Joel Cauchi’s mother did not testify at the coroner’s inquest investigating her son’s life and the tragic day when he killed six individuals at a well-known shopping center in Bondi Junction. However, her influence was frequently evident through the notes she left behind.
written to his doctor
or in a
discussion with a law enforcement agent
.
One of the most notable instances during the inquest occurred when Michele Cauchi, who is in her mid-70s, was recorded using a body-worn video camera operated by a police officer.
Standing beside her well-kept house adorned with blossoming hydrangeas, she shared details about her son — fluent in several languages and possessing a university degree — whose condition has been worsening since he discontinued his medications. “Without some severe incident happening, I’m not sure how we can secure help for him,” she remarks.
These moments painted a picture of a mother engaging in a Sisyphean struggle to get her son – then living with untreated schizophrenia – help. But she could keep pushing only so far.
Related:
A heartbroken mother told an inquest she feels “lost” following the ‘horrifying’ murders at Bondi Junction.
One after another, those giving heart-wrenching testimony during the five-week inquiry recounted stories of trying their hardest within an “imperfect system.” This consensus emerged as a crucial insight: the system is failing individuals in times of crisis, much like what happened with Cauchi.
‘The state has genuinely let them down.’
The assault carried out by Cauchi and its intensity were uncommon events.
However, the system’s inability to detect his decline after he ceased taking his medication for treatment-resistant schizophrenia is unfortunately a common tale.
The psychiatrists testifying at the inquiry indicated that back in the 1970s, the prevailing view regarding mental health institutions in Australia was for community-based services to take over the role of supporting individuals requiring assistance.
However, Queensland psychiatrist Professor Edward Heffernan informed the inquiry that the intended funding for community services “did not actually follow” the transition.
The psychiatrists informed the inquest that support services had failed to keep up with the rising population. Additionally, they noted that mental distress was escalating among the general public, compounded by heightened issues related to substance misuse and other contemporary pressures.
Ian Korbel, a psychiatrist not part of the inquest, tells Guardian Australia he once worked in a mental health outreach team that would respond to people in crisis. But that program stopped running in the mid-2000s.
Korbel mentions that the group operating in Sydney’s eastern suburbs would regularly patrol the beaches to look for individuals who were homeless. It is reported that Cauchi was living rough in the area when the incident occurred.
Korbel states that the decline in service quality has led to responsibility being shifted onto the police and judicial systems. “Their role is punishment,” he comments. “This should not be their duty, yet the healthcare sector lacks the resources needed to address this issue.”
Law enforcement officers are frequently called upon to handle these emergencies.
The inquiry revealed that in New South Wales, law enforcement dealt with 40% more mental health cases in 2022 than they did four years prior.
Sergeant Tracy Morris informed the inquiry, “Our approach will always be through a law enforcement perspective. This could result in charges being filed and individuals proceeding through the judicial process, even though these actions are primarily due to mental health issues.”
Morris serves as the mental health intervention coordinator within the Queensland police division located in Darling Downs, near where Cauchi’s parents reside. When Mrs. Cauchi contacted law enforcement, they directed her to Morris’ position, aimed at assisting individuals connect with healthcare providers, for further evaluation. However, an officer who temporarily assumed Morris’ duties overlooked this crucial email during her absence. A psychiatrist later characterized this lapse as a “lost chance” during the coroner’s investigation.
Related:
Is the inquest into the Bondi Junction murders further stigmatising schizophrenia?
Struggling to hold back tears, Morris informed the court that this situation did not reflect the officer’s competence but was instead a result of inadequate resources. According to her, at least four additional personnel should be assigned to her role within that specific police division.
The harshest twist of the under-resourcing problem surfaced briefly during the inquest, almost slipping past unnoticed. Morris mentioned that nobody covered her responsibilities while she attended the proceedings for the week. She struggled to locate someone willing to fill in.
Matthew Morgan, an expert in policing mental health responses who lectures at the Australian Catholic University, says: “The only people really to blame here is the government. If they’re not going to invest in a proactive and responsive mental health system that can provide the community around-the-clock care … then the buck stops with them.”
