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.

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,........

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