Latest news with #JoelCauchi
ABC News
a day ago
- Health
- ABC News
Why so many psychiatrists are quitting
Sam Hawley: Hi, just a warning before we begin this episode, we will be discussing suicide. ... There are so many stories of patients being left in emergency rooms for too long, of being admitted but then discharged too early or even being sent home without any care at all. As a result, in New South Wales, psychiatrists are quitting in droves, leaving a system they say is broken. And they're now speaking out amid fears it could lead to another Bondi Junction-style attack where innocent people are killed or injured. Today, Avani Dias on her investigation into a mental health system in desperate need of repair. I'm Sam Hawley on Gadigal land in Sydney. This is ABC News Daily. Avani, you've been investigating a crisis in mental health care in Australia's most populous state, of course, New South Wales, but this is really important for everyone across the country, right? Because if this sort of care is not available at a time of crisis, there can be really serious consequences. Avani Dias: Absolutely, Sam, and I think the first thing that pops into everyone's head is the Bondi Junction attack, which was just so devastating. And we've been hearing the inquest over the last couple of weeks and, you know, that just shows when there are gaps in the mental health system, there can just be such, such serious consequences. It's obviously worth noting that the Bondi Junction attacker, Joel Cauchi, had been treated in the Queensland public system until 2012, then by a private psychiatrist also in Queensland, and that was years before he moved to Sydney. But when I spoke to all these psychiatrists across New South Wales, they told me they saw the news breaking and they just got this pit in their stomach. They thought, oh, my goodness, is that my patient? And a lot of them actually told me they weren't surprised by this attack because of the just devastating conditions they're watching in the public mental health system. Sam Hawley: All right, well, as we said, of course, there's a real problem at the moment in New South Wales because this year alone, more than 60 psychiatrists have quit in protest over the state of the system. At least another 100 have actually threatened to resign their permanent roles. Now, tell me about Dr Suzy Goodison. She used to work at Sydney's largest hospital, RPA. Avani Dias: Yeah, so Dr Goodison resigned with all the other psychiatrists in January, and hearing her talk about the state of the system and what she had seen at her decade at RPA, it was really clear that she just felt what she called a moral injury. She felt she couldn't treat her patients properly. Dr Suzy Goodison, psychiatrist: I realised that I was burning out. Sorry. I just couldn't keep walking on by and pretending that this was normal and that we were delivering care that was adequate. Avani Dias: People were coming in for care and she spoke of these cases where she worked in the emergency department and she would actually say to people who were critically unwell that they should just go home because she thought the wait times that they would have to experience in the emergency department would actually make their conditions worse. Dr Suzy Goodison, psychiatrist: There were people who I remember being discharged and they'd be back in the emergency department the next day. It's pretty awful and demoralising and I think it wears you down and it felt hopeless at times. There were times when I thought, what am I actually doing for this patient? Avani Dias: And then she spoke about one of the last cases that she saw in January. It was this man who was living with schizophrenia and he had come into the hospital, he was looking for care. Dr Suzy Goodison, psychiatrist: And he came in to RPA, to the emergency department, with a nail gun and he had shot nails actually into his knees because the voices were telling him to do that. And so I immediately flagged that this man needed a significant amount of care. He needed a bed in an acute sort of mental health unit and that I was very concerned about him being in the general hospital. I then went off on a weekend and when I called on the Monday, he'd absconded from the ward, the hospital ward, and no-one knew where he was. He had no fixed address and I don't know what happened to him. Avani Dias: So could he still be out there in the community in that current state? Dr Suzy Goodison, psychiatrist: Yeah. Avani Dias: She was just really worried about the fact that some of these people who were so unwell, who needed treatment, weren't getting it in time and then they could be just out in the community. Dr Suzy Goodison, psychiatrist: These are the risks that we carry when we work in this field and when I can't deliver that care to keep either individuals safe or the community safe. And... Sorry. It's another Bondi Junction waiting to happen. Sam Hawley: How concerning. And you've also spoken to another psychiatrist, Avani, who quit the New South Wales health system this year. She had one word to describe what's going on and it is broken. Avani Dias: Yeah, it's a pretty big word, isn't it? And, I mean, it is really what we are witnessing, according to these doctors, medical staff, patients, is the collapse of mental health care in New South Wales in the public system. And, yeah, we spoke to this one psychiatrist, Dr Anu Kataria, and she has worked at Australia's largest mental health hospital, Cumberland Hospital, for 22 years and she also resigned with the other psychiatrist. But she echoed this really disturbing pattern that doctors have told us about, that she was told by bosses to discharge patients before it was safe to do so. Dr Anu Kataria, psychiatrist: We often would reach work and at half past eight in the morning get a text message saying, ED is backed up, Westmead ED is backed up, there's 15 people waiting, there's a dozen waiting at Blacktown and we're the overflow hospital for Blacktown Hospital as well. Please discharge. The expectation from senior administration, from the executives, is that I just get people out as soon as I can. Avani Dias: And we heard from a lot of people as well that that was their experience. They'd be dealing with these serious mental illnesses and then asked to leave and they felt they weren't ready. Sam Hawley: All right, well, we're going to unpack what is going so wrong in New South Wales, but before we do, Avani, what about mental health services across the country? Are they any better? Avani Dias: Well, the thing is that in New South Wales, the government is spending the lowest per capita in the country on mental health services. So it is really the bottom of the barrel when it comes to spending and that's why we decided to focus on New South Wales. But, yeah, a lot of the other states