The psychiatrist of a man responsible for a deadly stabbing spree at a Sydney shopping mall is facing criticism for not addressing clear indicators of his patient’s declining mental health.

In a tragic incident at Bondi Junction Westfield in April 2024, Joel Cauchi, 40, fatally stabbed six individuals, including Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27, and security guard Faraz Tahir, 30. He injured ten more people, among them a 9-month-old infant. Cauchi had a history of schizophrenia and was reportedly experiencing psychotic episodes at the time of the attack.

State coroner Teresa O’Sullivan, in a statement released on Thursday, acknowledged that psychiatrist Andrea Boros-Lavack made a justified decision to discontinue Cauchi’s antipsychotic medication in 2019. However, she criticized Boros-Lavack for failing to adequately monitor her patient’s condition thereafter.

The coroner identified a “significant oversight” in Boros-Lavack’s failure to recognize early warning signs, which should have prompted a reconsideration of medication. This neglect occurred despite repeated concerns raised by Cauchi’s mother, who reported that her son was experiencing auditory hallucinations and writing notes under the delusion that he was being controlled by satanic forces.

The doctor made a “major failing” in not heeding early warning signs and pushing for the resumption of medication, the coroner found.

This was despite multiple warnings from his mother that he was hearing voices and writing notes believing he was under satanic control.

In hundreds of pages of findings, O’Sullivan said Boros-Lavack didn’t subsequently urge Cauchi to resume his medication and failed to provide the 40-year-old’s treating GP with enough information when she discharged him from her care.

However, the coroner said these failings were not the sole cause of the mass stabbing, saying they were but one of a series of shortcomings.

O’Sullivan will refer Baros-Lavack to the health ombudsman of Queensland to review her care and treatment of Cauchi.

Police officer’s ‘courageous’ actions commended

The 40-year-old was shot dead as he ran towards NSW Police inspector Amy Scott, who was the first officer on the scene.

Scott attended Lidcombe Coroners Court on Thursday.

O’Sullivan commended Scott for her brave actions in facing Cauchi alone.

“They were extraordinary, calm, skillful and courageous and actions which clearly saved lives,” O’Sullivan said.

It wasn’t until two minutes after Cauchi was fatally shot by Scott that the emergency evacuation alarm was activated.

O’Sullivan found that the sole CCTV operator in the Westfield control room wasn’t competent enough to handle the stressful situation.

She said the management of security firms Scentre Group and subcontractor Glad should’ve been aware of the operator’s inexperience and taken steps to ensure better staffing.

The coroner made a series of recommendations including that the NSW government obtain advice on the decline of and demand for mental health outreach in the state.

The state has also been advised to inquire about mental health resources and come up with a timeline to improve these services.

The coroner also recommended the government promote the “Escape, Hide, Tell” slogan to encourage civilians to remain safe when an armed offender is on the loose.

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