Warning: This article contains details about the Bondi Junction stabbings on 13 April 2024 which may be upsetting for some readers. Reader discretion is advised.
The NSW Coroner made her findings regarding the inquest into the deaths at Westfield Bondi Junction on 13 April 2024. The attacker’s psychiatrist, Dr Boros-Lavack, was criticised for her management of Mr Cauchi and was referred to the Health Ombudsman of Queensland.
In issue
On 5 February 2026, the NSW State Coroner, Magistrate Teresa O’Sullivan, handed down her findings from the inquest into the deaths at Westfield Bondi Junction on 13 April 2024. During the inquest, the Coroner made multiple criticisms regarding the treatment provided by Joel Cauchi’s primary psychiatrist, Dr Andrea Boros-Lavack, in particular, regarding her ignorance of Mr Cauchi’s warning signs and failure to accept criticisms of her management of Mr Cauchi. The psychiatrist was ultimately referred to the Health Ombudsman of Queensland for review.
The background
On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, resulting in the deaths of six of the victims. He was shot dead by Detective Inspector Amy Scott of the NSW Police Force.
Mr Cauchi had a history of mental illness, including schizophrenia, and was treated for over a decade by the Queensland public health system until 2012. From 2012 to 2020, Mr Cauchi received treatment at the Mi-Mind Centre in Toowoomba, under the care of psychiatrist, Dr Andrea Boros-Lavack. Dr Boros-Lavack initially diagnosed Mr Cauchi with Obsessive Compulsive Disorder (OCD) and chronic paranoid and disorganised schizophrenia, the latter of which was controlled with Clopine.
After receiving a discharge summary from the public mental health team, Dr Boros-Lavack revised this diagnosis to first episode psychosis, which remitted on treatment with clozapine. Under Dr Boros-Lavack’s care, Mr Cauchi’s clozapine levels gradually decreased over a six-year period until it was ceased in June 2018. Dr Boros-Lavack explained that the clozapine level and Abilify dose was 'sub-therapeutic' but this was inconsistent with expert evidence and ultimately rejected by the Coroner.
On 28 November 2018, Mr Cauchi’s mother contacted Mi-Mind Centre with concerns over her son’s symptoms. Dr Boros-Lavack consulted with Mr Cauchi and concluded that he was not psychotic but had developed a new mannerism or complex tic. While the Coroner accepted that a trial of cessation of clozapine was in line with standard practice, the Coroner noted that it would have been best practice for Dr Boros-Lavack to have kept clear records about her thought processes around the cessation of the medication and the actions she took to explain the risks of doing so to Mr Cauchi and his mother.
The decision at trial
The Coroner found that Dr Boros-Lavack’s classification of Mr Cauchi’s symptoms was 'inconsistent and confusing at times'. The Coroner also criticised Dr Boros-Lavack’s care of Mr Cauchi post-2019, especially her failure to recognise the seriousness of Mr Cauchi’s condition by ignoring critical early warning signs as a result, and neglecting to emphasise the importance of commencing the prescribed medication.
The expert panel agreed that Mr Cauchi was psychotic on the day of the incident. Dr Boros-Lavack initially disagreed with this consensus, but later withdrew her evidence and accepted that he was likely psychotic. The Coroner found that Dr Boros-Lavack’s confirmation bias in believing that Mr Cauchi’s medication was having no effect, when in fact it was, had devastating consequences as she was unable to recognise Mr Cauchi’s warning signs and could not accept that Mr Cauchi had relapsed causing the incident on 13 April 2024. The Coroner commented that 'Dr Boros-Lavack’s evidence was wholly inappropriate, wrong, and had a traumatizing effect on the victims’ families.'
The Coroner concluded that Dr Boros-Lavack’s oral evidence was unhelpful and noted her reluctance to accept criticism of her management of Mr Cauchi and her failure to make appropriate concessions. The Coroner ultimately referred Dr Boros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Mr Cauchi.
Dr Peggy Dwyer, counsel assisting the Coroner, commented, 'Even the most competent practitioners make mistakes…[t]he problem here was the combative nature of Dr Boros-Lavack and the failure to accept responsibilities for the deficiencies'.
Implications for you
An inquest is an inquisitorial process aimed at determining facts and making preventative recommendations concerning public health and safety. As a medical practitioner, you may be considered an 'interested party' and compelled or subpoenaed to attend an inquest and give evidence. In such a case, you may be subject to criticism and could potentially be referred to AHPRA or the relevant healthcare complaints organisation in your state.
A witness statement in an inquest should be confined to the facts and medical records and should not be based on opinion or memory. To facilitate this, it is crucial that medical practitioners keep up-to-date, accurate and legible records. Further, it is important to avoid being defensive and combative when giving evidence. It is also recommended to respond only to the questions or issues being asked rather than stating what should have occurred. Insight and reflection is key when giving your evidence.
Should you ever find yourself needing to respond to a request from the Coroner please reach out to your professional indemnity insurer and obtain assistance in the first instance.