aren't far behind and we actually received the results of a landmark national survey by Beyond Blue and it revealed that rates of severe mental illness in Australia are rising. So now four and a half million Australians are experiencing a serious mental health challenge, but more than half of them aren't getting the help they need when they need it. And so that just shows you that this is a national problem, but New South Wales really is struggling the most when it comes to these services. Sam Hawley: Well, Avani, as you went about your investigation, you not only spoke to psychiatrists, of course, but you wanted to hear from people who'd had experiences trying to get help in the New South Wales system and you had a really big response, didn't you? Avani Dias: That's right. We asked our audience at Four Corners to tell us their stories about getting help for a serious mental illness in New South Wales and the response was overwhelming. There was one case that really stood out to me and that was the case of Carly Richardson. She's 20, she's had depression, she has PTSD, she's been in and out of the mental health system since she was 13, so super little and she's still dealing with these severe mental illnesses. And she actually self-harmed around New Year's and she actually went to hospital to try and get help but was discharged early. Carly Richardson, former patient: I had a suicide attempt in the ward and I was saying, like, look, I'm not OK, you know, like nothing had changed for me. And they said to me, they're like, we can't do anything because the beds everywhere were full. So they just had to send me home, essentially. Once I got out, I didn't even make it home before I was sectioned again by six police officers and brought back to the emergency department after trying to harm myself again. And once again, I was, like, sent home just 10 hours later. Avani Dias: She was just really worried about the lack of help out there for someone who was in such a severe state like she was. Sam Hawley: And you've heard a lot about safety in emergency departments. Avani Dias: That's right. And, you know, this starts from a kind of earlier position because we were leaked a whole series of wait times at one of Australia's busiest emergency departments, Sydney's Westmead Hospital. And this came from inside sources who told us people were waiting four days in one case in emergency to get treatment for a serious mental illness. So that was a man with schizoaffective disorder and he waited 93 hours. We had another case in that month where two men had been waiting more than 80 hours to be seen. There are so many different examples like this. That leads to agitation, frustration and anger. And so doctors are telling us that it then exacerbates this mental illness and what they're seeing then is people lashing out, acting violently, and then frontline staff are the ones that are actually dealing with that. We spoke to one security guard at Sydney's Westmead Hospital. He actually got stabbed by a mental health patient who had been waiting for hours. Sam Hawley: So, Avani, what do the psychiatrists say is needed to fix the system? At the heart of their dispute is pay, isn't it? What do they want? Avani Dias: There's been months and months of negotiations with New South Wales psychiatrists who are saying they want a 25% pay increase. And they're saying it's not because we want more money necessarily, it's because they need a solution to actually retain staff in the system. They're finding that staff are either moving interstate or they're going to the private system where they can make a lot more money. The government, on the other hand, has said, look, doctors already make a lot of money, they don't need this pay rise. And so now they're deadlocked and they've gone to the workplace disputes referee to kind of nut this out and that's still ongoing, the Industrial Relations Commission. Sam Hawley: What has the state government had to say then? Can it actually meet this pay demand? Avani Dias: Well, the New South Wales Mental Health Minister, Rose Jackson, she declined our requests for an interview, but she has in the past said that the government needs to think about the overall state budget, that it can't necessarily afford this sort of pay rise and that the government's gone back with this counter offer of 10.5% over three years. Rose Jackson, NSW Mental Health Minister: Their solution to this challenge is a 25% wage increase in a single year. That's not something the government is able to agree to. We have to think about the broad, not just mental health system, but overall state budget. Avani Dias: And what was really surprising was that, despite the minister not talking to me, we did hear from the state's chief psychiatrist. His name's Dr Murray Wright and he's the most senior advisor on mental health to the government, so he's a bureaucrat in the department as well and he said he actually supports this 25% pay rise. So that's contrary to the government. Chief Psychiatrist Dr Murray Wright: I am sympathetic to the issues that they raise and I think in particular the disparity in wages between New South Wales and other states. Avani Dias: So are you supportive of that pay rise? Chief Psychiatrist Dr Murray Wright: Yes. Avani Dias: But what the psychiatrist is saying is it's not just about this pay rise, it's a much bigger issue. There's a lot more that needs to be fixed and that comes down to under-resourcing and so there's a push for the government to do more there as well. Sam Hawley: So, Avani, what is the way out of this then? Why would psychiatrists want to work in a sector if it is indeed broken and the sector needs more psychiatrists, clearly? Avani Dias: Oh, the sector is desperate for more psychiatrists. We're seeing job ads coming out saying if we don't hire someone soon, this ward will have to close. Oh, my gosh. Wards are just shutting down continuously just because there aren't enough psychiatrists and that means as a patient, if you're trying to get help, you're just not going to get it. The New South Wales government has admitted to us that the system needs improvement, that it needs reform. It said it is investing $2.9 billion in mental health services and it's saying that if you do need help, you should seek it because there are services there. I guess the question is what can people do in the meantime as they wait for this system to be repaired? Sam Hawley: Avani Dias is a reporter with Four Corners. You can watch her full report tonight on ABC TV at 8.30 or on iView. If this episode has raised any issues for you or anyone you know, Lifeline is one service that can help. Contact them on 13 11 14. This episode was produced by Sydney Pead. Audio production by Adair Sheppherd. Our supervising producer is David Coady. I'm Sam Hawley. Thanks for listening.
