For the first time in nearly 14 years, Joel Cauchi wasn’t on any antipsychotic medications.
He lived separately from his parents, pursued studies with aspirations to become a Chinese language interpreter.
It was in June 2019.
Cauchi ceased using all psychotropic medications, and his psychiatrist at the time noted that his true personality was beginning to surface.
However, by April 13, 2024, the individual who had uncovered a way of living without experiencing the side effects of his medication was described as “severely delusional” according to Counsel Assisting the Coroner Peggy Dwyer SC during the inquiry into the Bondi Junction stabbing incident.
Equipped with a knife, 40-year-old Cauchi went into the Westfield Bondi Junction shopping centre in eastern Sydney and fatally wounded six individuals, leaving ten more injured during this violent outbreak. He was killed later by an officer from the police force.
Over the last five weeks, New South Wales Coroner Teresa O’Sullivan has overseen an emotionally charged inquiry into the disaster, aiming to unveil the errors and deficiencies that resulted in the fateful day which altered countless lives irrevocably.
She will examine how Cauchi slipped “through the cracks” of the mental health system, as was revealed during the inquest, essentially getting “lost within the system.”
And whether healthcare workers and law enforcement took adequate measures to stop it.
Schizophrenia diagnosis
The inquiry extensively listened to testimonies from Cauchi’s attending physicians, experts, and nursing staff.
Born on June 13, 1983, he began exhibiting behavioral shifts around the age of 14 as noted by his family.
He resided in his hometown of Toowoomba, an inland metropolis situated to the west of Brisbane.
When he turned 17, he was admitted to the Toowoomba Hospital and remained there for nearly a month.
He informed medical professionals about experiencing hallucinations, describing visions of and sensations from what seemed like demonic entities invading him. He felt as though his actions were being manipulated and believed others were implanting ideas into his head.
The preliminary diagnosis indicated paranoid psychosis along with schizophreniform disorder, which is a psychiatric condition akin to schizophrenia but does not persist for more than half a year.
Half a year afterward, he received a diagnosis of schizophrenia.
For nearly 14 years, Cauchi was treated with the drug Clozapine – an antipsychotic medication used solely when two other types of treatment prove ineffective at managing psychosis symptoms.
From 2012 to 2015, Cauchi, along with his treating psychiatrist Andrea Boros-Lavack and his family, decided to gradually decrease his dosage of Clozaril.
In early 2016, Dr Boros-Lavack documented: “Joel became increasingly lively, communicative, and positively engaged with his feelings. He expressed gratitude for experiencing these emotions as he decreased his dosage of Clopine.”
So far, there have been no adverse effects. Discussed aiming to become a Chinese language interpreter, followed by finding a lovely wife, purchasing a home, and having a stable job to lead a good life at work and in daily routines.
The doctor mentioned that Cauchi was highly engaged in the procedure of decreasing the potent medication and expressed fear about experiencing a relapse.
By mid-2018, he stopped taking Clozapine but continued with another medication known as Abilify, until it was discontinued in June 2019.
Cauchi left his parents’ house and started living alone in a nearby apartment. According to Dr Boros-Lavack, he advanced from being unable to brew a simple cup of tea to preparing two-minute noodles. She described this achievement as a significant “milestone.”
Dr Boros-Lavack stated her desire to maintain Cauchi in psychiatric care for the remainder of his life.
Mum’s concerns
In November 2019, Cauchi sent an email to Dr Boros-Lavack’s clinic, asking for suggestions on how to create a pornography-free phone and other gadgets.
He voiced worries regarding his overuse of pornography and the resulting sleeplessness.
In the same month, Cauchi’s mother Michele contacted the clinic stating that her son was “quite ill” after stopping his medication and requested he be evaluated.
That same month, Michele Cauchi sent an email to the clinic, informing them about the steady deterioration in her son’s health after he stopped taking the medication.
She mentioned that he had been placing notes on papers throughout the area, and she thought he might be experiencing auditory hallucinations.
She mentioned that his OCD had become quite severe, noting that he used up an entire cake of soap during just one shower.
