A coroner has found Joel Cauchi's doctor failed to heed warnings he was having a relapse of schizophrenia.
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Joel Cauchi, first diagnosed with schizophrenia in his teens, was unmedicated and homeless when he stabbed 16 people inside Westfield Bondi Junction in 2024, killing six.
The New South Wales coroner said Dr Andrea Boros-Lavack had provided 40-year-old Cauchi "exemplary" care over a long period, but failed to heed warnings from family that he may be relapsing, years before the attack.
This mistake was one of many that led to the tragedy, the coroner said, also pointing to a series of actions by police and shopping centre security.
Six people - Dawn Singleton, 25; Yixuan Cheng, 27; Jade Young, 47; Ashlee Good, 38; Faraz Tahir, 30; and Pikria Darchia, 55 - died during the attack in April 2024.
Ten others, including Good's baby, were injured in the six minutes before Cauchi - who was suffering a psychotic episode - was shot dead by New South Wales (NSW) police inspector Amy Scott.
During a five-week coroner's inquest that finished last May, the coroner heard from dozens of witnesses including doctors, police, survivors and the families of victims in a bid to unearth the events leading up to the attack and prevent such a tragedy occurring again.
The coroner's 800-page plus findings were due to be released at the end of 2025 but they were delayed as a mark of respect for the victims of the Bondi Beach attack, in which 15 people were killed by two gunmen on 14 December.
On Thursday, Teresa O'Sullivan told the coroner's court that Boros-Lavack had provided "personalised, consistent and compassionate treatment" for Cauchi for many years after she first took him on as a private patient in 2012.
Between 2018 and mid-2019, the Queensland psychiatrist had worked closely with Cauchi to wean him off the medications he had been taking to treat his condition, a move that was not criticised by the coroner.
However, in late-2019 when Cauchi's mother raised concerns that he
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