Ask Onix
Updated 5 February 2026 - A coroner's report has recommended a formal investigation into a psychiatrist's treatment of a man who carried out a deadly stabbing spree in Sydney.
Coroner finds gaps in mental health care before attack
A psychiatrist who treated Joel Cauchi, the man behind the 2024 Bondi Junction stabbing rampage, will be referred to Queensland health authorities after a coronial inquiry identified critical failures in his care. Cauchi, 40, killed six people and injured ten-including a baby-during a six-minute attack at Westfield Bondi Junction in April 2024 before being shot dead by police.
Family warnings ignored, coroner says
New South Wales State Coroner Teresa O'Sullivan found that Dr Andrea Boros-Lavack had provided Cauchi with "exemplary" long-term care but missed key signs of relapse. In late 2019, Cauchi's mother alerted Boros-Lavack to concerns about her son's deteriorating mental state, but the psychiatrist "failed to take more active steps," according to the coroner.
O'Sullivan described this as a "major failing," noting that Boros-Lavack did not push Cauchi to resume medication or ensure follow-up care when he moved to another city. A discharge letter sent to his new doctor also lacked urgency, failing to stress the need for immediate psychiatric review.
Systemic failures contributed to tragedy
The coroner's 800-page report, delayed until 2026 out of respect for victims of a separate Bondi Beach mass shooting in December 2025, outlined multiple missed opportunities to prevent the attack. Among them:
- A police officer overlooked an email flagging Cauchi's mental health due to staff shortages.
- A Westfield security guard, deemed unqualified for the CCTV control room, was the only person monitoring the area when Cauchi struck his first victim.
- Mental health outreach services and short-term housing for at-risk individuals were insufficient.
O'Sullivan praised the "commendably rapid" police response but called for better coordination between agencies. She also recommended a public safety campaign promoting the "escape, hide, tell" protocol for active threats.
Victims remembered as families seek answers
The six victims-Dawn Singleton (25), Yixuan Cheng (27), Jade Young (47), Ashlee Good (38), Faraz Tahir (30), and Pikria Darchia (55)-died during Cauchi's psychotic episode. Good's nine-month-old daughter survived after her mother shielded her with her body.
"The evidence has shown that what first appeared to be a sudden and random act of violence was, in fact, the end point of a long story."
Noel McLaughlin, husband of victim Jade Young
Cauchi, diagnosed with schizophrenia as a teenager, was unmedicated and homeless at the time of the attack. His parents issued a statement expressing hope that the coroner's findings would help prevent future tragedies.
Recommendations and recognition
O'Sullivan's 23 recommendations include:
- Bravery awards for NSW Police Inspector Amy Scott, who shot Cauchi, as well as two French bystanders and Good's husband, who intervened during the attack.
- Stricter media guidelines for covering mass casualty events, following criticism of reporting that "exacerbated trauma" for victims' families.
- Improved mental health services and housing support for vulnerable individuals.
The coroner's report, originally due in late 2025, was postponed to avoid compounding grief after the Bondi Beach shooting, which claimed 15 lives.
