How Bondi Junction killer fell 'through the cracks' of mental health system

Australia Broadcast Center

31-05-2025

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.