have been aware of the fact.
However, the inquest found there would not have been sufficient time for the security team to warn the public before Cauchi killed his victims.
Key recommendations from the inquest include that the Health Ombudsman of Queensland review Boros-Lavack’s care and treatments, and that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) update its guidelines for managing schizophrenia.
In response, RANZCP President Dr. Astha Tomar said the college was committed to implementing the coroner’s recommendations.
“Public safety depends on a well-functioning health system. Once a person has been out of treatment for years, the predictive and preventive capabilities of any individual clinician are inherently limited. Without system-level mechanisms for follow-up, outreach and coordinated care, or even access to care, risk becomes a system responsibility, not an individual one.”
Meanwhile, the inquest has also recommended an advertising campaign to raise awareness about how to deal with an armed offender and that bravery awards should be issued for those who come to the aid of others.
It further suggested that media guidelines should be amended to prevent reporting that may cause readers distress.
“My recommendations are intended to achieve practical, meaningful and lasting reform in respect of critical areas of urgent need,” O'Sullivan said.
