"It was a major failing for Joel Cauchi's former psychiatrist not to recognise he had relapsed in the lead up to the Bondi Junction stabbings in 2024, a coroner has found. The state coroner, Teresa O'Sullivan, handed down her findings in an 837-page report on Thursday after she had delayed its release following the Bondi beach terror attack in December. She recommended changes to the New South Wales mental health system."
"While this inquest cannot ever change what happened, it is hoped the recommendations can provide an opportunity for reform which could save future lives, O'Sullivan said on Thursday. O'Sullivan said she would be referring Cauchi's former psychiatrist, Andrea Boros-Lavack, to the Queensland ombudsman to examine her care of him. But O'Sullivan said it was important to note that her care was not a major factor that led Cauchi to murder six people."
"The coroner said on Thursday that Boros-Lavack's care of Cauchi from 2012 to 2019 was exemplary and compassionate, and she did the right thing in listening to his wishes to wean off his medication. However, O'Sullivan found that Lavack failed to assess the seriousness of what was unfolding before her when he relapsed. The care that was provided was one of the many factors that led to this tragic outcome, she said."
Teresa O'Sullivan found that a major failing occurred when Joel Cauchi's former psychiatrist did not recognise his relapse before the 2024 Bondi Junction stabbings. O'Sullivan released an 837-page report and recommended reforms to the New South Wales mental health system. Cauchi, who lived with schizophrenia, killed six people and injured ten before being shot by police Insp Amy Scott; all six fatalities resulted from stab wounds. O'Sullivan said the psychiatrist's care from 2012–2019 had been exemplary but failed to assess the seriousness of Cauchi's relapse. The psychiatrist is being referred to the Queensland ombudsman to examine that care.
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