New South Wales, Australia, State Coroner Teresa O’Sullivan delivers remarks in inquest into the stabbings at Bondi Junction shopping center on 13 April 2024. — Image pulled from Coronors Court New South Wales video, 5 February 2026

In Search for Lessons, Inquest into Bondi Junction Stabbings Delivers

By Scott Briscoe

9 February 2026

“The intention of the court… was to conduct the inquest in a trauma-informed manner that would endeavor to provide much needed answers to the families who lost their loved ones and to the wider community. This was with a view to learning lessons in order to save lives in [the] future. I’m confident that through these findings this goal will be achieved.”

After speaking those words, New South Wales, Australia, State Coroner Teresa O’Sullivan explained the findings from the “Inquest into the deaths at Westfield Bondi Junction on 13 April 2024,” which was presented to the public on 5 February.

On that April afternoon, Joel Cauchi terrorized the Westfield Bondi Junction shopping center, using a foot-long hunting knife to kill six people and stab several others before police shot and killed him. The after-action inquest report investigated Cauchi’s history as well as the incident and response as it unfolded. It provides several insights and suggestions, particularly in three areas: the mental health of the assailant, additional touchpoints with the assailant, and the center’s onsite security posture.

Findings and Recommendations in the Area of Mental Health

The report said Cauchi had been diagnosed with chronic paranoia and disorganized schizophrenia and appeared to have received competent and appropriate mental health care from 2012 to 2019. During that time, the doctor slowly weaned Cauchi off antipsychotic medication, a decision the inquiry’s panel of psychiatric experts said was a reasonable course of treatment.

However, the inquiry then found several faults in the treatment of Cauchi. The investigating coroner found that the doctor had not adequately explained the risk of relapse to Cauchi or his family and she failed to miss obvious signals that Cauchi’s mental health was deteriorating. When Cauchi moved and was no longer under her care, she sent a remand letter to the general practitioner she had on record for Cauchi, but that letter was “wholly unsatisfactory. …That letter should have contained more details about the concerns reported by Mrs. Cauchi, updated [the GP] as to the events that had transpired, provided details with respect to Mr. Cauchi’s medication, and conveyed to [the GP] that Mr. Cauchi needed to be urgently and closely reviewed during this period. It also would have been helpful for the letter to state that Mr. Cauchi needed ongoing psychiatric care in Brisbane.”

Thus Cauchi’s subsequent encounters with medical professionals, such as when he was evaluated when applying to obtain a firearm, were not conducted with a detailed account of his mental health diagnoses and treatments. As a result, the following recommendations were included in the inquiry’s summary of this area. (Note: These recommendations have been significantly summarized for brevity. For the complete recommendations, see the full list of recommendations in the report.)

Recommendation: The coroner recommend that the Health Ombudsman of Queensland review the attending psychiatrist’s care and treatment of Cauchi.

Recommendation: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) should give prompt attention to updating its out-of-date “Clinical practice guidelines for management of schizophrenia and related disorders” and amend it in several ways, including: a definition of “Treatment-Resistant Schizophrenia,” that evidence demonstrates a significant risk of relapse for patients with schizophrenia who cease medication, and that patients who do relapse should be advised to stay on medication indefinitely.

Recommendation: RANZCP, in partnership with other relevant organizations, should develop new guidelines, including one on deprescribing antipsychotic medication—whether it is prescribed or patient-initiated—and one on management of patients with chronic schizophrenia, including treatment-resistant schizophrenia.

Recommendation: The New South Wales government should support the establishment and ongoing evaluation of long-term accommodation for people experiencing mental health issues and homelessness. The government should consult with health experts on the demand for mental health outreach services and seek advice on what additional resources are needed in the outreach to people suffering severe untreated mental illness.

