EDITORIAL: Action needs to follow Coroner’s findings on Bondi Junction attack
It is important that the passage of time does not prevent the Government from responding swiftly to the Coroner’s recommendations.
It has been nearly two years since Westfield Bondi Junction shopping centre became the scene of shocking violence that left six innocent people dead.
Another ten people were left injured on April 13, 2024, during a rampage by Joel Cauchi, who was wielding a 30cm hunting knife and in the midst of an acute episode of psychosis.
Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were killed.
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By continuing you agree to our Terms and Privacy Policy.There were striking displays of bravery by members of the public as the attack unfolded before Cauchi was shot dead by police officer Inspector Amy Scott.
On Thursday NSW Coroner Teresa O’Sullivan handed down her findings, including 23 recommendations.
Ms O’Sullivan was highly critical of Cauchi’s psychiatrist Andrea Boros-Lavack.
She ruled that Dr Boros-Lavack’s determination that Cauchi was not suffering early warning signs of psychosis in late 2019 after he was taken off all antipsychotic medications was a “major failing”.
This was despite the concerns of Cauchi’s mother, Michele, who on seven occasions flagged her son’s declining mental health, including by reporting that he may have been hearing voices and was leaving notes that he was under “satanic control”.
Ms O’Sullivan found that while Dr Boros-Lavack initially suspected Cauchi was showing signs of relapse, she “revised her view” and thus failed to “recognise the seriousness of the situation”.
Ms O’Sullivan has asked that Queensland’s Health Ombudsman review Dr Boros-Lavack’s care of Cauchi.
She also recommended amendments to guidelines on schizophrenia disorders, which should reflect the significant risk of relapse for patients who cease medication.
She also recommended the NSW government model short-term accommodation needs for those experiencing mental health issues and support the establishment of long-term accommodation options.
NSW Health should also obtain advice on the decline of mental health outreach services and what additional resources are needed for psychiatric services.
The Coroner has asked for consideration of bravery awards for Ms Good, Ms Young’s husband Noel McLaughlin, who was threatened by Cauchi and warned other shoppers the killer had a knife, and Silas Despreaux and Damien Guerot, who led Ms Scott to Cauchi after they threw bollards at the killer.
In a moving speech outside the NSW Coroner’s Court on Thursday, Mr McLaughlin said while the inquest could not “undo” his family’s loss, “it has mattered”.
“My hope now is that the findings and the recommendations are treated not as abstract lessons, but as practical obligations,” he said.
The findings go a long way towards providing answers about the tragedy, and show again that mental health is an issue that requires serious attention. It is important that the passage of time does not prevent the Government from responding swiftly to the Coroner’s recommendations.