A recently published report co-authored by Morgan examined Queensland coroners’ investigations into instances where individuals were killed during encounters with police while suffering from mental illnesses.
Since 2008, twenty-four individuals have lost their lives to gunshots within the state. He points out a distinct pattern: “The state seems to have utterly let them down.”
There are numerous instances of inconsistent medical intervention, coupled with inadequate aftercare, which often leads to law enforcement being criticized for their punitive—and occasionally fatal—actions when dealing with these circumstances.
‘Years of neglect’
The inquest heard there had been multiple improvements in crisis response since police spoke to Cauchi and his mother in January 2023.
Law enforcement officers have the ability to consult with health experts for guidance during incidents, and some regions employ co-response strategies where medical personnel accompany police when attending calls.
These modifications – as Peggy Dwyer, the counsel assisting the coroner, highlighted during the inquest – were implemented following numerous investigations, internal law enforcement and governmental reports, along with coronal inquests. Each of these sources suggests a consistent approach: healthcare providers ought to address mental health emergencies instead of police officers – ideally not without support from others.
Families supporting this shift include those who
loved ones have had their lives taken by gunfire
By law enforcement while enduring a psychotic episode. Recently, one of the most prominent advocates has been Judy Deacon, Jesse’s mother.
whom the police killed in Glebe
In 2023 following claims that he was engaging in self-harm.
However, co-response models haven’t been implemented across the country, even though they’ve been recommended for wider adoption. In New South Wales, the foremost model called Pacer is active in only 20 out of the state’s 57 police jurisdictions.
At the inquest, Dwyer questioned Dr Brendan Flynn, who serves as the executive director of the mental health division at NSW Health, with the following inquiry: “Given that this report was published nearly four years ago and substantial demand exists, why hasn’t PacER been rolled out more extensively throughout New South Wales?”
Related:
Less than 2% of the promised $1 billion for mental health from Labor would be allocated for spending in the coming fiscal year.
Flynn replied, “This is about resources. Securing additional funding is necessary, which ultimately depends on the government.”
Dwyer later questioned: “Could it be possible that we remain stagnant here for an additional four years without any further support being implemented?”
”
Flynn responded: “I sincerely hope that isn’t true.”
Despite the rollout of a version of Pacer across NSW, Korbel indicates that additional efforts are required.
“We don’t allocate sufficient funds for mental health anywhere in Australia,” he states. “New South Wales is at the bottom. It allocates only 5% of its healthcare budget to mental health.”
Korbel states that this number “should be increased twofold at minimum” to align with comparable initiatives in places like England and Canada.
Putting funds into healthcare services may reduce expenses over time.
Professor Olav Nielssen, a Sydney-based psychiatrist who testified during the inquest, discussed his work with a supported housing charity. This organization assists individuals who frequently move between hospitals, prisons, and homelessness services.
He calculated that supporting individuals in subsidized accommodation costs approximately one-tenth of what it would typically require to manage their needs through repeated hospital stays, incarcerations, and involvement with various facilities. He mentioned that NSW aimed for 70 such beds but emphasized that at least 1,000 are necessary to adequately address the demand.
Elizabeth Young, the parent of Jade Young, who was a victim of the
stabbings
appeared before the inquest and depicted her 47-year-old daughter’s murder as “nightmare material.”
She likewise characterized it as a consequence of “decades of disregard” within the mental health sector.
It appears to me that my daughter and five others lost their lives due to the combined lapses of several individuals across various flawed systems.
• In Australia, the crisis support service
Lifeline
Is 13 11 14. In the UK and Ireland,
Samaritans
can be reached via toll-free number 116 123, or through an email
[email protected]
or
[email protected]
. In the United States, you have the option to make a phone call or send a text message using 911.
National Suicide Prevention Lifeline
on 988, chat on
988lifeline.org
, or
text HOME
Call 741741 to reach a crisis counselor. You can find additional international hotlines at
befrienders.org