Findings and Recommendations in the Area of Police Authority

Cauchi did not have a police record; however, he had been part of several incidents over a few years. He had been pulled over three times for erratic driving in a 12-month period in 2020 and 2021. In 2022, complaints were made that he had “persistent contact with an all-girls boarding school.” Authorities considered the behavior concerning, but after several attempts to contact Cauchi failed, the police closed the investigation at the end of the year.

In 2023, Cauchi called the police to report that his father had stolen his knives, prompting a visit to the home by police. Cauchi’s parents reported they had removed the knives because Cauchi was “mentally unstable.” The officers told Cauchi to respect his parents and left the scene. As part of following the report, the officers requested the department’s mental health intervention coordinators (MHIC) conduct a mental health check at the Cauchi home at a future date. However, that recommendation was missed. The inquiry noted the department had already made changes to the MHIC referral system so future oversights would be less likely.

However, the report noted that in any of these interactions, particularly the 2023 incident in which Cauchi’s mother reported that Cauchi had shoved her, authorities can only detain and transport someone to a care and treatment facility if they are at risk of doing serious harm to themself.

Recommendation: Amend the law giving authorities an additional duty to detain and transport someone to a care and treatment facility if they are at risk of doing serious harm to others.

Findings and Recommendations Related to Management of the Incident

The inquiry laid out the timeline of the attack minute-by-minute and, when available, second-by-second.

3:32:55 p.m.: Cauchi stabbed first victim.
3:33:33 p.m.: Center security made radio call relating to incident, but the nature of that call is disputed. It does not make definitive identification that this is an active assailant, what the report calls active armed offender (AAO).
3:35 p.m.: Police radio broadcast of “multiple calls, multiple stabbings, multiple locations” at the shopping center.
3:36:11 p.m.: Center security makes contact with emergency services.
3:37:15 p.m.: Inspector Amy Scott arrives at the center and is met by two citizens who accompany her into the center. Given the information she received, Scott determined there was an immediate threat and she should enter immediately without waiting for others. Scott would see Cauchi, yell at him to stop, and, when he ran, pursued him on foot.
3:38:34 p.m.: Cauchi, who had stopped, runs toward Scott with knife in hand.
3:38:40 p.m.: Scott takes steps to back away from Cauchi, draws her firearm, and fires three times, fatally wounding Cauchi.
3:39:40 p.m.: Scott makes radio broadcast including a call for ambulance.
3:39:45 p.m.: Center issues evacuation notice to video monitors in throughout the center.
3:40:38 p.m.: Center auditory alarm goes off.

The inquiry said Scott’s actions were exemplary. However, there were several areas where the inquiry found issues or shortcomings in the center’s security protocols:

When the first stabbing occurred, the only security officer posted to the CCTV control room was in the bathroom. Even though the hundreds of surveillance cameras in the center are intended to provide situational awareness rather than incident prevention, the center changed its policy so that the control room must be attended at all times.
The officer stationed in the control room had several concerning lapses in previous shifts, including one from just three days prior to the incident, and therefore should not have been given the assignment of being the sole person in the control room.
The initial radio broadcast at 3:33:33 p.m. needed to make it absolutely clear that the incident was an AAO incident. The fact it, and subsequent contacts, did not make this clear led to a significant delay in appropriate incident response.
The inquiry deemed the call from the control room officer to emergency services as “subpar” because it conveyed no additional situational information than what the many calls from the public were telling emergency services.
The emergency message conveyed, an evacuation notice, was not adequate. The public protocol for an AAO is not strictly evacuation; rather, for New South Wales, it is “Escape. Hide. Tell.”
The inquiry commended the center for several changes it has made since the incident, including: the installation of an automated PA system, creation of a secondary control room, staffing of the control room by two officers during core business hours, and introduction of stab-resistant vests for security officers.
The police set up a command center quickly; however, it took two hours before the first multi-agency tactical command meeting, which was needed to coordinate actions among police, medical response, and other departments. In addition, the inquiry noted a shortcoming in that there was no specific official appointed to facilitate communication between the police and other agencies.