ABC News
2 days ago
- Health
- ABC News
How Bondi Junction killer fell 'through the cracks' of mental health system
For the first time in almost 14 years Joel Cauchi was not taking any anti-psychotic medication. He was living independently of his parents and was studying and had ambitions of becoming a Chinese language interpreter. It was June of 2019. Cauchi had stopped taking any psychotropic medication and his then psychiatrist said his personality was emerging. But, by April 13, 2024 the man who had discovered life, free from the side effects of that medication, was "floridly psychotic", Counsel Assisting the Coroner Peggy Dwyer SC told the inquest into the Bondi Junction stabbings. Arming himself with a knife, 40-year-old Cauchi entered the Westfield Bondi Junction shopping centre, in Sydney's east, and stabbed six people dead, injuring another 10 during his horrific rampage, before being shot dead by a police officer. For the past five weeks the New South Wales Coroner, Teresa O'Sullivan, has presided over an emotional inquest into the tragedy, seeking to uncover failings and shortcomings that led to the day that forever changed so many lives. She will consider how Cauchi fell "through the cracks" of the mental health system, as the inquest heard, effectively becoming "lost to the system". And whether medical professionals and police did enough to prevent it. The inquest heard at length from Cauchi's treating doctors, specialists and nurses. He was born on June 13, 1983 and his family first noticed behavioural changes when he was about 14. He was living in his home town of Toowoomba, an inland city west of Brisbane. At 17, he was admitted to the Toowoomba Hospital where he stayed for almost a month. He told doctors that he had hallucinations, reported seeing and feeling demons entering his body, feeling as though his movements were controlled and that people were inserting thoughts in his mind. The initial diagnosis was paranoid psychosis and schizophreniform disorder, a mental health condition similar to schizophrenia but lasting less than six months. Six months later, he was diagnosed with schizophrenia. For almost 14 years, Cauchi was medicated on the drug Clozapine – an anti-psychotic medication only prescribed when two other forms of medication fail to manage symptoms of psychosis. Between 2012 and 2015, a decision was made, between Cauchi's then treating psychiatrist Andrea Boros-Lavack, himself and his family, to slowly reduce his Clozapine dose. In early 2016, Dr Boros-Lavack made a note: "Joel was becoming more animated, talkative, and getting in touch with his emotions in a good way. He was appreciating the opportunity to feel this way with reducing the dose of Clopine [a brand name for Clozapine]." "There were no negative effects so far. Spoke about the goal of becoming a Chinese language interpreter then marrying a nice girl, buying a house and working, and to work and live well." Cauchi himself, the doctor said, was very involved in the process of reducing the powerful drug and was "frightened of relapse". By mid-2018, he had ceased Clozapine but remained on a second drug, called Abilify, which then also ceased in June 2019. Cauchi moved out of home and was living independently, in a unit not far from his family home. He had progressed, according to Dr Boros-Lavack, from an inability to even make a cup of tea, to making two-minute soup. It was, in her words, a "milestone". Dr Boros-Lavack said she wanted to keep Cauchi in psychiatric care "for the rest of his life". By November 2019, Cauchi emailed Dr Boros-Lavack's clinic, seeking "ideas for a porn-free phone and other devices". He was expressing concerns about his excessive use of pornography and related insomnia. The same month, Cauchi's mother Michele called the clinic to say that her son was "very unwell" since coming off the medication and would like him reviewed. Michele Cauchi also emailed the clinic that month, telling them of a gradual decline in her son's condition since ceasing the medication. She said he was leaving notes on paper around the place and she believed he may be hearing voices. His obsessive-compulsive disorder, she said, was getting out of hand and that he was going through half a cake of soap in one shower. "He found out last week the place where he volunteers teaching English put someone new on and he'd been hoping to get a job there, so that was a real blow," Mrs Cauchi said. "I would hate to see him have to go back into hospital after 20 years of being stable on medication. But of course, being off it has made him realise how sedating it was … he quite possibly won't let on what is going on in his head, but I think you need to know how he is." Mrs Cauchi had read some of the notes left by her son. They referred to "under satanic control" and religious themes. A decision was made to recommence the drug Abilify, in a low dose. Dr Boros-Lavack was fearful it was early warning signs of a relapse of schizophrenia. Cauchi didn't take the medication. In an exchange with Dr Dwyer, Dr Boros-Lavack maintained she did not believe Cauchi was psychotic at that time of his mother's concerns. In fact, she said, he had been fearful of having contracted HIV after a sexual encounter and had gone to hospital to get antiviral drugs. "It wasn't the psychosis. It wasn't even early warning signs of relapse. It was based on his fear of STD. It was based on his sexual frustration, what he told us later on, about prostitutes and women and sex," Dr Boros-Lavack told the inquest. Her last face-to-face appointment with Cauchi was January 8, 2020. Dr Dwyer put to her that she must have suspected at that time that there might be symptoms of psychosis, given what had been reported by his mum and conflict at home. Dr Boros-Lavack's answer was unequivocal: "I was absolutely sure that he wasn't psychotic and that early warning signs of relapse was a false alarm. It was not psychotically driven." A month later, Cauchi's mother again rang the clinic, expressing concern that his self-care was poor, his place was a mess, he was isolated and irritable and swearing. A panel of five psychiatrists, called by the court to provide opinions on Cauchi's mental health treatment, agreed it was "reasonable" for Dr Boros-Lavack to reduce Cauchi's dose of Clozapine in order to find an "optimal dose" that would minimise