Inquest findings into Bondi Westfield stabbing: Coronor refers Joel Cauchi’s psychiatrist for review

The hero police officer who ended killer Joel Cauchi’s stabbing rampage that claimed the lives of six people has been praised for her bravery, as the findings of the coronial inquest into the tragedy are delivered.

Dawn Singleton, Yizuan Cheng, Faraz Ahmed Tahir, Ashlee Good, Jade Young and Pikria Darchia were all killed during one of the worst massacres the country has ever seen on April 13, 2024.

Inspector Amy Scott arrived at the Coroner’s Court in Lidcombe on Thursday morning wearing a colourful bandana, having recently been diagnosed with a rare and aggressive breast cancer.

Ms Scott is a 19-year veteran of the NSW Police Force, and has been credited with saving many lives with her quick response to the stabbing attack.

‘All the very best for the road ahead’

Coroner Teresa O’Sullivan praised the bravery of Ms Scott during her closing remarks, calling her actions “extraordinary” and crediting her with saving lives.

“... Inspector Amy Scott, whose heroism has been a centre piece of this inquest. Not only did she act unhesitatingly and with enormous courage and service…but she attended court throughout the inquest to provide comfort to others. She combined skill and compassion with great humility,” Ms O’Sullivan said.

“She now faces a health chalenge… I wish her and her family all the very best for the road ahead.”

Ms O’Sullivan also acknowledged the alleged terror attack at Bondi Beach, which happened less than a week before she was due to hand down her findings on the Bondi inquest.

“I had hoped that our community would not need to grapple again so soon with such a violent event…I express my heartfelt condolences to all who were impacted,” she said.

She said she took “comfort” from reports paramedics and police worked together seamlessly, with inter-agency communication probed during the Bondi stabbing inquest.

Cauchi was “floridly psychotic” as he carried out his fatal rampage at Westfield Bondi Junction in Sydney’s east before he was shot dead by Ms Scott.

Shocking details were uncovered last year as fifty witnesses were called to give evidence during a five-week coronial inquest into the tragedy, including claims of failures in the care provided by psychiatrist Andrea Boros-Lavack to treat Cauchi’s schizophrenia.

The victims’ loved ones, who were left “traumatised” when the psychiatrist claimed Cauchi’s fatal rampage had “nothing to do with psychosis” and was instead fuelled by a “hatred for women” and “sexual frustrations”, want Dr Boros-Lavack to be referred to a regulator for investigation.

‘Major failing’

Ms O’Sullivan, on Thursday, referred Dr Boros-Lavack to the Health Ombudsman of Queensland, following these calls made by the victims’ families.

The coroner has recommended that the regulator review the psychiatrist’s treatment and care of Cauchi, she told the inquest on Thursday.

She found it was a “major failing” by Dr Boros-Lavack to ultimately rule that Cauchi was not suffering early warning signs of psychosis, following concerns raised by his mother, Michele.

Dr Boros-Lavack initially had a suspicion that Cauchi was showing signs of relapse, the coroner said, however she then “revised her view”.

Ms O’Sullivan noted Dr Boros-Lavack’s care of Cauchi was “exemplary” from 2012 to September 2019, and made no criticism of the decision to trial weaning Cauchi off all medications at his request.

An expert psychiatric panel found Cauchi — who had been slowly weaned off all antipsychotic medication and a drug to treat obsessive compulsive disorder by the psychiatrist — was suffering psychosis at the time of the killings.

Dr Boros’ Lavack’s care of Cauchi was probed at length, with claims Cauchi’s mother was not taken seriously enough when she raised concerns about her son’s mental health decline.

This included Michele raising that Cauchi may have been hearing voices and was leaving notes that he was under “satanic control”, none of which was mentioned in letters to his GP when Cauchi was discharged from the psychiatrist’s care in 2020 ahead of his move to Brisbane.

Dr Boros-Lavack acknowledged there were “deficiencies” in her discharge of Cauchi.

Claims lives could have been saved had alarms been sounded earlier, and had there been a more competent control room operator (CRO) present, were also made during the final days of the inquest.

The need for improved interagency communications between NSW Police and Ambulance services was also flagged after confusion about whether the shopping centre was a “hot zone”, and if there was a second offender.

Ms O’Sullivan will hand down her findings on Thursday.

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