Jade Young’s tearful husband hopes lessons learned through a probe into the death of his wife and five others during a mass stabbing will save lives in the future.

His 47-year-old wife was slain along with Dawn Singleton, 25, Ashlee Good, 38, Pikria Darchia, 55, Yixuan Cheng, 27, and security guard Faraz Tahir, 30, at Bondi Junction Westfield shopping centre in Sydney’s east in April 2024.

Ten others, including a nine-month-old baby, were injured by 40-year-old schizophrenic Joel Cauchi who was experiencing psychotic symptoms.

A coroner today released 23 recommendations directed to police, medical organisations and governments with the aim of preventing future tragedies.

Young’s husband Noel McLoughlin welcomed the chance to expose the gaps, missed opportunities and systematic failures that led to Cauchi’s mental health decline.

“These issues are not theoretical – they have consequences measured in human lives,” he told reporters.

“If these findings lead to changes that prevent even one family from experiencing what ours has endured, then this process will have meaning beyond our lives.”

Joel Cauchi, 40, carried out the deadly stabbing spree.© Supplied

Coroner Teresa O’Sullivan found Cauchi’s psychiatrist Andrea Boros-Lavack made the right choice taking him off his antipsychotics in 2019.

But she failed to follow up.

The doctor – who was treating Cauchi when he lived in Toowoomba, Queensland – made a “major failing” in not thinking his psychotic symptoms had deteriorated, the coroner said.

This was despite clear warning signs from his mother he was hearing voices and writing notes suggesting he believed he was under satanic control.

In her 831-page findings, O’Sullivan said Dr Boros-Lavack did not urge Cauchi to resume his medication.

NSW Police Inspector Amy Scott fatally shot Cauchi.© Supplied

She also failed to provide the 40-year-old’s treating GP with enough information when she discharged him from her care.

However, the coroner said these failings were not the sole cause of the mass stabbing, but were but one of a series of shortcomings.

O’Sullivan has referred Dr Baros-Lavack for a review by the Health Ombudsman of Queensland.

Other gaps flagged included the provision of housing for those with mental illnesses, education for police on spotting mental health red flags and the use of “wanding” to allow officers to search for knives.

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, who is now battling a cancer diagnosis, attended Lidcombe Coroners Court today.

O’Sullivan commended the officer for her “extraordinary, calm, skilful and courageous” actions which saved lives as she faced Cauchi alone.

It was not until two minutes after the 40-year-old was fatally shot by Inspector Scott the emergency evacuation alarm was activated.

O’Sullivan found the sole CCTV operator in the Westfield control room was not competent enough to handle the stressful situation.

She blamed management at security firms Scentre Group and subcontractor Glad, who should have been aware of the operator’s inexperience and taken steps to ensure better staffing.

Good’s father Kerry told reporters his daughter would still be alive if the shopping centre staff had done their jobs.

But the coroner said it would not have been realistically possible to inform the public through an alarm or announcement before Cauchi carried out his final murder.

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 improve these services.

The coroner recommended the government promote the “Escape, Hide, Tell” slogan to encourage civilians to remain safe when an armed offender was on the loose.