A shocking claim made by Joel Cauchi’s psychiatrist that left the families of the killer’s victims “traumatised” has been lashed by a coroner.

The shocking claim made by Joel Cauchi’s psychiatrist that his deadly rampage was fuelled by a “hatred for women” and “sexual frustrations” has been lashed by a coroner, who ruled the medico should be investigated.

Dawn Singleton, Yizuan Cheng, Faraz Ahmed Tahir, Ashlee Good, Jade Young and Pikria Darchia were all killed during one of Australia’s worst massacres on April 13, 2024, at Westfield Bondi Junction in Sydney’s east.

Cauchi, who was unmedicated for schizophrenia and “floridly psychotic” at the time, was shot dead by Inspector Amy Scott, who has been credited with saving lives as a result of her bravery and quick action.

The inquest was told the victims’ families were left “traumatised” when his psychiatrist, Andrea Boros-Lavack, claimed during her evidence that Cauchi’s fatal rampage had “nothing to do with psychosis” and was instead fuelled by a “hatred for women” and “sexual frustrations”.

Dr Boros-Lavack later withdrew the claim, which has now been deemed as “wholly inappropriate” and “wrong” by NSW Coroner Teresa O’Sullivan in findings from a five-week coronial inquest into the tragedy.

A coroner has asked that psychiatrist Andrea Boros-Lavack’s care of Joel Cauchi be reviewed. Picture: NewsWire / Damian Shaw
She ruled that Dr Boros-Lavack’s determination that Cauchi was not suffering early warning signs of psychosis in late 2019 after he was taken off all antipsychotic medications was a“major failing”.

Cauchi’s mother, Michele, had on seven occasions flagged her son’s declining mental health, including by reporting that he may have been hearing voices and was leaving notes that he was under “satanic control”.

Ms O’Sullivan found that while Dr Boros-Lavack initially suspected Cauchi was showing signs of relapse, she “revised her view” and thus failed to “recognise the seriousness of the situation”.

Her claim during the inquest that Cauchi was not suffering psychosis was “extraordinary and shocking”, Ms O’Sullivan found, speculating it may have been a result of the psychiatrist’s confirmation bias and desire to maintain her stance that Cauchi had not relapsed.

“Not only did she minimise many of Mr Cauchi’s early warning signs, but even when the worst thing happened – that is, the events on 13 April 2024 – Dr Boros-Lavack could still not accept that Mr Cauchi had relapsed,” Ms O’Sullivan said.

“This was a serious flaw in her judgment.

“In any case, Dr Boros-Lavack’s evidence was unhelpful.”

Ms O’Sullivan has asked that Queensland’s Health Ombudsman review Dr Boros-Lavack’s care of Cauchi following calls from the victims’ families.

Noel McLaughlin, husband of Jade Young, made a moving speech outside the court. Picture: NewsWire / Max Mason-Hubers

Jade Young’s husband, Noel McLaughlin, should be considered for a bravery award, a coroner has ruled. Picture: NewsWire / Max Mason-Hubers
Counsel assisting the coroner Peggy Dwyer SC last year slammed what she called Dr Boros-Lavack’s “exceptional” belligerence during her evidence.

Ms O’Sullivan on Thursday noted Dr Boros-Lavack’s care of Cauchi was “exemplary” from 2012 to September 2019, and made no criticism of the decision to trial weaning Cauchi off all medications at his request.

Hero husband’s touching words

Ms Young’s husband Noel McLaughlin, who was threatened by Cauchi as the tragedy unfolded and warned other shoppers the killer had a knife, should be considered for a bravery award, Ms O’Sullivan ruled in her inquest findings.

Mr McLaughlin said while the inquest could not “undo” his family’s loss, “it has mattered”, in a moving speech delivered outside the Coroner’s Court on Thursday.

Gaps, missed opportunities and systemic failures were revealed during the five-week inquest, which Mr McLaughlin hopes will prevent other families from enduring the same loss he has.

“Jade was my wife, the person I shared life with for more than two decades. Her absence has left a vast and permanent space, one that can’t be filled, only carried,” Mr McLaughlin said.

“The (inquest’s) evidence has shown that what first appeared to be a sudden and random act of violence was, in fact, the end point of a long story.”

“My hope now is that the findings and the recommendations are treated not as abstract lessons, but as practical obligations.

Bondi stabbing victims (top l-r) Dawn Singleton, Ashlee Good, Cheng Yixuan, (bottom l-r) Faraz Ahmed Tahir, Jade Young and Pikria Darchia.
“These issues are not theoretical, they have consequences measured in human lives.

“Jade’s murder cannot be undone, but 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 loss.”

‘My daughter would still be alive today’

Ms Good’s father, Kerry, maintained his daughter would still be with him today had security staff done their jobs correctly.

“If the shopping centre systems were correct and the staff that worked there in the positions that they were in that day, if they had done their job successfully, my daughter would still be alive today,” Mr Good said outside the coroner’s court.

The sole staffer rostered to monitor the CCTV room on the day (known as CR1) had gone to the bathroom seconds before the fatal attack began, and had been flagged for “ongoing issues” in the months prior, including that she was responding too slow and needed retraining.

