After a man went on a stabbing spree at a shopping mall, his psychiatrist faced heavy criticism for not acting on clear warnings that he was descending back into psychosis and experiencing delusions involving Satan.

On Thursday, Coroner Teresa O’Sullivan highlighted a significant oversight by psychiatrist Andrea Boros-Lavack, who failed to identify the early signs of Joel Cauchi’s psychosis and did not reinstate his medication.

Cauchi’s mother, Michele, had informed Dr. Boros-Lavack’s practice that her son was seriously unwell after discontinuing his medication.

Additionally, Michele pointed out that Cauchi might have been hearing voices and making notes indicating he believed he was under satanic influence, according to the Coroner.

However, the psychiatrist attributed Cauchi’s behavior to his anxiety over possibly contracting a sexually transmitted infection.

“Dr. Boros-Lavack ultimately did not take adequate measures or recognize the severity of the developing situation,” stated Ms. O’Sullivan.

 ‘(She) did not do so because she did not believe Mr Cauchi was experiencing a relapse into psychosis.

‘It was ultimately a major failing that Dr B revised her view with respect to Mr Cauchi’s early warning signs and did not do more to proactively urge Mr Cauchi to resume his medication.’

Joel Cauchi’s psychiatrist Dr Andrea Boros-Lavack has been slammed 

Ms O’Sulllivan was delivering her findings into the events at Bondi Westfield shopping centre on April 13, 2024.

Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were killed by Joel Cauchi at Bondi Junction Westfield in Sydney’s east on the afternoon of that day.

In just under three minutes, he stabbed 16 people. Ten were injured, including Ms Good’s nine-month-old baby. 

Ms O’Sullivan found that between 2012 and September 2019, Dr Boros-Lavack had managed Cauchi’s mental health treatment ‘with personalised, consistent and compassionate treatment’.

He had taken the anti-psychotic Clozapine, and then been prescribed a further drug, but ceased medication altogether in June 2019. 

‘The evidence suggests that he did not commence any further psychotropic medication after this time,’ Ms O’Sullivan said, ‘I have concerns regarding Dr Boros-Lavack’s management of Mr Cauchi from October 2019.’

In her 831-page findings, Ms O’Sullivan said Dr Boros-Lavack did not then urge Cauchi to resume his medication and failed to provide the 40-year-old’s treating GP when enough information when she discharged him from her care.

‘She should have placed greater emphasis on the importance of Mr Cauchi commencing the prescribed medication … and did not do more to proactively urged (him) to resume.’ 

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.

Ms O’Sullivan will refer Dr Baros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Cauchi.

After the attacks, Joe Cauchi was shot dead as he ran towards NSW Police Inspector Amy Scott who was the first officer on the scene.

The hero cop attended Lidcombe Coroners Court on Thursday.

Ms O’Sullivan commended the police officer for her brave actions in facing Cauchi alone.

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

It was not until two minutes after Cauchi was fatally shot by Inspector Scott that the emergency evacuation alarm was activated.

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

She blamed management of security firms Scentre Group and subcontractor Glad who should have 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 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 was in the loose.