unpleasant side effects of the drug. But one of the psychiatrists, Edward Heffernan, said he counted nine occasions that were of concern – relating to insomnia, his mother suspecting symptoms, a change in behaviour and satanic control. "To me, this flags we are probably having a psychotic episode here," Professor Heffernan said. Merete Nordentoft, a leading Danish psychiatrist, said the concerns were not taken seriously enough and described this period as a "missed opportunity" to put Cauchi back on anti-psychotic medication. In her opening address, Dr Dwyer said the inquest would review Cauchi's mental health treatment, where he was effectively without treatment and without adequate supervision for nearly five years before the Bondi killings. "We know from the evidence in the brief that Mr Cauchi had several interactions with Queensland police officers, including most notably in January 2023 where Queensland Police were called to Mr Cauchi's family home [in Toowoomba] following an incident where his father had confiscated a number of knives that were a similar style to that used by Mr Cauchi on April 13, 2024," Dr Dwyer said. "Mr Cauchi's father was worried about him having those knives, and the court will explore whether that was an opportunity missed for intervention by police, which may have resulted in Mr Cauchi being re-engaged with the mental health system at that time." By April 2024, Cauchi had been unmedicated for almost five years and was homeless in Sydney, where he had moved. "He had no consistent or formal engagement with the mental health system, or the health system more generally, and he was effectively lost to follow-up, the consequences of which were the catastrophic events of 13 April," Dr Dwyer said. "How that happened, and what could have been done differently, are key issues in this inquest." The inquest has now adjourned until October, when submissions will be heard ahead of coronial recommendations.
The Guardian
2 days ago
- Health
- The Guardian
Cauchi's mass murders put harsh spotlight on failings of mental health and police systems
Joel Cauchi's mother didn't appear before the coronial inquest examining her son's life and the day her son murdered six people at a popular Bondi Junction shopping centre. But her presence was often felt, taking shape in the form of notes she had written to his doctor or in a conversation with a police officer. One of the most striking moments of the inquest was when Michele Cauchi, now in her mid-70s, was filmed via body-worn video camera on a police officer. She was standing outside her tidy home next to blooming hydrangeas, explaining how her son – who spoke multiple languages and had a university degree – had been deteriorating since he stopped taking medication. 'I don't know how we're going to get him treatment unless he does something drastic,' she says. These moments painted a picture of a mother engaging in a Sisyphean struggle to get her son – then living with untreated schizophrenia – help. But she could keep pushing only so far. Person after person who gave painful evidence at the five-week inquest told a similar story of doing their best in a 'fallible system'. It crystallised into a key takeaway: the system is letting down people in a crisis, like Cauchi. Cauchi's attack and the severity of it was a rare occurrence. But the system's failure to pick up on his slide after he stopped taking his medication for treatment-resistant schizophrenia is sadly a familiar story. Psychiatrists who appeared as experts before the inquest said the vision when mental health asylums in Australia were dismantled in the 1970s was for community services to instead support those people in need. But Queensland psychiatrist Prof Edward Heffernan told the inquiry the planned funding for community services 'never really followed' the shift. Psychiatrists also told the inquest that services hadn't kept pace with population growth. Meanwhile, psychological distress was increasing across the population, and patterns of substance abuse and other modern stressors had made things worse. Ian Korbel, a psychiatrist not part of the inquest, tells Guardian Australia he once worked in a mental health outreach team that would respond to people in crisis. But that program stopped running in the mid-2000s. Korbel says the team that worked in Sydney's eastern suburbs used to check the beaches for people experiencing homelessness. Cauchi was reportedly sleeping rough there before the attack. Korbel says the faltering of services has resulted in the buck passing to police and the justice system. 'They're in the punishment business,' he says. 'They shouldn't respond to this, but the health system isn't resourced to respond to it.' Police are increasingly responding to such crises. The inquest heard that in New South Wales, police responded to 40% more mental health incidents in 2022 compared with four years earlier. Sen Sgt Tracey Morris told the inquiry: 'We will always look at [those incidents] from a policing lens. That may lead to charges and them going through the court system when [it's] effectively because of the mental illness.' Morris works as the mental health intervention coordinator in the Queensland police district where Cauchi's parents live, in Darling Downs. The day Cauchi's mother spoke to police, they referred Joel to her role – which helps people link in with health services – for a follow-up check. But the officer acting in her role while she was on leave missed the email. This moment to get Cauchi help was described by a psychiatrist at the inquest as a 'missed opportunity'. Fighting back tears, Morris told the court this was no reflection on that officer's capability, but a direct consequence of under-resourcing. At least four people should be doing her job in that particular police district, she said. One of the cruelest ironies of that under-resourcing issue came during the inquest in a blink-and-you-might-have-missed it-moment, where Morris said no one was covering her role while she was at the inquest for the week. She couldn't find anyone to backfill it. Matthew Morgan, an expert in policing mental health responses who lectures at the Australian Catholic University, says: 'The only people really to blame here is the government. If they're not going to invest in a proactive and responsive mental health system that can provide the community around-the-clock care … then the buck stops with them.' A recent report Morgan co-authored analysed Queensland coronial inquests into people fatally shot by police while experiencing a mental illness. Twenty-four people have been fatally shot in the state since 2008. There is a clear patten, he says. 