Kerry Good and Noel McLaughlin both spoke outside the court. Picture: NewsWire / Max Mason-Hubers

Kerry Good, father Ashlee Good, claimed his daughter ‘would still be alive today’ if security staff had done their jobs correctly. Picture: NewsWire / Max Mason-Hubers
In addition, evacuation alarms were only sounded about two minutes after Cauchi had been killed, while the screens throughout the shopping centre told people to “evacuate” when it should have been encouraging people to “escape, hide, tell”, the inquest was previously told.

However Ms O’Sullivan on Thursday found lives could not have been saved, ruling it was not “realistically possible” for the public to be informed of the looming danger at any point before Cauchi had completed his fatal attacks.

Sheraz Ahmad Tahir and Muzafar Ahmad Tahir, brothers of victim Faraz Tahir, at the Coroners Court on Thursday. Picture: NewsWire / Max Mason-Hubers

Many of the victims’ families embraced outside the court. Picture: NewsWire / Max Mason-Hubers
She did find that CR1 was not equipped to carry out the critical duties required of her, though, stating the shopping centre operator Scentre Group and security contractor Glad Group, “should have been aware” of this.

Ms O’Sullivan noted the centre was well prepared for an active armed offender (AAO) incident, and their policies were “excellent”.

Mr Tahir’s family said they would tell him how proud they are of him and his sacrifice if he were here today.

Hero police officer Amy Scott (centre) attended the findings of the Bondi Junction. Picture: NewsWire / Max Mason-Hubers
‘Very best for the road ahead’: Hero cop praised

Ms Scott’s bravery was praised by the coroner, who called her actions “extraordinary” after the 19-year veteran of the NSW Police Force arrived at the court wearing a colourful bandana, having recently been diagnosed with a rare and aggressive breast cancer.

“Not only did she act unhesitatingly and with enormous courage and service … but she attended court throughout the inquest to provide comfort to others. She combined skill and compassion with great humility,” Ms O’Sullivan said.

“She now faces a health challenge … I wish her and her family all the very best for the road ahead.”

Ms O’Sullivan also expressed her condolences for those affected by the alleged terror attack at Bondi Beach last year, telling the court she felt “comfort” from reports emergency services worked together seamlessly after issues with inter-agency communication were probed during the stabbing inquest.

“I had hoped that our community would not need to grapple again so soon with such a violent event … I express my heartfelt condolences to all who were impacted,” she said.

Joel Cauchi killed six people and injured another 10 during a stabbing rampage. Picture: Supplied.
Bravery awards for bollard men

The coroner has asked for Ms Good, Mr McLaughlin, Inspector Scott,and “bollard men” Silas Despreaux and Damien Guerot to be considered for bravery awards.

Cauchi stabbed 16 people in just less than three minutes, running through the centre for an additional three minutes after stabbing his last minute.

During this time he was confronted and distracted by French construction workers Mr Despreaux and Mr Guerot, who led Ms Scott to Cauchi – armed with a chair and trolley by this stage – after they threw bollards at the killer.

L to R: Damien Guerot and Silas Despreaux, the two french nationals who confronted Cauchi with bollards. Picture: NewsWire / John Appleyard

The French nationals threw bollards at Cauchi. Picture: X
Ms O’Sullivan handed down a total of 23 recommendations, with her findings amassing more than 800 pages.

Among the recommendations are amendments to the Royal Australian and New Zealand College of Psychiatrists’ guidelines on schizophrenia disorders, which should reflect the significant risk of relapse for patients who cease medication.

A separate guideline should be created on “deprescribing” psychotic medications, including advice on how to recognise early warning signs of relapse.

Cauchi was homeless at the time of the fatal stabbings, with the state government now asked to establish and support services for short-term accommodation for those experiencing mental health issues, as well as long-term accommodation with on-site or easily accessible long term mental health care.

Kerry Good (centre), father of Ashley Good, and other families of the victims gathered outside the Coroners Court. Picture: NewsWire / Max Mason-Hubers
Advice should also be sought by the government on a realistic timeframe to achieve additional resources to meet the need for outreach psychiatric services.

A guideline for media reporting on mass casualty incidents has also been recommended to the Australian Press Council, while the Australian Communications and Media Authority has been asked to consult on whether their Codes of Practice on mass casualty event reporting should be amended.

NSW Police Commissioner Mal Lanyon has said recommendations relating to police will be considered while thanking the coroner for acknowledging the bravery of Inspector Scott and the work of the tragedy’s investigator, Detective Chief Inspector Andrew Marks.

NSW Premier Chris Minns similarly announced the recommendations would be reviewed.

A Scentre Group spokesperson said the company would review the report in detail.

“We fully supported the careful process undertaken by the NSW Coroner to reflect, learn and understand how public safety could be improved in the future,” the spokesperson said.

Cauchi was 40 at the time of the fatal attacks. Picture: Supplied.
Cauchi’s family offer condolences

A stack of media releases outside the home of Cauchi’s family say his parents, Andrew and Michele, offer their condolences to the loved ones of those who died in the fatal attack, the Courier Mail reported.

“Their thoughts are also with the people who were injured, the emergency responders, their families and friends and other people affected by the terrible incidents on the day,” the statement said.

“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 the ongoing coverage of it.

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