Last week, Mr Cauchi discovered that the organization where he volunteers as an English teacher hired a new person, and he had been looking forward to potentially joining their team, which came as quite a disappointment for him, she mentioned.
I’d be devastated if he had to return to the hospital after 20 years of stability with his current medications. However, coming off them has helped him recognize just how drowsy they were making him feel. He might not disclose everything happening inside his mind, but I believe you should be aware of his condition.
Mrs Cauchi had gone through some of the notes written by her son. These mentioned being “under satanic control” and explored various religious ideas.
It was decided to restart the medication Abilify at a low dosage.
Doctor Boros-Lavack was concerned it might be early indications of a potential recurrence of schizophrenia.
Cauchi chose not to take the medication.
‘He wasn’t delusional,’ says psychiatrist
During her conversation with Dr Dwyer, Dr Boros-Lavack asserted that she didn’t think Cauchi was suffering from psychosis when his mother raised her concerns.
Actually, she mentioned that he was scared about potentially contracting HIV following a sexual experience and went to the hospital for antiviral medication.
“It wasn’t due to psychosis. Nor were these early indicators of an impending episode. The issue stemmed from his fear of sexually transmitted diseases. He also expressed feelings of sexual frustration, discussing later how this related to encounters with prostitutes, general interactions with women, and issues around sexuality,” explained Dr Boros-Lavack at the inquest.
Her most recent in-person meeting with Cauchi took place on January 8, 2020.
Dr Dwyer suggested to her that she likely suspected back then there could be signs of psychosis, considering what was reported by his mother and the conflicts occurring at home.
Dr Boros-Lavack’s response was clear-cut: “I had absolute certainty that he was not psychotic, and those initial indicators suggesting a possible relapse were mistaken. There was nothing indicating psychosis.”
A month later, Cauchi’s mother again rang the clinic, expressing concern that his self-care was poor, his place was a mess, he was isolated and irritable and swearing.
‘A missed opportunity’
A group of five psychiatrists, appointed by the court to assess Cauchi’s mental health care, concurred that it was “appropriate” for Dr Boros-Lavack to decrease Cauchi’s dosage of Clozapine with the aim of determining an “ideal dose.” This adjustment was intended to lessen the undesirable side effects associated with the medication.
But one of the psychiatrists, Edward Heffernan, said he counted nine occasions that were of concern – relating to insomnia, his mother suspecting symptoms, a change in behaviour and satanic control.
“To me, this flags we are probably having a psychotic episode here,” Professor Heffernan said.
Merete Nordentoft, a prominent Danish psychiatrist, stated that the worries were insufficiently addressed and characterized this timeframe as a “lost chance” to reintroduce antipsychotic drugs for Cauchi.
At the start of the proceedings, Dr Dwyer stated that the inquiry would examine Cauchi’s mental healthcare. He had received virtually no treatment and insufficient oversight for almost half a decade prior to the murders at Bondi.
“As evidenced in the document provided, Mr Cauchi engaged multiple times with Queensland police officers; particularly noteworthy was an event in January 2023 when local law enforcement responded to Mr Cauchi’s residence in Toowoomba due to an occurrence wherein his father took possession of several knives akin to those reportedly wielded by Mr Cauchi during the incident on April 13, 2024,” stated Dr Dwyer.
Mr Cauchi’s father expressed concern over his possession of the knives, and the court will examine if this presented a chance overlooked by law enforcement for early intervention. This could potentially have led to Mr Cauchi reconnecting with the mental health services back then.
By April 2024, Cauchi remained without medication for nearly half a decade and was living as a homeless person in Sydney after relocating there.
Dr Dwyer stated, “He did not have any steady or organized involvement with either the mental health care network or the broader healthcare system, leading him to essentially fall through the cracks. The tragic outcomes of April 13th were direct consequences of this lack of follow-up.”
The main concerns of this inquiry revolve around how things transpired and what alternative actions might have been taken.
The inquest has been put on hold until October, at which time submissions will be reviewed before making any coroner’s recommendations.
