Psychiatric failings linked to Bondi Junction stabbings in NSW

Published: 05 February 2026. The English Chronicle Desk. The English Chronicle Online.

A “psychiatric failings” concern has emerged following the fatal Bondi Junction stabbings in 2024, a coroner has determined. Teresa O’Sullivan, the state coroner, highlighted that Joel Cauchi’s former psychiatrist did not adequately recognise early signs of his relapse, a major failing that contributed to the tragic event. Cauchi, 40, who lived with schizophrenia, killed six people and injured ten others at a Westfield shopping centre before being shot by police. The coroner’s findings were delivered in an 837-page report, delayed due to public sensitivities after the Bondi beach terror incident.

O’Sullivan said the report aims to provide an opportunity for reform and strengthen mental health responses. She recommended urgent systemic changes to the New South Wales mental health system, focusing on early intervention and improved support for patients at risk of relapse. Family members of the victims attended the court hearing as the coroner detailed Cauchi’s psychiatric care history and its limitations.

The coroner referred Andrea Boros-Lavack, Cauchi’s former psychiatrist, to the Queensland ombudsman for examination regarding her management of his care. While noting Boros-Lavack’s prior treatment from 2012 to 2019 as exemplary and compassionate, O’Sullivan found she failed to assess the severity of Cauchi’s relapse, particularly after discharging him to his GP in 2020. This oversight was described as a “major failing” in psychiatric care, highlighting systemic psychiatric failings, although it was clarified it was not the sole factor leading to the murders.

Senior counsel assisting the inquest, Dr Peggy Dwyer SC, said the violent events of 13 April 2024 could not have been predicted, emphasising that Boros-Lavack could not have foreseen Cauchi’s actions. The coroner agreed, noting that while the care he received was one contributing factor, it reflected broader psychiatric failings rather than being the direct cause of the tragedy.

O’Sullivan said the inquest examined not only individual psychiatric care but also systemic issues within the NSW mental health system. Recommendations included the establishment of long- and short-term accommodation options for people facing mental health challenges and homelessness. She urged the government to assess the decline of outreach services and determine timelines for their resourcing within the next twelve months.

Family reactions were profound and emotional. Jade Young’s husband, Noel McLaughlin, described the enduring impact of losing his wife and expressed that the inquest’s scrutiny helped provide some clarity and understanding about the events. Relatives of Faraz Tahir, a security guard who was killed on his first day, also spoke of his courage and commitment.

Security procedures at the shopping centre were also reviewed. The coroner concluded that earlier activation of security alerts would not have realistically prevented the fatalities. Cauchi was armed with a 30cm hunting knife and attacked 16 people within three minutes, moving across three levels of the mall. O’Sullivan praised the rapid and coordinated response of emergency services while recommending improvements in police and ambulance collaboration frameworks.

Concerns were raised about the competency of one CCTV control room operator, identified only as CR1 under a suppression order. The coroner noted that the operator’s lack of skills was a management oversight rather than a personal failing. She commended Scentre Group’s overall active armed offender policies as excellent but suggested stricter supervision and accountability measures.

The coroner also recommended that NSW roll out a public awareness campaign regarding the “escape, hide, tell” protocol for active offender situations. The government confirmed it would carefully review twelve of the twenty-three recommendations relevant to its operations. Premier Chris Minns acknowledged the difficult impact on families, first responders, and the broader Bondi community, affirming a commitment to implement measures that reinforce mental health and public safety.

The report underscores significant psychiatric failings and systemic gaps that require urgent reform to prevent future tragedies. Coroner O’Sullivan’s detailed findings serve as a critical reminder of the need for vigilant monitoring of high-risk mental health patients, improved communication between health services, and strengthened community safety frameworks. While the inquest cannot undo the losses, it seeks to ensure that reforms address both care deficiencies and emergency response systems comprehensively.

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