'The state has really just failed them. 'There's just lots of patterns of sporadic treatment, lack of follow-up care, and then the police get blamed for their criminalising and sometimes lethal response to such situations.' The inquest heard there had been multiple improvements in crisis response since police spoke to Cauchi and his mother in January 2023. Police can connect with health professionals to get advice on incidents, and there are co-response models where healthcare workers respond to call-outs alongside police. Those changes – as Peggy Dwyer, counsel assisting the coroner, pointed out in the inquest – have come after multiple inquiries, internal police and government reports and coronial inquests. All make a similar recommendation: health professionals should respond to mental health crises, not police – at least not alone. Joining calls for this change are families whose loved ones have been shot dead by police while they were suffering a psychosis. One of the loudest recent voices has been Judy Deacon, the mother of Jesse, who police shot dead in Glebe in 2023 after reports he was self-harming. But co-responder models have not been rolled out nationwide, despite recommendations to do so. The leading model in NSW, known as Pacer, operates in just 20 of NSW's 57 police commands. During the inquest, Dwyer asked Dr Brendan Flynn, the executive director of the mental health branch of NSW Health: 'Why has there not been an expanded Pacer across NSW where sufficient demand is demonstrated, when this report came out almost four years ago?' Flynn responded: 'It's a resourcing issue. It would require new funds, and that's a matter primarily for government.' Later Dwyer asked: 'Is there a risk that we just then get stuck here for another four years where there's no rollout of more supports?' Flynn replied: 'I hope very much that's not the case.' Even if a version of Pacer were rolled out across NSW, Korbel says, more work needs to be done. 'Nowhere in Australia do we fund mental health as we should,' he says. 'NSW is the worst. It gives 5% of its health budget to mental health.' Korbel says that figure 'would need to be doubled at least' to match similar programs in countries such as England and Canada. Investment in health services can save money in the long term. Prof Olav Nielssen, a Sydney-based psychiatrist who appeared before the inquest, spoke about a supported housing charity he works at. It supports people revolving between hospital, prison and the homeless sector. He estimated the cost of having people in supported housing was a tenth of what it would otherwise cost having them bouncing around a network of hospitals, prisons and other institutions. He said NSW had 'plans' to have 70 of these beds but that there should be 1,000 to meet the need. Elizabeth Young, the mother of Jade Young, a victim of the stabbings, appeared before the inquest and described her 47-year-old daughter's murder as the 'stuff of nightmares'. She also described it as the result of 'years of neglect' within the mental health system. 'It seems to me that my daughter and five others were killed by the cumulative failures of numbers of people within a whole series of fallible systems.' In Australia, the crisis support service Lifeline is 13 11 14. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@ or jo@ In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on or text HOME to 741741 to connect with a crisis counselor. Other international helplines can be found at
News.com.au
3 days ago
- Health
- News.com.au
Confusion and chaos: Key failings in the Westfield Bondi Junction attack revealed
Warning: Distressing content. People walked through the popular shopping centre with ease, there was nothing to suggest to them their afternoon would amount to anything other than the regular autumn day it should have been. Some were pushing prams, others running mindless errands. As shoppers began to run through the Westfield Bondi Junction, it was easy to brush the behaviour off. No one yelled as one woman, known as Witness I, saw people running towards her: she thought they were just being 'silly'. It was only after she 'felt an intense thud in her back' that she turned to see a man walking away with a knife, the large blade reminding her of the Crocodile Dundee movie. She placed her hand on her back and saw blood on her hand as she realised she had been stabbed. There had been nothing to alert her that the 'floridly psychotic' Joel Cauchi was in the midst of a deadly rampage, stabbing 16 people in less than three minutes. Witness I was his 13th victim, and as quickly as he'd stabbed her, he was onto the next victim. Another woman saw Cauchi approaching from the same way she'd seen people run from, less than a minute after Witness I was stabbed. 'Why is everyone running?' she asked him, before he stabbed her in the chest. Once inside the shelter of a nearby store the woman, known as Witness X, called her mum, believing 'she was going to die'. Cauchi's last victim, Liya Barko, saw the killer 'veer' her way and 'immediately felt a hot pain'. Realising she'd been stabbed, she believed Cauchi told her 'Catch you' before running away. Witness I, Witness X, Ms Barko and seven other victims survived the attack. Dawn Singleton, Yixuan Cheng, Faraz Ahmed Tahir, Ashlee Good, Jade Young and Pikria Darchia were all killed, tearing apart the lives of their loved ones, some of whom described their grief as 'bone deep, soul crushing agony' that follows them 'like a shadow'. CCTV showed Ms Cheng walking through the centre on her phone, 'oblivious' to what was unfolding, before she was killed. The sheer speed at which the attack unfolded left many in the centre unaware of what was happening: 'bollard men' Silas Despreaux and Damien Guerot told an inquest into the attack they ushered a woman, unaware of Cauchi lurking below, off an escalator before they threw bollards at the knife-wielding killer. Even security staff weren't entirely sure what was going on, with footage showing a