Lessons from Bondi Junction attack show what we really need from schizophrenia care

Joel Cauchi’s psychiatrist failed to see the early warning signs of his relapse into psychosis and should be investigated by the Queensland health ombudsman, New South Wales coroner Teresa O’Sullivan has concluded.

Cauchi, who had a recurrent form of schizophrenia, was un-medicated and homeless when he killed six people and injured ten others at the Westfield shopping centre in Bondi Junction in 2024.

In the 837-page coronial inquest report, released yesterday, O'Sullivan outlined how Cauchi’s psychiatrist weaned him off his medication and discharged him to his GP in 2020. He lost touch with family in Queensland and was sleeping rough in Sydney at the time of the attack.

The care provided was “one of the factors that led to this tragic outcome,” O'Sullivan said.

The tragedy has again exposed a system that doesn’t reach out to those who are most unwell.

The coronial report makes several recommendations to improve the care of people with schizophrenia, encourage the use of medication and boost housing and social supports for people with severe mental illness.

How can schizophrenia affect thoughts and behaviour?

Severe, untreated schizophrenia can rob a person of their capacity to understand their normal environment, form rational thoughts or stop antisocial or violent behaviours. This is known as psychosis.

People with schizophrenia may receive false information, through auditory or visual hallucinations or misinterpretations of social cues, and may develop complex, paranoid but wrong explanations (known as delusions) of ordinary events.

A person with acute schizophrenia is often terrified: afraid of the harm that some threatening entity is about to do them. Sometimes they lash out against people they perceive to be driving those threats.

How is schizophrenia managed?

The symptoms of acute schizophrenia can usually be treated with medications. These reduce hallucinations and delusions, agitation and the risks to the person or others that arise from these experiences.

But there is often a price to pay in terms of side-effects. These medications can cause sedation, weight gain, sexual dysfunction and emotional numbing.

Many people are keen to stop the medicines as soon as they regain reasonable control over their life.

Why family and support is crucial

Seeing a loved one experience recurrent episodes of psychosis can be traumatic for family and carers. They are the ones at greatest risk from the unpredictable or threatening behaviours that may accompany the illness.

Over time, a person with un-managed schizophrenia can become disconnected from, family, housing and social supports. Homelessness and social isolation can quickly follow.

As these connections are lost, they may experience a recurrence of their psychotic state. Stopping medical care accelerates this process.

Once a person with schizophrenia is out of home, and out of their local community, the chances that our private or public mental health services will maintain contact is very low.

The worst outcome

The tragedy here is that Cauchi was effectively treated while engaged with Queensland’s public mental health services and, at that time, posed no threat.

But when he stopped treatment, with the assistance of his psychiatrist, he quickly relapsed.

His family raised concerns about his deteriorating mental state but this information was not validated or acted on.

In a psychotic state, Cauchi abandoned his family and health care supports. He moved interstate and became homeless.

NSW health authorities were not looking for him. No one had an agenda to reconnect him to care or provide continuity of support. The result was catastrophic.

Housing is intricately linked

This is not an isolated story. Thousands of people with mental illness, often young men, are living transient lives in cars, temporary accommodation or on couches. They are disconnected from family, housing and services. They are largely invisible to our mental health system.

Rough sleeping has surged to record levels in Australia, and the system set up to house and support the most vulnerable people is in crisis.

While Australia has repeatedly acknowledged that proactive, home-based care is optimal, investment has remained limited and inconsistent. Australia’s mental health spending is predominantly directed towards hospital inpatient and emergency services, not in the community.

What are the solutions?

To prevent another attack, coroner O'Sullivan recommends:

• the NSW government establish and support short- and long-term accommodation for people with severe mental illness, with accessible, ongoing mental health care

• renewed investment in outreach psychiatric services capable of engaging people who are severely unwell, including those without housing

• clinical bodies develop up-to-date guidelines for psychiatrists who “de-prescribe” anti-psychotic medications for patients with schizophrenia

• indefinite monitoring of patients who choose to stop treatment

• better guidance for clinicians and families on how to recognise the early warning signs of a relapse and what to do next.

Effective community-based care for people with severe mental illness also relies on better service coordination. It requires clinical services delivered by states, housing and social support that are largely funded federally, and implementation tailored to local and regional needs.

We have a new hospital funding agreement between the Commonwealth and states. We now we need a similar commitment to mental health care between state, Commonwealth and local services to improve the care for people with severe mental illness and prevent further tragedy.

Australians understand mental illness better now than previous generations. They expect this part of our health system to function like any other medical care, which should be affordable, accessible and effective.

If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.