3 weeks ago
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February 6, 2026 — 5:00am
The 2024 Bondi Junction stabbing murders horrified the nation, but the coronial inquest recommendations released on Thursday unveil inadequacies in the mental health system that have been lurking in the shadows for decades.
State coroner Theresa O’Sullivan pointedly recommended the need for new guidelines and policies in relation to the care and management of those suffering schizophrenia in NSW and Queensland, as well as short-term accommodation in the greater Sydney area for those experiencing mental health issues and homelessness.
The coroner recommended the NSW government, over the next 12 months, obtain advice about the decline of mental health outreach services and determine a “realistic timeline” to resource such services.
Among the 23 recommendations, she also referred the killer’s doctor to the Health Ombudsman of Queensland to review “failures” in her treatment, recommended bravery awards for the heroism displayed by police, victims and witnesses to the tragedy and gave a wake-up call to the media over the trauma caused by its coverage of mass casualty incidents.
Queenslander Joel Cauchi, 40, was shot dead by NSW Police Inspector Amy Scott six minutes after he began his rampage in the Bondi Junction Westfield shopping centre and stabbed 16 people on the afternoon of April 13, 2024. Six people died.
Cauchi had been treated by a Queensland psychiatrist Andrea Boros-Lavack between 2012 and 2021 for chronic schizophrenia. She weaned him off psychotic medication entirely and subsequently ignored family concerns on seven occasions that he had relapsed.
He was sleeping rough at Maroubra Beach before the attack.
Governments began closing large state-run psychiatric hospitals and in their place, community-based mental health services were intended to provide care within less restrictive and more humane environments. The de-institutionalisation of psychiatric care in the 1970s and 1980s was a profound shift in mental health policy. The intentions were admirable, but outcomes were often problematic – particularly for patients with chronic psychotic illnesses and severe functional impairments.
In retrospect, Cauchi’s rampage was a tragedy waiting to happen. But clearly there are many others waiting in the wings.
To that end, O’Sullivan said the Bondi Junction terror attack reinforced the need for an awareness campaign to better equip the public response to active armed offender events.
“I recommend that the NSW government actively promote, by way of an advertising campaign, the principles of ‘escape, hide, tell’, including by encouraging operators and owners of crowded places to disseminate the messaging among staff, retailers and attendees,” she said.
O’Sullivan said victims’ families who shared their experiences of the media coverage of the attack suggested some coverage “exacerbated” their trauma: she made recommendations to the Australian Press Council and the Australian Communications and Media Authority, which she hoped would inform future coverage of mass casualty incidents.
The massacre sends a clear signal.
De-institutionalisation remains a double-edged sword that rightfully ended many abuses and excesses, but also dismantled essential infrastructure for the care of individuals with the most disabling mental illnesses.
Governments must consider prioritising investment in long-term residential clinical and rehabilitation services to repair the mental health system.
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