security supervisor running towards a danger he had scarce information on. Through tears, he told the court he'd seen 'people on the ground' and had radioed to ask where the attacker was. When Inspector Amy Scott shot Cauchi at 3.38pm, the supervisor – like many in the centre – didn't know they were police shots, instead thinking he was being shot at. Fifty witnesses were called to give evidence to a five-week coronial inquest into the tragedy, many breaking down and crying in the witness box as they relived the horrors of April 13, 2024. The bar table and media room weren't spared from the tears, with tissue boxes placed throughout the building as the inquest concluded on Thursday. Red flags, missed opportunities The evidence painted a picture of confusion, missed opportunities and red flags in the care of Cauchi as well as the responses of emergency services and the centre's operator. This included a psychiatrist, known as Dr C, who deemed Cauchi fit for a weapons license in January 2021. This is despite Cauchi telling Dr C he'd only been on clozapine for two years, when in fact he'd been on the antipsychotic drug for nearly two decades to treat schizophrenia before he was gradually weaned off it. Dr C only discovered this after contacting Cauchi's former Toowoomba psychiatry clinic, and agreed with counsel assisting the coroner Emma Sullivan this was a 'red flag': he acknowledged he shouldn't have deemed him fit for the license. Counsel assisting the coroner Peggy Dwyer SC said it was 'very fortunate' Cauchi didn't follow through with a gun license after the Queensland Police Force issued him a statement of eligibility. Mum's concerns 'not taken seriously enough' An expert psychiatric conclave pored over evidence of the mental health care Cauchi received, with Denmark psychiatrist Professor Merete Nordentoft telling the court concerns raised by his mother of a deterioration in his mental state were 'not taken seriously enough'. Diagnosed with schizophrenia in 2001, Cauchi's dose of the antipsychotic, clozapine, was gradually titrated down by his private Toowoomba psychiatrist, Dr Andrea Boros-Lavak, over complaints of over-sedation. He was entirely weaned off it in 2018, and was taken off the drug prescribed for his obsessive compulsive disorder (Abilify) the following year. Shortly after his Abilify was stopped, Cauchi's mother, Michele raised concerns with Dr Boros-Lavak's clinic seven times between November 2019 and February 2020, ringing them, sending emails, and visiting in person to report a potential relapse. She reported her son may have been hearing voices, was leaving notes he was under 'satanic control', and his OCD was 'getting out of control'. Dr Boros-Lavak prescribed him Abilify in November 2019 as a precaution, but said in hindsight it wasn't necessary, chalking the symptoms up to concern over a risky sexual encounter he'd had. He did not fill the script. Dr Boros-Lavack told the court 'Michele is a beautiful, beautiful mother, but she is not a psychiatrist'. The psychiatrist discharged him from her care to a GP when Cauchi moved to Brisbane in March 2020: the referral letter was the subject of scrutiny for failing to mention Mrs Cauchi's concerns. Her concerns were also not mentioned in any further correspondence with other practitioners caring for Joel, including Dr C. Dr Boros-Lavack's lawyer at one stage lifted a massive binder before the court and questioned the likelihood of practitioners actually reading a referral containing a patient's entire medical history. The expert psychiatric panel ultimately agreed Dr Boros-Lavack's care did meet the accepted standards for private psychiatrists during that period, but there were 'shortcomings' in her handover. Cops' 'missed opportunity' year before attack Years later in 2023 Cauchi called police to his family's Toowoomba home, with body-worn video of the attending police officers revealing Cauchi had assaulted his father in a 'rage' after he confiscated his pigging knives. One of the officers said Cauchi had a 'real hard on for his knives' during the call out. Mrs Cauchi again expressed she was worried about her son, telling the officers she was unsure how to get him help 'unless he does something drastic'. Under the belief they had no powers to force Cauchi for an urgent assessment due to 'confusing' changes to the Emergency Examination Authority (EEA) criteria, the officers requested a follow-up for the Cauchi family. In what was agreed as an 'oversight' and 'missed opportunity', the email — like Cauchi — slipped through cracks and was missed, despite the court being told evidence painted a 'clear picture' he needed an emergency examination at some point in time. A better system for follow-up has since been put in place. By 2024, Cauchi was making notes on his phone to 'Call knife sharpener and confirm it doesn't need sharpening for mall use' and to 'Check out malls and also where to run'. Chillingly, he made searches related to the 1999 Columbine shooting in the US on the morning of the fatal attack. Evidence suggested Cauchi was a 'totally different' person while he was medicated. Control room operator not 'up to speed' The CCTV control room was unmonitored as Cauchi began his deadly rampage, as the operator, known as CR1, had gone to the bathroom just 40 seconds prior. Her colleague, CR2, was also out of the room, having been pulled out for training. International security expert Scott Wilson told the court CR1 obviously wasn't 'up to speed' in her role, with the court earlier told she was on the verge of being replaced and had been flagged for 'ongoing issues' on multiple occasions: retraining needed to be scheduled as she was responding too slow, notes made days before the attack stated. Former Glad Group project and training manager Andrew David denied suggestions he was directed to 'rush' CR1's training due to staffing pressures, telling the court 'there was pressure … I hope that didn't affect my training'. The delay in activating public announcements, alarms and messaging through the centre was also identified as an issue, with it accepted all actions should have been rolled out earlier and should have encouraged people to 'escape, hide, tell' rather than evacuate. A suite of measures have since been put in place at the centre, including an automated PA system. Confusion over whether the