Inquest into the deaths at Westfield Bondi Junction Recommendations

Coroners Court of New South Wales Inquest into the deaths at Westfield Bondi Junction on 13 April 2024 List of Recommendations Findings of Magistrate Teresa O'Sullivan New South Wales State Coroner 5 February 2026

State Coroner of New South Wales Inquest into the deaths at Westfield Bondi Junction on 13 April 2024 Findings and Recommendations 5 February 2026

Published 5 February 2026 by the Coroners Court of New South Wales 1A Main Avenue, Lidcombe NSW 2141 Phone: (02) 8584 7777 Fax: (02) 8584 7788 Email: lidcombe.coroners@justice.nsw.gov.au The photograph on the report’s cover was taken by Brendan Esposito of ABC News.

It is reproduced here with the kind permission of ABC News.

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) Recommendation 1: To the Health Ombudsman of Queensland I recommend that the Health Ombudsman of Queensland review Dr Andrea BorosLavack’s care and treatment of Mr Joel Cauchi.

Recommendation 2: To the Royal Australian and New Zealand College of Psychiatrists

(RANZCP) The document entitled “Clinical practice guidelines for management of schizophrenia and related disorders” contains a watermark stating: “This document is more than five years old and is under review”.

Prompt attention should be given to an amendment of the Guidelines on the management of schizophrenia and related disorders, which should include the following matters (as appropriately formulated by those undertaking the review):

(a) An outline of the types of psychotic disorders described in the DSM-5TR, including schizophrenia; schizophreniform disorder; schizoaffective disorder; brief psychotic disorder and delusional disorder;

(b) A description of the disorder known as schizophrenia;

(c) A definition of “Treatment Resistant Schizophrenia”;

(d) That evidence demonstrates a significant risk of relapse for patients with schizophrenia who cease medication;

(e) That patients with chronic forms of schizophrenia who have relapsed after ceasing medication should be advised to stay on medication indefinitely, given the high risk of relapse; and

(f) That if a patient with treatment resistant schizophrenia elects to cease their medication, they should be monitored indefinitely if possible, and in accordance with the separate practice guideline on “deprescribing” antipsychotic medication.

Recommendation 3: To the Royal Australian and New Zealand College of Psychiatrists

(RANZCP) The RANZCP should draw up and distribute a separate professional practice guideline on “deprescribing” antipsychotic medication, where a patient with schizophrenia declines to remain on medication, or is deliberately deprescribed.

Such a guideline should be based on expert opinion and contemporary evidence.

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 1

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) Such a Guideline should include:

(a) Advice to the patient on the risk of relapse and the longitudinal clinical adversity associated with relapse (that is, not only is the patient likely to relapse, but each time they do, the illness has greater long term impacts on their outcomes);

(b) Advice to the patient on how to recognise early warning signs of relapse;

(c) A contingency plan articulating appropriate actions to be taken and pathways to care, should a person or their support network find evidence of early warning signs;

(d) Advice on who to contact in the event of signs of relapse;

(e) Advice on how to educate family and friends to recognise the signs of relapse;

(f) The requirement for a written discharge letter on handover of a patient with treatment resistant schizophrenia, with the following minimum requirements: i. A history of the patient’s illness and treatment; ii. Overview of symptoms in last six months of treatment; iii. Findings from the most recent mental state examination; iv. Probability of relapse; v. Advice as to early warning signs of relapse; vi. Any relevant support persons who are available to assist the patient and contact details; and

(g) Advice that regular review by a psychiatrist should be included in any management plan for the patient.

Recommendation 4: To the Royal Australian and New Zealand College of Psychiatrists

(RANZCP) That the RANZCP collaborate with the Royal Australian College of General Practitioners (RACGP) to develop shared care guidelines to optimise the

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 2

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) management of patients with chronic schizophrenia, including treatment resistant schizophrenia, and that the RANZCP assume the role of lead organisation in this process.

Recommendation 5: To the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Commissioner of the NSW Police Force and the Commissioner of the Queensland Police Service That the Commissioner of the NSW Police Force and the Commissioner of the Queensland Police Service convene with relevant representatives from the RANZCP to form a working group to consider the nature and role (if any) of psychiatrists in preparing assessments of fitness for weapons licensing, and whether that role should be incorporated into weapons licensing legislation (including in the form of a Multi-Disciplinary Assessment Panel or other such panel of experts), including having regard to the following matters:

(a) The extent to which the RANZCP “Professional Practice Guideline 23 – Firearms Risk Assessment” (2023) provides appropriate guidance for psychiatrists and firearms licensing authorities;

(b) The extent to which persons with chronic mental health disorders involving psychotic episodes (such as schizophrenia) should be permitted to have any access to firearms; and

(c) The views expressed in the evidence of the expert psychiatric panel obtained during the Inquest hearing.

