‘A vast and permanent space’: Grieving families speak after Bondi stabbing inquest findings

The inquest into the Bondi Junction Westfield stabbing attack has urged the government to house and care for the mentally unwell, referred the killer’s psychiatrist to the watchdog over treatment “failures”, and recommended bravery awards for the heroism displayed by police, victims and witnesses to the tragedy.

The families of those who died spoke outside the coroners court in Sydney of the voids that remained in their lives, while experts have called for urgent changes to care and support for people with mental illness.

Queenslander Joel Cauchi, 40, was shot dead by NSW Police Inspector Amy Scott after he stabbed 16 people in the shopping centre on the afternoon of April 13, 2024.

Six people died of their injuries: Dawn Singleton, 25; Ashlee Good, 38; Jade Young, 47; Cheng Yixuan, 27; Pikria Darchia, 55; and Faraz Tahir, 30. A further 10 people were injured but survived.

“His attacks were a quintessential example of an active armed offender – rapid, unpredictable and fatal within a very short period of time,” NSW Coroner Teresa O’Sullivan said, handing down her findings with 23 recommendations on Thursday.

O’Sullivan praised Scott, who had raced into the centre alone. The hero officer told the inquest she had resigned herself to death and found Cauchi on a pedestrian footbridge on an upper level.

Cauchi charged at Scott with a military knife in hand and she shot him dead. Her actions undoubtedly prevented more deaths, the coroner said.

“Her actions were extraordinary, calm, skilful and courageous – actions which clearly saved lives.”

Scott was diagnosed with breast cancer last year. Her condition was made public over the Christmas break and triggered a massive outpouring of support and donations from a country indebted to the inspector.

Cauchi was profoundly psychotic after going off the medication for his chronic schizophrenia, the coroner said, and sleeping rough at Maroubra Beach before the attack.

His psychiatrist, Andrea Boros-Lavack, began weaning Cauchi off his anti-psychotics in 2019 after changing his diagnosis from “chronic schizophrenia” to “first-time psychosis”.

Cauchi relapsed into psychosis, and his mother, Michelle, tried to raise the alarm to Boros-Lavack seven times.

Boros-Lavack was told her patient was scrawling countless messages about “satanic control”, obsessing over pornography and showering compulsively.

“It was ultimately a major failing that she revised her view and did not do more to proactively urge Mr Cauchi to resume his medication,” O’Sullivan said on Thursday.

Even after the tragedy, the psychiatrist dismissed Michelle’s comments as “just an opinion of the mother”. In evidence, Boros-Lavack made bizarre claims about Cauchi’s mental state and motivation.

“That was nothing to do with psychosis. He couldn’t have organised himself to do what he did. I think it might have been due to his sexual frustration, pornography and hatred towards women,” she said.

O’Sullivan on Thursday recommended the Health Ombudsman of Queensland review Boros-Lavack’s treatment of Cauchi.

The coroner’s main recommendations were directed at a much larger failure – the underfunded and fractured mental health systems through which Cauchi slipped.

O’Sullivan recommended that the NSW government establish short-term accommodation in Sydney for people with mental illness and homelessness with on-site care and services.

She also urged the government to reverse the decline in outreach services which could have found and helped Cauchi.

“This impacts upon all of the community — first responders, the health system and the population at large,” O’Sullivan said.

O’Sullivan’s final recommendations were to consider bravery awards for people who confronted Cauchi during the rampage: Inspector Scott; Jade Young’s husband Noel McLaughlin; Frenchmen Damien Guerot and Silas Despreaux, known as the bollard men; and Good, who was fatally wounded while saving her baby.

McLaughlin on Thursday said he had shared two decades of life with Young, and her death “left a vast and permanent space, one that can’t be filled, only carried”.

“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,” he said.

Kerry Good, the father of Ashlee, laid blame at the feet of the staff and systems of the shopping centre. The inquest found one of the security control room operators was not fit to man the desk without supervision, and the emergency warnings had been unclear to shoppers.

“If they had done their job successfully, my daughter would still be alive today,” Good said.

Security guards Faraz Tahir, who died in the attack, and his colleague, Mohammed Taha, have both been recognised with security bravery awards already.

Tahir’s brothers, outside the court, said he would be remembered for sacrificing his life to save others.

The Royal Australian and New Zealand College of Psychiatrists accepted the recommendations, noting the findings highlighted “weaknesses… which are not isolated and represent sector-wide structural risks within the mental health system framework”.

“This tragedy has laid bare the critical fault lines in the mental health system. When provision or continuity of care in the public health system beaks down, the risks do not disappear – instead they accumulate with devastating consequences,” President Astha Tomar said.

Dr Pramudie Gunaratne, CEO of the Australian Society of Psychiatrists, said the findings reflected the severe gaps in the mental health system and what life was really like for people with severe and complex mental illness who slip through the cracks.

“I really hope that decision-makers are able to take these findings seriously and see this as a turning point for change in the system,” she said.

“All of us, we probably walk past people every day, outside train stations or in the main streets of cities, who might be psychotic. We have to do something as a community, as a nation, to turn things around, so that people who have severe and complex mental illness are not left to languish.”

Professor Jackie Curtis, executive director of Mindgardens Neuroscience Network, said the findings highlighted that “an individual clinician is often not sufficient to look after someone with schizophrenia and similar conditions”.

“We are going to need to look at the broader community mental health sector in NSW.”

NSW Premier Chris Minns on Thursday told parliament his government would consider all findings to “further strengthen our mental health system in the days, months and years ahead”.

He spoke about the bravery of Scott and Tahir, a refugee from Pakistan on his first day on the job, who “gave his life in defence of a complete stranger”.

“Also, a nurse who found safety within a shop asked to leave that place of refuge. She left that place of refuge because there were people outside that needed a hand,” Minns said.

“There was a French tradie known as ‘bollard man’, many of us who met him. He faced down the attacker so that other people could get out of the way and undoubtedly saved scores of lives.”

Minns said many of the paramedics and police dispatched to the stabbing were again deployed to the terror attack at Bondi Beach on December 14, 2025.

Mental Health Minister Rose Jackson said the Minns government had taken immediate action in the aftermath of the attack to strengthen community mental health supports and improve information sharing across all Australian jurisdictions, “but there is always more work to do”.

NSW Police Commissioner Mal Lanyon said all recommendations directed to the force would be considered.

“I also wish to thank the coroner for acknowledging what she described as the immense bravery and extraordinary courage of Inspector Amy Scott, as well as members of the public who provided assistance on that day,” he said in a statement.

The terror attack forced O’Sullivan to delay handing down her findings, which were scheduled for late last year.

“I had hoped that our community would not need to grapple again so soon with such a violent event and the devastating consequences wrought by it,” O’Sullivan said.

She said the stabbing inquest had led NSW Police and Ambulance to change how they work together in major crises – which appears to have saved lives during the terror attack.

The findings, which run over 800 pages, mark the end of the formal coronial process, but not of the grieving, O’Sullivan said.

Those were words echoed in a rare public statement by Cauchi’s parents, released this week, which offered condolences to all those who suffered from their son’s “terrible” actions.

“Mr and Mrs Cauchi also extend their thoughts to all families and other unpaid carers of people
experiencing mental ill-health, knowing they too are likely to have been affected by the incident and the ongoing coverage of it,” the statement reads.

“As Mr and Mrs Cauchi are also living with the ongoing complexities and grief of this tragedy, they ask all media to please respect their need for privacy and refrain from calling or visiting their home.”

Anyone needing support can contact Lifeline 13 11 14 and Kids Helpline 1800 55 1800.

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