Timeline of confusion revealed at inquest into Westfield Bondi Junction stabbings
The attacker, Joel Cauchi, had been shot dead just four minutes earlier.
Mr Wilkinson was based at Bankstown Airport, 33km away. But he and emergency specialist doctor Ruby Hsu got in their ambulance, activated lights and sirens, and made extraordinary time to Bondi Junction, arriving at 4.03pm.
They were part of a specialist team with the expertise and training for mass casualty events like this. But as Mr Wilkinson and Dr Hsu prepared to enter the mall and assist with the 17 casualties inside, they were told to wait.
CCTV footage shows Joel Cauchi running through the shopping centre.
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Supplied: Coroners Court of New South Wales
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At 4.01pm, this message had been broadcast on ambulance radio: "Intelligence reporting at this stage states that there is a second armed offender at the scene. All crews in place with patients are to remain in situ and not move until I get the all clear once I've spoken to police."
There was no second attacker. But confusion and communication problems meant that senior ambulance personnel did not know this, and thought the mall was too dangerous for crews to enter.
Mr Wilkinson and Dr Hsu helped treat security guard Faraz Tahir, who was so badly injured that he underwent emergency surgery as soon as he was brought out of the mall on a stretcher.
Paramedic Chris Wilkinson says he felt "inadequate" when he was barred from entering the shopping centre.
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AAP: Bianca De Marchi
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Mr Wilkinson couldn't understand why waiting ambulance crews weren't entering.
"Somebody with my experience of 42 years – Special Casualty Access Team, critical care paramedic – I felt inadequate being forced to stay on the outside when I thought people may be passing away on the inside," he told the inquest.
"And I gathered that because I had received Mr Tahir and wondered whether there were others similar to him."
'Need to change the way we do things'
The six people killed, clockwise from top left: Yixuan Cheng, Faraz Tahir, Jade Young, Pikria Darchia, Dawn Singleton and Ashlee Good.
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At 4.28pm, NSW Ambulance declared the mall a "hot zone" — which meant the ambulance crews already inside the mall were instructed to leave.
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Even if there was another attacker, Mr Wilkinson said that ambulance crews with appropriate training and protection should have been allowed in.
He said NSW police had shifted their approach to dealing with active, armed attackers from "contain and negotiate" to "save lives".
"I also think that we need to change the way we do things," Mr Wilkinson told the inquest.
"For me, standing around with boots on the ground on the outside of a premises, knowing that there are people that could possibly be dying on the inside of the premises and simply not going to them because there could be a second offender, or it could be a hot zone, I don't think is good enough.
Emergency services at Westfield Bondi Junction after the attack.
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AAP: Steve Markham
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"
When Dawn Singleton was stabbed, she asked a bystander to ... ring an ambulance. There's an expectation that an ambulance will arrive. There's an expectation via the community and just an expectation that if you ring an ambulance, we'll come.
"
In her opening address, counsel assisting the inquest, Peggy Dwyer, said it was extremely unlikely that better communications would have made a difference on the day, as expert evidence was that the injuries suffered by those who died that day were not survivable — with the possible exception of security guard Faraz Tahir.
"Any form of lockdown or restriction on access by first responders would obviously have the potential to compromise care and could've had a catastrophic consequence. Fortunately it did not," Dr Dwyer said.
'It gave me faith in humanity'
Police Inspector Amy Scott says she wasn't the only brave person at the shopping centre that day.
There is plenty to praise about the emergency response on April 13 — even beyond the actions of Inspector Amy Scott — who entered the mall within two minutes of the first radio call of an attack, and chased down and stopped Cauchi 72 seconds later.
She was so conscious of not hurting anyone else that day that she didn't draw her firearm until the last possible moment, as Cauchi was running directly at her.
She'd already cleared her line of fire by spotting a woman with a pram and gesturing for her to escape the possible trajectory of a bullet.
As Inspector Scott noted, she wasn't the only brave person in the mall that day.
"I think we as a society think that police don't feel fear, don't feel the burden and pressures of what everyday humans do, and I can assure you that they do," she said at the inquest.
"I can assure you on that day that they were fearful running in, and whilst I was the person that faced Joel, those young officers ran in with the exact same intentions."
She also praised the ambulance officers, the civilians who accompanied her through the mall, and the young retail workers who dealt with the crisis.
"And that day, as tragic as it is, it gave me faith in humanity, restored some faith in humanity and the goodness of people," she said.
Security control room empty
The two operators in the shopping centre's security control room that day were not in the room when the attack started
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ABC News: Monish Nand
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But one purpose of a coronial inquest is to make recommendations about how to do things better.
And there were problems in the mall that day — many of them centred around the security control room in the mall's underground car park.
When Cauchi began his attack there was nobody in the Bondi Junction CCTV control room on the mall's P4 parking level.
There had been two operators in the subterranean control room, but one left at 3pm to undertake training in another part of the complex, and the remaining control room operator went to the bathroom at 3.32.15pm. Cauchi's attack began 40 seconds later, and she re-entered the room one minute after that, at 3.33.55pm.
Bondi Junction Inquest Counsel Assisting, Dr Peggy Dwyer, delivering the opening address on April 28.
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Supplied: Coroners Court of New South Wales
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"During that time Cauchi had attacked eight individuals, three of whom would die from their wounds,"
Peggy Dwyer said.
"That the CCTV control room was vacant at the time of the attacks appears to have impeded [Westfield operator] Scentre's initial response … they were playing catch-up to understand what was unfolding."
There was initial confusion among Scentre staff about whether police had been called, and the first call from the control room to police was long after members of the public began calling Triple-0.
"The initial contact and exchange of information between the CCTV control room and emergency services occurred approximately ten minutes after the attack, about four minutes after Cauchi had been shot by Inspector Scott," Dr Dwyer said.
Wrong messages given to shoppers
Shoppers take shelter inside a store during the attack.
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ABC News
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The mall's emergency alarm system wasn't activated until after Cauchi had been shot, and it broadcast the wrong message.
It told shoppers to "evacuate now", when it was supposed to tell them to hide from an active attacker and only escape if they could see a clear route out.
Billboards in the malls should have displayed a message that said: "Attention armed offender, escape, hide, tell," but instead stated: "Attention emergency evacuation. Please evacuate the centre."
An operator had hit the wrong button on a large control panel.
And the automated message and alert tone that was broadcast was so loud that it impeded communications between first responders.
"It was difficult to hear the radio," Inspector Scott said.
"
I had my radio turned up really, really loud, like as high as it can, and I still was struggling to hear what other police were communicating.
"
She asked for it to be turned off.
The first public announcement was not made from the control room until around 3.52pm — 20 minutes after the start of the attack.
Emergency services outside the shopping centre after the attack.
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ABC News
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Dr Dwyer said the witnesses in the mall recalled that the person making the announcement sounded "distressed and distraught, so much so that they weren't sure whether that person had actually been taken hostage".
"There were concerns from civilian bystanders that the person might have been making the announcement under duress, and they weren't sure whether they could trust the announcement being made."
The Coroner heard that the control room operator on the day had previously twice answered incorrectly when tested on the two main objectives of security in an active armed offender situation – to get people to safety and inform police.
One security supervisor told the inquest that, upon reflection, "I wish we did better. I wish we did different."
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