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TRANSCRIPT
Six people died at Westfield Bondi Junction on the 13th of April 2024 and a psychiatrist for the man responsible for the killings has been criticised by the state coroner for what she called a major failing in her treatment of Joel Cauchi.
Cauchi stabbed 10 people, killing six before he was shot dead by New South Wales Police Inspector Amy Scott.
Queensland psychiatrist Doctor Andrea Boros-Lavack treated Cauchi for chronic schizophrenia from March 2012 until his discharge in early 2020.
In 2019, she weaned Cauchi off his anti-psychotic medication, but State Coroner Teresa O'Sullivan found Dr Boros-Lavack failed to adequately monitor him for early warning signs of a relapse.
"It was, ultimately, a major failing that Doctor Boros-Lavack 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. This failing was further compounded by the discharge process that occurred early in 2020. That process was inadequate and constituted a clear and serious missed opportunity. All of the expert psychiatrists who assisted the inquest agreed that Doctor Boros-Lavack's letter to Doctor Grundy - Mr Cauchi's GP based in Toowoomba - dated the 19th of March 2020 lacked important and significant information concerning Mr Cauchi's mental health. I find this discharge letter to have been wholly unsatisfactory."
Coroner O'Sullivan described Doctor Boros-Lavack's evidence to the inquest as "inconsistent" and "combative" and found she been "reluctant to accept any criticism of her management" of Cauchi.
While highly critical, the coroner said the psychiatrist's treatment was not the major reason for the events at Westfield Bondi Junction.
"Despite these issues, it is important to note that Dr Boros-Lavack's care of Mr Cauchi cannot be said to be the major reason for the events on the 13th of April 2024. The care that was provided was only one of the many factors that led to this tragic outcome."
Magistrate O'Sullivan has also recommended the Royal Australian and New Zealand College of Psychiatrists urgently review outdated health care guidelines around the management of schizophrenia and related disorders.
The Executive Director of the Australian Society of Psychiatrists, Dr Pramudie Gunaratne, says there are many gaps between GP and specialist services.
"It's been too long that we've had people falling between the cracks of our mental health care system and we think if anything can come of this incredible tragedy, it's that we have a greater focus on what's needed to bolster our mental health system. One of the big things that has been shown through the findings is how there are so many gaps between GP and specialist services, between public and private services. We've seen the real lack of homelessness and outreach services for people with severe mental illness and we have to do something to change and turn that around."
Family members of the six people killed have welcomed the findings, which include recommendations for bravery awards for those who confronted Cauchi during his rampage: Inspector Scott, Damien Guerot, Silas Despreaux and Noel McLaughlin.
Mr McLaughlin lost his wife Jade in the attack.
"Nothing can alter what we lost on the 13th of April. Jade was my wife, the person I shared life with for more than two decades. Her absence has left a vast and permanent space. One that can't be filled, only carried. While the inquest can't undo our loss, Jade's murder cannot be undone but if these findings lead to change that prevents even one family from experience what ours has endured then this process will have meaning beyond our loss."
And if this story has raised issues for you, you can contact 24-hour crisis hotline Lifeline on 13 11 14; or Beyond Blue on 1300 224 636.
