The inquest into the Bondi Junction Westfield stabbing attack has urged the government to house and care for mentally unwell people, 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.

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.

NSW Police Inspector Amy Scott, left, heroically faced and killed Joel Cauchi during the attack on her own. She was diagnosed with cancer last year.© Sam Mooy

“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 on Thursday.

Scott raced into the centre alone. She 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 saved lives, O’Sullivan 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 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.

Andrea Boros-Lavack, who treated Bondi Junction killer Joel Cauchi from 2012 to 2020.© A Current Affair

“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, however, 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.

Julie Singleton, mother of victim Dawn Singleton, arrives at the NSW Coroners Court in Lidcombe on Thursday.© Sam Mooy

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 fiancé Noel McLaughlin; Frenchmen Damien Guerot and Silas Despreaux, known as The Bollard Men; and Good, who was fatally wounded while saving her baby.

Musawar Ahmad Bashir and Muzafar Ahmad Tahir, the brothers of murdered security guard Faraz Tahir, arrive at the court.© Sam Mooy

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

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

Ivan (centre) and Elizabeth Young (right), parents of victim Jade Young.© Sam Mooy

“Mr and Mrs Cauchi hope the findings and recommendations of the Coronial Inquiry provide guidance on preventing any such similar event ever taking place.”

“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.”