Bondi Junction Inquest Concludes, Psychiatrist Referred for Review
Almost two years after the tragic April 13, 2024, Westfield Bondi Junction mass stabbing, the coronial inquest has concluded, with significant findings and recommendations handed down. The coroner has advised that the psychiatrist who treated attacker Joel Cauchi be reviewed and issued public safety advice for armed offender situations.
The inquest's findings aim to prevent future tragedies and provide clarity on the events of that day.
Attack Details
On April 13, Joel Cauchi murdered six individuals—Yixuan Cheng, Faraz Tahir, Jade Young, Pikria Darchia, Dawn Singleton, and Ashlee Good—and injured 10 others while experiencing psychosis. He was fatally shot by NSW Police Inspector Amy Scott within six minutes of the attack's commencement.
Psychiatrist's Conduct Reviewed
Dr. Andrea Boros-Lavack, Cauchi's psychiatrist from 2012 to 2020, who treated him for chronic schizophrenia, has been referred for review by the Queensland Health Ombudsman.
The coroner accepted submissions indicating that Dr. Boros-Lavack "did not adequately monitor him for early warning signs of relapse" after weaning him off anti-psychotic medication in 2019. This occurred despite reports of Cauchi "hearing voices."
Magistrate Teresa O'Sullivan described Dr. Boros-Lavack's evidence as "inconsistent" and "combative," noting her reluctance to accept criticism as "a shame."
However, the coroner clarified that Dr. Boros-Lavack's care was not identified as the primary reason for the April 13 events.
Recommendations for Public Safety and Mental Health
The inquest issued a total of 23 recommendations, focusing on public safety and mental health initiatives:
- The NSW government should promote the 'Escape. Hide. Tell.' principles through an advertising campaign to inform the public about actions during active armed offender incidents.
- Development of a shared care guideline on chronic schizophrenia for Australian health bodies.
- The NSW government to address the decline in mental health outreach services and the critical need for accommodation for individuals experiencing mental health issues and homelessness in greater Sydney.
- Specific health and police recommendations directed towards Queensland, Cauchi's home state.
Westfield Security
During the initial moments of the attack, the Westfield control room was unmonitored due to the sole security guard's absence. Scentre Group, owner of Westfield, has since mandated constant staffing of the control room.
The coroner determined it was not realistically possible to have alerted the public via PA announcements or emergency overrides before Cauchi completed his fatal attacks.
Media Reporting and Victim Families
Some victims' family members reported learning of their loved one's death through media, detailing privacy intrusions. The coroner recommended the Australian Press Council consider developing advisory guidelines for reporting mass casualty incidents, aiming to balance public information with the well-being of bereaved families.
Commendations
The coroner recommended that the Council for the Australian Bravery Decorations consider awards for Inspector Amy Scott, Noel McLaughlin, Damien Guerot, Silas Despreaux, and posthumously for Ashlee Good, in recognition of their courageous actions during the attack.
Perpetrator's Parents' Statement
Joel Cauchi's parents, Andrew and Michelle Cauchi, issued a statement expressing their deepest condolences to the victims' families and all those affected. They also extended their thoughts to unpaid carers of individuals with mental ill-health, voicing hope that the inquest's findings would aid in preventing similar future events.