The psychiatrist treating a man who went on a stabbing rampage at the Westfield shopping centre in Bondi Junction has been slammed for failing to act on warnings and signs that he was lapsing back into psychosis.
On Thursday, Coroner Teresa O’Sullivan found that it was ‘a major failing’ of Joel Cauchi’s psychiatrist, Andrea Boros-Lavack, that she didn’t recognise ‘early warning signs’ he was psychotic and put him back on medication.
This was despite the fact that Cauchi’s mother, Michele, had alerted Dr Boros-Lavack’s private practice that her son ‘was very unwell since he came off his medication’, and ‘that he may have been hearing voices and that he was making notes which suggested that he believed he was under Satanic control’, the coroner said.
Instead, Dr Boros-Lavack had attributed Cauchi’s behaviour to ‘his apparent concern that he may have contracted a sexual transmissible infection.’
‘Dr Boros-Lavack ultimately failed to take more active steps or to realise the seriousness of the situation that was unfolding before her,’ Ms O’Sullivan said.
‘She did not do so because she did not believe Mr Cauchi was experiencing a relapse into psychosis.’
‘It was ultimately a major failing that Dr B revised her view with respect to Mr Cauchi’s early warning signs and did not do more to proactively urge Mr Cauchi to resume his medication.’
Ms O’Sullivan was delivering her findings into the events at the Bondi Westfield shopping centre on April 13, 2024.
Joel Cauchi’s psychiatrist Dr Andrea Boros-Lavack has been slammed
Joel Cauchi stabbed 16 people in under three minutes on his rampage at Bondi Westfield, killing six, while he was delusional after ceasing medication for schizophrenia four years earlier
After the attacks, Joe Cauchi was shot dead as he ran towards NSW Police Inspector Amy Scott (pictured) who was the first officer on the scene
Dawn Singleton, 25; Ashlee Good, 38; Jade Young, 47; Pikria Darchia, 55; Yixuan Cheng, 27; and security guard Faraz Tahir, 30, were killed by Joel Cauchi at Bondi Junction Westfield in Sydney’s east that afternoon.
In just under three minutes, he stabbed 16 people. Ten were injured, including Ms Good’s nine-month-old baby.
Ms O’Sullivan found that between 2012 and September 2019, Dr Boros-Lavack had managed Cauchi’s mental health treatment ‘with personalised, consistent and compassionate treatment’.
Cauchi had taken the anti-psychotic Clozapine and was later prescribed a further drug, but he ceased medication altogether in June 2019.
‘The evidence suggests that he did not commence any further psychotropic medication after this time,’ Ms O’Sullivan said.
‘I have concerns regarding Dr Boros-Lavack’s management of Mr Cauchi from October 2019.’
In her 831-page findings, Ms O’Sullivan said Dr Boros-Lavack did not urge Cauchi to resume his medication and failed to provide the 40-year-old’s treating GP with enough information when she discharged him from her care.
‘She should have placed greater emphasis on the importance of Mr Cauchi commencing the prescribed medication … and did not do more to proactively urge (him) to resume.’
Floridly psychotic, Joel Cauchi attacked and killed (clockwise, from top left), Ashlee Good, Faraz Tahir, Dawn Singleton, Yixuan Cheng, Pikria Darchia and Jade Young
Joel Cauchi’s mother Michele (above) had warned Dr Boros-Lavack’s private medical practice that her son was very unwell off his anti-psychotic medication, hearing voices and believing he was under the control of Satan
However, the coroner said these failings were not the sole cause of the mass stabbing, saying they were only one of a series of shortcomings.
Ms O’Sullivan will refer Dr Boros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Cauchi.
After the attacks, Cauchi was shot dead as he ran towards NSW Police Inspector Amy Scott, who was the first officer on the scene.
The hero cop attended Lidcombe Coroners Court on Thursday.
Ms O’Sullivan commended the police officer for her brave actions in facing Cauchi alone.
‘They were extraordinary, calm, skilful and courageous and actions which clearly saved lives.’
It was not until two minutes after Cauchi was fatally shot by Inspector Scott that the emergency evacuation alarm was activated.
Ms O’Sullivan found that the sole CCTV operator in the Westfield control room was not competent enough to handle the stressful situation.
She blamed the management of security firms Scentre Group and subcontractor Glad, who she said should have been aware of the operator’s inexperience and taken steps to ensure better staffing.
The coroner made a series of recommendations, including that the NSW government obtain advice on the decline of and demand for mental health outreach in the state.
The state has also been advised to inquire about mental health resources and come up with a timeline to improve these services.
The coroner also recommended the government promote the ‘Escape, Hide, Tell’ slogan to encourage civilians to remain safe when an armed offender is on the loose.
