A NSW coroner has handed down the findings from a six-week inquest into the fatal 2024 Bondi Junction stabbing.
Queensland man Joel Cauchi stabbed 16 people at a shopping centre in Sydney’s east in April 2024, killing six.
NSW State Magistrate Coroner Teresa O’Sullivan recommended the Qld Health Ombudsman review the treatment Cauchi received from a psychiatrist in the 2010s, which she said was a “factor” in the stabbing.
Inquest
In NSW, a coronial inquest is held when a person dies in “sudden or unexplained” circumstances, and when there are “unresolved issues” left from an initial investigation.
It is not the same as a court hearing, and a coroner cannot find someone guilty of a crime.
At the end of an inquest, the coroner may make recommendations to the Government or relevant agencies on ways to improve public health and safety.
Stabbing
On 13 April 2024, Queensland man Joel Cauchi fatally stabbed six people at Bondi Junction Westfield. Cauchi injured 10 more, including a nine-month-old baby.
The 40-year-old had previously been diagnosed with schizophrenia, and was homeless at the time.
The six people he killed were Dawn Singleton, Jade Young, Ashlee Good, Pikria Darchia, Yixuan Cheng, and Faraz Tahir.
Inspector Amy Scott, on duty in the area at the time, fatally shot Cauchi.
Findings
The report outlines Cauchi’s history of treatment for schizophrenia, including seeing a private psychiatrist in Toowoomba, Dr Andrea Boros-Lavack.
Cauchi saw Boros-Lavack from 2012 to 2020, when he moved to Brisbane. Over this period, Boros-Lavack reduced Cauchi’s doses of two anti-psychotics. By 2019, he was not medicated.
All experts who gave evidence to the inquest agreed the decision to slowly take Cauchi off medication was a reasonable course of action.
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However, the coroner found that Boros-Lavack didn’t respond appropriately to concerns raised by Cauchi’s mother on several occasions between October 2019 and February 2020.
Cauchi’s mother told Boros-Lavack that her son had been “very unwell since he came off his medication,” was hearing voices, and was writing notes about “Satanic control”.
O’Sullivan found Boros-Lavack did not respond well to these “early warning signs and in some instances, embellished how well [Cauchi] was doing” in her notes.
The coroner said it was “a major failing” that Boros-Lavack did not try harder to ensure Cauchi resumed taking medication.
It was also found that Boros-Lavack should have included more information in a letter she wrote to Cauchi’s GP after the last time she saw him.
The coroner found Cauchi’s GP could not have known from Boros-Lavack’s letter that Cauchi needed to be reviewed urgently.
Ultimately, however, the coroner said these decisions could not be considered “a major reason” for the stabbing, but rather “one of the factors”.
Motivation
The coroner did not make any conclusions on the motivation behind Cauchi’s attack.
One expert psychiatrist involved in the inquest suggested Cauchi specifically targeted young girls and women.
However, the other expert psychiatrists said they couldn’t reach a clear conclusion on this.
Five of the six people who died during the attack were women.
Recommendations
O’Sullivan recommended the Qld Health Ombudsman review Boros-Lavack’s “care and treatment” of Cauchi.
She made several recommendations to top doctors and psychiatrists’ bodies about updating guidelines for treatment and medication of schizophrenia and similar disorders.
O’Sullivan also recommended several people be considered for the Governor-General’s special award for bravery, including Inspector Amy Scott, and Damien Guerot and Silas Despreaux, who confronted Cauchi.