Recommendation 6: To the Royal Australian College of General Practitioners (RACGP) That the RACGP collaborate with the RANZCP on the development of shared care guidelines to optimise the management of patients with chronic schizophrenia, including treatment resistant schizophrenia (noting the RANZCP is the lead organisation in this process).

The Guideline should include: General Recognition that:

(a) General practitioners have a key role in supporting patients with schizophrenia.

(b) General practitioners have a role in the early detection of prodromal symptoms, monitoring and preventing risks, including relapses, and providing high-quality primary and secondary prevention and treatment of common physical problems. However, this must be done in

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 3

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) conjunction with the patient’s specialist mental health service/consultant psychiatrist, who have an important role assisting general practitioners, patients and carers to understand the risks and presentation of relapse for each patient.

(c) Effective care requires a thorough understanding of local specialist services, cardiometabolic and other effects of pharmacotherapies, familiarity with psychosocial interventions and proactive multidisciplinary chronic disease management. This must be led by the patient’s specialist mental health service/consultant psychiatrist who commit to informing the patient, carers and the patient’s general practitioner to assist them to provide care in a collaborative framework effectively.

(d) The general practitioner should ensure that they liaise with specialist mental health teams/consultant psychiatrists to obtain advice with respect to the matters outlined below, and to ensure that advice is passed on to the patient and carers. Such advice should cover: i. Advice on the risk of relapse if not medicated; ii. Advice on how to recognise early warning signs of relapse; and iii. Who to contact in the event of signs of relapse.

Regarding Treatment Resistant Schizophrenia

(a) Treatment resistant schizophrenia is uncommon, and general practitioners should not be expected to have thorough knowledge of this condition. Specialist mental health services/consultant psychiatrists must provide the patient, carers and the patient’s general practitioner with the following: i. A definition of treatment resistant schizophrenia; ii. Advice as to the circumstances in which a general practitioner can prescribe clozapine, noting that options and requirements may be different in each state. This must include ongoing support from the patient’s mental health service/consultant psychiatrist; iii. A clear understanding that a psychiatrist should be involved in the ongoing management of patients with chronic schizophrenia, including treatment resistant schizophrenia;

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 4

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) iv. Advice that it is preferable for persons with treatment resistant schizophrenia to remain on medication; v. An indication regarding the risk of relapse for patients with treatment resistant schizophrenia, who cease medication (for example, expressed as an “extremely high risk” or by way of percentage) and associated risks with regard to harm to self and others; and vi. Advice about risks with regard to driving and access to/use of heavy equipment/machinery and weapons.

Minimum standards for a general practitioner on initial intake of a patient with treatment resistant or chronic schizophrenia

(a) Once ongoing shared care of a patient with chronic schizophrenia (including treatment resistant schizophrenia) has been actively accepted by a general practitioner, the specialist mental health team/consultant psychiatrist must provide the patient, carers and the patient’s general practitioner with the following: i. All relevant records from the public/private sector carer involved (including all recent discharge summaries and specialist outpatient letters); ii. Information to assist with ongoing assessment of the current risk of relapse and other risks for the patient; iii. The likely signs/symptoms of relapse; and iv. The early warning signs/symptoms of relapse.

(b) These aspects of care are a shared responsibility between specialist mental health services and general practitioners and require appropriate and timely clinical handover/communication.

(c) The specialist mental health team/consultant psychiatrist has an important role in ensuring that they review the person at regular intervals appropriate for each patient in collaboration with the patient’s general practitioner.

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 5

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) Minimum clinical handover standards for a general practitioner when the care of a patient with treatment resistant or chronic schizophrenia is transferred to another provider On transfer of a patient with treatment resistant or chronic schizophrenia to another general practitioner, the current treatment team (specialist mental health services/consultant psychiatrists/general practitioner) have a responsibility to:

(a) Explain to the patient, carers and the patient’s new general practitioner the need for ongoing medical care and regular review by a general practitioner and psychiatrist;

(b) Prepare a comprehensive clinical handover letter, outlining: i. The patient’s current mental health status; ii. The risk of relapse and any other risks (for example, self-harm, suicide, homicide, access to weapons, driving, ability to adhere to medications) at the time of discharge; iii. The early warning signs and symptoms of relapse;

(c) Provide the patient with a copy of the letter; and

(d) Provide the patient, and (where possible) the patient's family/friends, with the contact details of other support services and the options for psychiatric care.

