Key failings revealed by coronial inquest into Bondi Junction Westfield stabbing attack
For five weeks the coronial inquest into the Bondi Junction Westfield attack tried to comprehend what could have been done to prevent the tragedy and how to better respond to similar acts.
Testimony was shared, tears wept and uncomfortable truths acknowledged.
On April 13, 2024, Joel Cauchi murdered six people and injured another 10 during a stabbing rampage.
Over one year on, here are some of the key failings uncovered during the inquest's hearings.
The profound impact of media reporting on the day of the attack and in the aftermath was examined at the request of the bereaved.
Sue Chrysanthou SC, who represents some of the victims' families, said her clients asked media companies to "take extreme care to address sensitivities".
Counsel assisting the coroner Peggy Dwyer SC said "the media will have to reflect deeply" on graphic footage shown in reports.
Julie Singleton, the mother of Dawn Singleton, provided a statement to the inquest, where she described the personal toll.
"Very soon after Dawn's death was first reported in the media, reporters appeared and took up position outside my house," she wrote.
"Reporters rang my doorbell and left notes in my mailbox seeking comment and/or information for a story. My family and I found this intrusive."
Many of Dawn's loved ones were informed of her death via media reports, with Ms Singleton saying their family's privacy was "violated".
Dawn's fiancé, Ashley Wildey, also criticised how Dawn's identity as one of the victims of the attack was revealed on talkback radio, Mr Wildey saying it was "extremely upsetting" for this to be done without consent.
In his statement to the inquest, he noted several printed inaccuracies in reporting of Dawn, as well as criticising unsolicited communication from journalists.
"The cumulative effect of the reporting has caused me and members of Dawn's family immense and immeasurable pain," he said.
Elizabeth Young, the mother of 47-year-old victim Jade Young, said of the media: "Our current world has lost site of decency.
"Images of Jade's lifeless body being worked on were cast around the world.
At the exact minute Cauchi stabbed his first victim, the sole security guard in the Westfield control room, referred to trhoughout the hearings as CR1, happened to be in the bathroom, leaving the CCTV screens unmonitored.
CR1's capability was reflected upon in the inquest, as well as the liability of her employer.
An independent security expert deemed CR1 to be incompetent as a control room operator due to her limited "skill set" for the role.
"You need to have good decision-making skills. You need to be able to multitask. You need to be able to give direction. You need to coordinate," the expert said of security guards reviewing CCTV.
"She wasn't obviously up to speed with her competence."
Glad Group, a subcontractor for security staff, and Scentre, the parent company of Westfield, were asked about their level of responsibility.
A former training manager from Glad Group, who trained CR1, was asked why some induction process documents pertaining to CR1 were not signed off.
"There was pressure for recruitment. I hope that didn't affect my training," said the manager, who cannot be identified for legal reasons.
A security manager from Scentre, whose name also remains under a non-publication order, acknowledged the pressure on guards to be informed, comfortable and confident in responding to extreme crisis events.
Scentre has since implemented stab resistant vests, made training more rigorous, and strengthened policies and procedures.
There were clear signs Cauchi had chronic schizophrenia.
Despite this, his long-term psychiatrist in Queensland, Andrea Boros-Lavack, weaned Cauchi off his anti-psychotic medication entirely by 2019.
"There was no evidence that he heard voices," Dr Boros-Lavack said during her evidence, to which Ms Chrysanthou acknowledged an email from Cauchi's mother to Dr Boros-Lavack's clinic in 2019.
Ms Cauchi had reported concerns her son was "now hearing voices" and writing notes he was "under satanic control".
A panel of five psychiatrists later told the inquest Cauchi's worsening mental health was "not taken seriously enough" by Dr Boros-Lavack.
They agreed Cauchi was experiencing psychosis during the 2024 attack — contradicting Dr Boros-Lavack's claim he was not.
A senior Queensland Police officer conceded the state's current mental health legislation was too confusing for officers to interpret.
Two officers who attended Cauchi's family home in Queensland in 2023 did not believe his mental health reached the threshold to detain him.
Currently, the legislation only provides a risk of suicide as an example for police to force someone to seek mental health support.
Acting Deputy Commissioner Mark Kelly said: "Our police are attending incidents every day. They maintain their professionalism, they're very considered, balanced, but they've got to operate within the legislation and our values, and also in terms of human rights."
Formal findings from the inquest will be released in months to come.
Regardless, for those directly affected by the events of April 13, 2024, their grief will remain "truly unfathomable", as Ms Dwyer noted.
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