centre was a 'hot zone', and if there was a second offender, also highlighted the need for improved interagency communications between NSW Police and Ambulance. Crucially, it was generally accepted decisions made on the day of the attack didn't affect anyone's survivability, however it's important to learn for any future mass casualty event. Many families slammed the media's reporting of the tragedy, including Ms Young's mother, who was sickened at the suggestion some of the footage aired of her daughter and grieving family after the attack was newsworthy. Ms Singleton's mother, Julie, and fiance, Ashley Wildey, both reported they were upset to find Ms Singleton had been identified in media reports before they were allowed to formally identify her, with the mother 'still hoping at this point there had been some kind of horrible mistake'. She slammed reporters requesting comment, including by leaving notes in her mailbox, as 'intrusive', while Mr Wildey said the reporting of the attack caused 'immense and immeasurable pain' to his and Ms Singleton's families. Families of the victims specifically requested the media response, and the impact this had on them, be examined during the inquest. Tensions in court prompted gasps Bubbling tensions were brought to the surface over the five weeks, including one moment where Ms Sullivan reminded Mr David he was under oath during questions about CR1's training. The court was shown CR1's training competency checklist: each section was signed off and dated at January 31, 2024, which was in stark contrast to another checklist which showed sections signed off on different dates. Accepting he had signed off on CR1's training, he simultaneously denied any recollection of it, prompting Ms Sullivan to ask if he was doing his 'very best'. She told him 'there are families in court who would really like some answers'. Even NSW coroner Teresa O'Sullivan interjected, asking him if he knew at all what he was doing on the day in question. 'From the look of this document that you've signed, it looks like everything happened on 31 January 2024, which you say is impossible to have done that much training,' Ms O'Sullivan said. 'The reason we're asking is it's troubling to see this without an explanation from you … I take it that you're doing your very best to try and remember how it came to be that your signature is on this document?' Ms O'Sullivan pressed. Mr David maintained he couldn't recall despite doing his best, and later told the court he didn't remember issues with CR1's performance being raised with him. 'That's your evidence on oath?' Ms Sullivan asked. He agreed. The court was told CR1's training could have been undertaken over a period of time, and simply signed off all at once. Cauchi's psychiatrist also sparked a collective gasp from the room of journalists when she claimed his attack had 'nothing to do with psychosis'. 'I think it might have been due to his frustration, sexual frustration, pornography, and hatred towards women,' Dr Boros-Lavack told the court. Almost equally shocking was Dr Dwyer's subsequent suggestion that Dr Boros-Lavack's refusal to accept Cauchi was psychotic on April 13 was 'because you don't want to accept yourself the failings in your care of Joel?' 'I did not fail in my care of Joel, and I refuse. I, I have no error on my behalf. That is my answer.' She withdrew the comment, branding it 'conjecture' the following day when questioned by lawyer Sue Chrysanthou SC, who represented the Good, Singleton and Young families. Through her evidence, Dr Boros-Lavack was constantly asked to please listen to the question and not to interject.
The Guardian
3 days ago
- Health
- The Guardian
‘I hurt so terribly': after weeks of detail, Bondi Junction inquest ends with reminder of families' anguish
Elizabeth Young has had her daughter's Chinese name, Meh Yuk, tattooed onto her left arm. 'Beautiful Jade, the name her grandparents gave her,' the heartbroken mother told the New South Wales coroner's court on Thursday, sitting close by her dog, Teddy, in the witness box. Jade Young, 47, was killed by Joel Cauchi in Sydney's Westfield Bondi Junction on 13 April 2024. The architect had been shopping with her daughter. Elizabeth's was the first family statement made on the final day of the coronial inquest into the shopping centre stabbing rampage that claimed six lives. It ended only when Cauchi, who had schizophrenia, was shot and killed by police inspector Amy Scott. Over 20 hearing days, the inquest heard from 50 witnesses. The brief contained 51 volumes and 8,000 witness statements over 40,000 pages. On the final morning, throughout the packed courtroom, overflow court and media room of the Lidcombe courts complex, boxes of tissues had been placed within easy reach. Unlike the 'carefully measured objectivity' of the court proceedings, Elizabeth said, her words were a 'distillation and a manifestation of anguish'. 'I hurt so terribly that our lovely, loving, clever, compassionate, thoughtful, slightly goofy, funny, gentle girl no longer has the chance to be, to exist in the now,' she said, flanked by her husband, Ivan, son, Peter, and son-in-law, Noel McLaughlin. 'The moment he casually plunged that blade into Jade, our ordinary lives were shattered. I remember too easily, too often, with instant, nightmarish recall … that she is dead. 'I long for her.' Over the five weeks of the inquest, much has been said about the minutiae of active armed offender incidents, security protocols, emergency responses and the erstwhile medication regimen of a man who killed and injured 16 people in the 'floridly psychotic' last five minutes of his life. This week, state coroner Teresa O'Sullivan heard a side of the day's horrors that had so far remained largely out of sight, as, one by one, the family and loved ones of the murdered had their say. The parents of Yixuan Cheng, 27, described their grief as a 'piercing, bone-deep, soul crushing agony that is beyond description, that follows you like a shadow'. In a statement read in court by their barrister, Daniel Roff, Jun Xing and Pengfei Cheng described losing their only child, who had been 'thriving' as a student in Sydney. The last time they saw her was the month before her death. 