Recommendation 7: To the NSW Government That the NSW Government:

(a) Model the need for short term accommodation in the greater Sydney area for those experiencing mental health issues and homelessness, and then establish and support those services.

(b) Support the establishment and ongoing evaluation of long term accommodation for those experiencing mental health issues and homelessness, with on-site or easily accessible long term mental health care, based on the models delivered by Habilis (NSW) and Haven (Victoria).

Recommendation 8: To the NSW Government (1) That the NSW Government, over the next 12 months:

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 6

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland)

(a) Obtain advice from NSW Health on the decline of and related demand for mental health outreach services in NSW, and on the work being done in this area;

(b) Obtain advice from NSW Health as to the additional resources that are required to meet the need for outreach psychiatric services that can effectively collaborate with stakeholders to evaluate and engage people with severe untreated mental illness - including people without housing; and

(c) Obtain advice from NSW Health as to a realistic timeframe to achieve those additional resources/services, noting the need to recruit skilled staff and build service capacity.

(2) Having regard to evidence that some patients with treatment resistant schizophrenia are cared for by community health centres (CHCs), and then discharged to general practitioners after episodes of care, the NSW Government, over the next 12 months:

(a) Obtain advice from NSW Health on what is required to provide a model to care for persons suffering complex, severe mental illness, with a risk of relapse;

(b) Obtain from NSW Health a comprehensive report advising of options to improve the current system in which public mental health services are provided to consumers, including: i. The need for additional resourcing for CHCs; ii. The need for a better understanding amongst private practitioners as to the treatment and support pathways already available within the NSW Health system that they can draw on; iii. More constructive engagement in collaborative care between mental health services and the primary care sector; and iv. A mapped timeframe for achieving those reforms, setting out the steps required to build frameworks and workforce capacity, and (3) For the assistance of CHCs, NSW Health should ensure clinicians have ready access to contemporary evidence based “deprescribing” guidelines, noting potential risk inherent when consumers, including those with treatment resistant schizophrenia cease prescribed psychotropic medication. In order to facilitate this goal, NSW Health should liaise with RANZCP in relation to the

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 7

LIST OF RECOMMENDATIONS Part 2: Mr Cauchi’s mental health history (and the mental health context in NSW and Queensland) development of deprescribing Guidelines referred to at Recommendation 3.

Part 3: Mr Cauchi’s interactions with QPS Recommendation 9: To Queensland Health That Queensland Health give consideration to an amendment to s 157B of the Public Health Act 2005 (Qld) to:

(a) Refer to “immediate risk of serious harm to others”, rather than only referring to “immediate risk of serious harm to self”;

(b) Expand the example in the provision beyond that of suicide; and

(c) Provide further clarification on the definition of “serious harm” for the purposes of the provision.

Recommendation 10: To the Commissioner of the Queensland Police Service That the Commissioner of the Queensland Police Service:

(a) Evaluate the service needs for Mental Health Intervention Coordinators (MHICs) in each region; and

(b) Give consideration to increasing staff in the Darling Downs region, an area of recognised need.

Recommendation 11: To the NSW Government That the NSW Government consider options to support the roll-out of appropriate co-responder models so that they are more widely available throughout NSW.

Part 4: Mr Cauchi’s movements in NSW from 2023-2024 and his interest in knives Recommendation 12: To the NSW Government That the NSW Government monitor and assess the trial of the amendments to the Law Enforcement Powers and Responsibilities Act 2002 (NSW) in respect of “wanding”, including whether:

(a) Such a trial should be made permanent; or

(b) The law should apply to certain “crowded places” without the need for a declaration to be made.

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 8

LIST OF RECOMMENDATIONS Part 5: Active Armed Offender (AAO) events Recommendation 13: To the NSW Government That the NSW Government actively promote, by way of an advertising campaign, the principles of “Escape. Hide. Tell.”, including by encouraging operators and owners of Crowded Places to disseminate the messaging amongst staff, retailers, and attendees.

Part 6: The Events of 13 April 2024 Recommendation 14: To the Council for the Australian Bravery Decorations Given the evidence disclosing exceptional bravery on the part of a number of individuals who confronted Joel Cauchi on 13 April 2024, I recommend that the Council for the Australian Bravery Decorations review the relevant evidence in the Inquest and consider an appropriate award in recognition of their actions on that day – namely: Inspector Amy Scott; Ashlee Good; Noel McLaughlin; Damien Guerot; and Silas Despreaux.

