The psychiatrist of a man who went on a shopping mall stabbing rampage in Sydney has been criticised for failing to act on warning signs that his mental health conditions were deteriorating.
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 in April 2024.
Ten others, including a nine-month-old baby, were injured by the 40-year-old schizophrenic, who was experiencing psychotic symptoms.
On Thursday, coroner Teresa O'Sullivan found that Cauchi's psychiatrist Andrea Boros-Lavack made the right choice in taking him off his antipsychotics in 2019 but she then failed to follow up.
The doctor made "major failings" in not thinking that Cauchi's psychotic symptoms had become worse.
This was despite clear warning signs from his mother that he was hearing voices and writing notes believing he was under satanic control.
In her 831-page findings, O'Sullivan said Boros-Lavack did not then urge Cauchi to resume his medication and failed to provide the 40-year-old's treating GP when enough information when she discharged him from her care.
However, the coroner said these failings were not the sole cause of the mass stabbing, saying they were but one of a series of shortcomings.
O'Sullivan will refer Baros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Cauchi.
The 40-year-old 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.
O'Sullivan commended the police officer for her brave actions in facing Cauchi alone.
"They were extraordinary, calm, skilful and courageous 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.
O'Sullivan found that the sole CCTV operator in the Westfield control room was not competent enough to handle the stressful situation.
She blamed management of security firms Scentre Group and subcontractor Glad who 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 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 was in the loose.
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