Inquest into the deaths at Westfield Bondi Junction Executive Summary

Contributing factors

• Gradual cessation of antipsychotic medications without adequate clinical monitoring for relapse
• Failure to adequately explain 86–90% relapse risk when ceasing antipsychotics to patient and family
• Inadequate response to early warning signs of relapse reported by mother October 2019–February 2020
• Failure to proactively encourage medication resumption despite recognised early warning signs
• Confirmation bias regarding patient's mental state and tendency to minimise warning signs
• Seriously deficient discharge letter when transitioning care in March 2020 lacking critical information
• Loss of mental health follow-up after relocation from Queensland to NSW
• Inadequate shared care arrangement between private psychiatry and general practice
• Cannabis use in context of untreated psychotic disorder

Coroner's recommendations

1. Health Ombudsman of Queensland to review Dr B.-Lavack's care and treatment of Joel Cauchi
2. RANZCP to amend Clinical practice guidelines for management of schizophrenia and related disorders
3. RANZCP to develop separate professional practice guideline on deprescribing antipsychotic medication where patients decline to remain on medication
4. RANZCP to collaborate with RACGP to develop shared care guidelines for patients with chronic schizophrenia including treatment-resistant schizophrenia
5. NSW and Queensland Police Commissioners and RANZCP to form working group to consider the role of psychiatrists in firearms risk assessment and whether this should be incorporated into weapons licensing legislation
6. RACGP to collaborate with RANZCP on development of shared care guidelines for chronic schizophrenia including treatment-resistant schizophrenia
7. NSW Government to model need for short-term accommodation for those experiencing mental health issues and homelessness, and establish and support those services
8. NSW Government to obtain advice on decline of mental health outreach services and additional resources required; improve system for provision of complex severe mental illness care; and ensure clinicians have access to contemporary deprescribing guidelines
9. Queensland Health to amend s157B of Public Health Act 2005 to include immediate risk of serious harm to others and expand definition of serious harm
10. Queensland Police Commissioner to evaluate service needs for Mental Health Intervention Coordinators in each region and consider increased staffing in Darling Downs region
11. NSW Government to consider options to support rollout of appropriate co-responder models for mental health crisis response throughout NSW
12. NSW Government to monitor and assess trial of amendments to Law Enforcement Powers and Responsibilities Act 2002 in respect of weapons wanding
13. NSW Government to actively promote principles of 'Escape. Hide. Tell.' by advertising campaign and encouraging dissemination amongst crowded place operators and staff
14. NSW Ambulance to confirm introduction of Tranexamic Acid as standard equipment in NSW Ambulance vehicles
15. NSW Ambulance to review NSW Ambulance Major Incident Response Plan addressing training, command and control structures, and procedures identified during inquest
16. NSW Ambulance to expedite consideration of Special Operations Unit becoming standalone unit with increased capacity and adequate ballistics protective equipment
17. NSW Government to convene urgent working group to develop and implement emergency services interoperability philosophy, model and framework drawing on JESIP principles
18. NSW Government working group to consider implementation of Ten Second Triage rapid screening tool by emergency services
19. NSW Police Force and NSW Ambulance to conduct joint review of interagency radio communication protocols and processes for major incidents
20. NSW Ambulance Commissioner to review potential utility of Rescue Task Force concept for coordinated police-ambulance response to major incidents
21. Australian Press Council to develop advisory guideline for reporting mass casualty incidents balancing accuracy against distress to victims and families
22. Australian Communications and Media Authority to engage with broadcasting industry to consider amendments to Code of Practice regarding reporting of mass casualty incidents
23. Five individuals recognised for extraordinary courage and bravery for referral to Council for Australian Bravery Decorations: Inspector Amy Scott, Ashlee Good, Noel McLaughlin, Damien Guerot, and Silas Despreaux