Part 9: Response of NSWA to the events of 13 April 2024 Recommendation 15: To NSW Ambulance That NSW Ambulance confirm the introduction of Tranexamic acid (TXA) as part of the standard products carried in NSW Ambulance vehicle equipment.

Recommendation 16: To NSW Ambulance That NSW Ambulance’s current review of the NSW Ambulance Major Incident Response Plan (NSW AMPLAN) includes consideration of the following matters (as highlighted during the evidence received during the Inquest):

(a) The roles and responsibilities of commanders and the functional roles they are to undertake (including as defined in the Action Cards);

(b) The command structure roles;

(c) The adequacy of the training for, and exercising of, commanders to ensure they obtain and maintain competency;

(d) A new command tabard system to better identify commanders and functional role on scene (drawing on the UK National Ambulance Service, Command and Control Guidance (dated February 2024) as relevant); and

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 9

LIST OF RECOMMENDATIONS Part 9: Response of NSWA to the events of 13 April 2024

(e) Appropriate training in relation to major incident management and the amended AMPLAN document.

Recommendation 17: To NSW Ambulance That NSW Ambulance give further and expedited consideration to the status of the 2024 review into the Special Operations Unit (SOU) response capability, including the merits of the SOU operating as a standalone unit and with a view to increasing the capacity for Special Operations Team (SOT) resourcing.

Part 10: Emergency Services Interoperability Recommendation 18: To the NSW Government That the NSW Government (in consultation with the Commissioners of the NSW Police Force, NSW Ambulance, and Fire and Rescue NSW and other emergency services agencies as appropriate) convene an urgent working group involving relevant representatives from emergency services to consider a) development, and b) implementation, of an emergency services interoperability philosophy, model and framework for NSW (including drawing on the evidence from the Inquest and from the Joint Emergency Services Interoperability Programme (JESIP) framework and doctrine in the United Kingdom, as appropriate) to provide a clear structure and framework for multiagency responses to major incidents.

Recommendation 19: To the NSW Government That the working group urgently convened by the NSW Government (per Recommendation 18), consider the implementation of the Ten Second Triage (TST) rapid screening tool by emergency services in NSW, including having regard to the expert evidence from the Inquest as to a) the significant benefits that may flow from use of the tool, and b) the need for utilisation of the tool within a broader model of emergency service interoperability (as referred to in Recommendation 18).

Recommendation 20: To the NSW Police Force and NSW Ambulance That NSW Police Force and NSW Ambulance conduct a joint review of existing interagency radio communication protocols and processes in relation to major incidents, to identify potential areas for enhancement or improvement (including having regard to the principles identified in the JESIP Doctrine regarding communications between Control Rooms), by way of developing or improving joint operating protocols.

Recommendation 21: To NSW Ambulance That the Commissioner of NSW Ambulance (in consultation with relevant personnel from the NSW Police Force) review the potential utility of a Rescue Task

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 10

LIST OF RECOMMENDATIONS Part 10: Emergency Services Interoperability Force concept, including having regard to models utilised in other jurisdictions, to consider the feasibility of such a model for NSW Ambulance.

Part 11: Media reporting Recommendation 22: To the Australian Press Council That the Australian Press Council consider developing an advisory guideline to apply to the reporting of mass casualty incidents. The guideline should, amongst other matters, balance the need and desire for accurate, timely and informative reporting of such incidents, against the significant distress and grief that reporting (including graphic/inaccurate reporting) may have on a) victims; b) families/friends of any deceased; and c) members of the wider community who may be impacted by such incidents. Regard should be had to the Independent Press Standards Organisation (IPSO), “Guidance on reporting major incidents”, United Kingdom.

Recommendation 23: To the Australian Communications and Media Authority That the Australian Communications and Media Authority engage in consultation with the relevant broadcasting industry representatives to consider whether their Code(s) of Practice should be amended to expressly include provisions that govern the reporting of mass casualty incidents. The Code(s) of Practice should, amongst other matters, balance the need and desire for accurate, timely and informative reporting of such incidents, against the significant distress and grief that reporting (including graphic/inaccurate reporting) may have on a) victims; b) families/friends of any deceased; and c) members of the wider community who may be impacted by such incidents. Regard should be had to the Independent Press Standards Organisation (IPSO), “Guidance on reporting major incidents”, United Kingdom.

INQUEST INTO THE DEATHS AT WESTFIELD BONDI JUNCTION ON 13 APRIL 2024 11