'Yixuan was the treasure of our lives … We aged overnight, our hair turned grey. We never had the chance to tell her that being her mother and father were the greatest gifts life gave us.' Sign up for Guardian Australia's breaking news email Roff fought back tears as he read, as did barrister Sue Chrysanthou SC, who read statements from the family of 38-year-old Ashlee Good. Muzafar Ahmad Tahir, the brother of Faraz Tahir, 30, told the court that Australia had given his brother a 'sense of security'. 'None of us could have imagined that such a tragedy would befall him.' The Pakistani citizen was on duty as a security guard inside Westfield Bondi Junction at the time of the attack. 'He will always be remembered as a symbol of bravery,' his brother said, adding that it was a moment of immense pride when the prime minister, Anthony Albanese, called Faraz a 'national hero'. George Darchia, the son of Pikria Darchia, 55, said in a statement read out in court that his mother's loss was accompanied by 'something deeper' than regret he had not been with her. His brother, Irakli Dvali, said of the way his mother 'left this world … it breaks me'. Cauchi's family was invited to give a statement to the inquest, but did not. Thursday's remarkable testimony closed an intensely studied and poignant inquest, punctuated by startling moments. In the first week, vision displayed in court of Scott's one-minute chase and shooting of Cauchi showed her calm and control. In a compilation of CCTV and 3D reconstructions released by the court, Scott, flanked by two French bystanders and a security guard – but without a police partner or bulletproof vest – can be seen walking up an escalator, pursuing Cauchi on foot. She was nauseous, she told the court, because 'I had resigned myself to the fact that I was probably going to die'. Sign up to Breaking News Australia Get the most important news as it breaks after newsletter promotion When Cauchi stopped, Scott stopped. Not wanting to shout within his earshot, she used silent signals to direct a woman with a pram – hiding near a large pot plant – to run. The officer then called out 'mate' to get Cauchi's attention. When he started to sprint towards her, she fired her gun three times. Two bullets hit him; one was later found in the pot plant. Scott's actions, the court heard, were 'absolutely perfect'. Westfield's security was heavily scrutinised throughout the inquest. The centre's CCTV control room – containing 954 camera views – was unstaffed for nearly the first two minutes of Cauchi's spree because its sole security room operator was using the bathroom. The controller's response when she returned was criticised during the inquest by UK security expert Scott Wilson as 'inadequate'. The court heard that paramedics' ballistic PPE was not easy to access, and that the Westfield centre was then designated a 'hot zone' by NSW Ambulance – meaning paramedics were not allowed to enterbecause of the risk of a second active armed offender, despite police already having determined Cauchi acted alone. Ultimately however, the inquest heard, the hot zone restrictions made no clinical impact that day. The lack of preparedness on some levels was perhaps a symptom of a more positive aspect of Australian life: the country is not a regular site of mass casualty events. Sydney's last major fatal active armed offender incident – the Lindt cafe siege in 2014, in which three people, including the attacker, died – was referenced several times in the inquest. Experts told the court the 'escape, hide, tell' safety mantra for terrorist attacks was not as well-known in Australia as in the UK. In court, Queensland police admitted to having missed an opportunity for intervention in 2023 when responding to Cauchi's allegations his father had stolen his knives. An email sent from one of the officers that day requested follow-up, the inquest heard, which an under-resourced mental health intervention coordinator then forgot to act on. How Cauchi came to be unmedicated for the last five years of his life was a key question for the coroner. Cauchi's mother, Michele, had raised concerns on at least seven occasions about possible early warning signs of relapse after her son was removed from his antipsychotic medication for his chronic schizophrenia in 2019. But Dr Andrea Boros-Lavack, Cauchi's private Toowoomba psychiatrist from 2012 until 2020, had repeatedly put those behavioural changes down to other factors. When she discharged him from her practice because of his move to Brisbane, Boros-Lavack did not refer Cauchi to a psychiatrist in his new home city, despite stating that he needed monthly psychiatric monitoring. While in Brisbane, he was given psychiatric approval for – but 'fortunately' did not follow through on – a gun licence. At one notable point in the inquest, Boros-Lavack stated that her former patient had not been psychotic at the time of his attack, which she believed was instead driven by 'sexual frustration, pornography and hatred towards women'. She sensationally withdrew the comments the next morning, calling them 'conjecture'. Her words nevertheless left their mark. In his statement on Thursday, Jade Young's brother, Peter, said his sister had been killed by a man whose 'rapid hunt' was 'fuelled by his frustration with not finding a 'nice' girl to marry. What a coward!' Even amid the highly technical level of detail canvassed by the inquest, barely a witness appeared untouched by the incident. On Thursday, however, their pain was dwarfed by that of the families. In some cases, media handling and coverage of the attack had heightened the heartache. In court on Thursday, the loved ones of Dawn Singleton, 25, did not make a statement – but this week, their grievances about radio host Ray Hadley mentioning Dawn's name on air before the family had formally identified her came to light in documents tendered to court. Elizabeth Young, too, described the horror of learning that images of her daughter's body had been broadcast and shared on social media. 'I learned a new phrase in the days after April 13,' she said: 'trauma porn.' For all the potential recommendations from the inquest, there was no way to make amends for her family's loss, she said. After the attack, her granddaughter – who was beside Jade when Cauchi delivered his single, catastrophic blow – drew her a plan, in blue crayon, showing exactly 'where Mummy fell'. 'Pause,' she told the court, 'and think on that.'
