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A recent inquest has revealed that the psychiatrist of a man responsible for a tragic mall shooting, resulting in six deaths, did not respond adequately to warning signs when he discontinued his antipsychotic medication.
The 40-year-old individual, diagnosed with schizophrenia, injured ten others, including a nine-month-old baby, while experiencing severe psychotic episodes.
Coroner Teresa O’Sullivan concluded that although psychiatrist Andrea Boros-Lavack initially made a justified decision in 2019 to stop the man’s antipsychotic treatment, the subsequent lack of follow-up was a critical oversight.
Dr. Boros-Lavack exhibited “significant failings” by not recognizing the deterioration in Cauchi’s mental state.
These oversights were highlighted by reports from his mother, who noted that he was hearing voices and writing alarming notes, indicating he believed he was under satanic influence.
In her 831-page findings, O’Sullivan said Boros-Lavack did not then urge Cauchi to resume his medication and failed to provide the 40-year-old’s treating GP with enough information when she discharged him from her care.
However, the coroner said these failings were not the sole cause of the mass stabbing, saying they were but one of a series of shortcomings.
O’Sullivan will refer Baros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Cauchi.
The 40-year-old was shot dead as he ran towards NSW Police Inspector Amy Scott, who was the first officer on the scene.
The hero cop attended Lidcombe Coroners Court today.
O’Sullivan commended the police officer for her brave actions in facing Cauchi alone.
“They were extraordinary, calm, skillful and courageous and actions which clearly saved lives.”
It was not until two minutes after Cauchi was fatally shot by Scott that the emergency evacuation alarm was activated.
O’Sullivan found that the sole CCTV operator in the Westfield control room was not competent enough to handle the stressful situation.
She blamed management of security firms Scentre Group and subcontractor Glad, who should have been aware of the operator’s inexperience and taken steps to ensure better staffing.
The coroner made a series of recommendations, including that the NSW government obtain advice on the decline of and demand for mental health outreach in the state.
The state has also been advised to inquire about mental health resources and come up with a timeline to improve these services.
The coroner also recommended the government promote the “Escape, Hide, Tell” slogan to encourage civilians to remain safe when an armed offender was on the loose.
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