Sydney — Nearly two years after a deadly stabbing shocked Australia, a New South Wales coronial inquest has found that critical failures in mental health care occurred before the attack at Westfield Bondi Junction, raising serious questions about how warning signs were missed.
State Coroner Teresa O’Sullivan on Thursday released findings into the 13 April 2024 attack, in which 40-year-old Joel Cauchi killed six people and injured 10 others inside the crowded Sydney shopping center. Police shot Cauchi dead at the scene, ending the violence but not the anguish for families left behind.
The inquest found that Cauchi, who had long lived with serious mental illness, stopped taking antipsychotic medication in 2019. Despite this, and despite concerns repeatedly raised by his mother about his declining condition, his long-term psychiatrist did not push strongly enough for treatment to resume or escalate the risks to other health services.
The coroner described this as a “major failing” and ordered that the psychiatrist be referred to Queensland’s health regulator for further review. While acknowledging that care provided earlier in Cauchi’s treatment had been compassionate and consistent, O’Sullivan said later decisions left serious gaps at a time when intervention mattered most.
Importantly, the coroner did not suggest the attack was inevitable or predictable in a simple way. Instead, she pointed to a gradual breakdown in continuity of care, where warning signs accumulated but did not trigger decisive action.
Cauchi had moved interstate, was living rough at times, and slipped out of structured treatment. The coroner said systems designed to protect vulnerable people failed to keep him connected, creating risk not only for him but for the wider community.
In total, the inquest made 23 recommendations aimed at preventing similar tragedies, including stronger community mental health outreach, better information sharing between services, and clearer police powers when responding to people in acute psychological distress.
The coroner also examined what happened inside Westfield Bondi Junction on the day of the attack. She found that security arrangements were inadequate for a major emergency, noting that only one CCTV operator was on duty and was not properly trained to manage a crisis of that scale.
The report also calls for better public education on how to respond during violent incidents. The NSW government has acknowledged the coroner’s recommendations and says it is reviewing how to implement them.