Bondi Inquest Erupts: Psychiatrist Blamed, Security Lapses Exposed

Paul Riverbank, 11/28/2025A Sydney inquest into the Bondi Junction attack spotlights deep failures in mental health care and security, revealing raw grief, systemic gaps, and intense calls for reform—leaving a nation wrestling with how to better protect its most vulnerable citizens from future tragedy.

On the defensive was Dr Andrea Boros-Lavack, a psychiatrist with nearly a decade of treating Joel Cauchi—a man later described as “floridly psychotic” at the time of the attack. The inquest, intended to untangle systemic failings, quickly sharpened to a point. Barrister Sue Chrysanthou, speaking for several families, wasted little time, “She failed, we say, to take into account the signs and symptoms that he was exhibiting...” Her words, sharp with grief, landed in the hush like stones on ice. The subtext was unmistakable: someone should have connected the dots before it was too late.

At the same time, the psychiatrist’s lawyer, Mark Lynch, argued that expecting faultless foresight of such tragedy is unrealistic. “He decided for himself—‘I’m not going to take those anymore,’” Lynch observed of Cauchi’s medication. His tone, while measured, had an edge—a reminder that professionals are not omniscient, that adults sometimes fall beyond the reach of even the most vigilant care.

But that logic, for many in the gallery, was cold comfort. As the coroner’s court grappled with the uncomfortable realities of chronic mental illness, families stared at unanswered questions. Why did signals of Cauchi’s deteriorating health go unheeded? Several references were made to his transient life between states, his struggles with homelessness, and the gaps opening in the web of care just wide enough for him to slip through.

One especially uneasy moment came when Dr Boros-Lavack speculated, in a now much-criticized remark, that Cauchi’s violence might have been powered by fury and misogyny, not only psychosis. Counsel assisting, Peggy Dwyer, described the statement as “shocking,” and it clearly stung. Lynch, Dr. Boros-Lavack’s barrister, countered swiftly, labelling the questioning itself “grossly unfair.” But the families, already feeling the weight of things unsaid, were not mollified.

Security measures at the shopping centre became a second flashpoint. CR1, the control room operator on duty, stood at the centre of a heated debate. Described as “not sufficiently trained or equipped,” she had reportedly faced the chaos alone. For the Tahir family—Faraz Tahir was the security guard who lost his life—this detail was unbearable. Their lawyer, Lester Fernandez, stated plainly, “Scentre Group and Glad Group should never have allowed CR1 to work in the control room alone and unsupervised.” Those words triggered ripples of frustration throughout the room.

Of course, the pace and brutality of the attack meant even the strongest security measures might not have staved off every loss, or so argued Dean Jordan, representing the Scentre Group. “The practical reality,” he said, “is that even the most robust security measures... will not be able to completely prevent all active armed offender attacks.” Muffled, uncomfortable agreement met this line, but no one left convinced that nothing could have been improved.

It was clear by day’s end that this inquest is not just about apportioning blame. The coroner is poised to recommend a raft of changes: stricter guidelines for discharging psychiatric patients, a revamp of security protocols, even a fresh look at how the media discusses mass violence. The mention of bravery awards indeed came as a kind of balm—names like Inspector Amy Scott and Ashlee Good, who stood between strangers and harm, drew the first gentle nods and tears from family members in hours.

Ultimately, nothing promised in this courtroom can restore what was lost. The ultimate question, unspoken but everywhere: how do we bind up the wounds of something like this—and what must change so it cannot happen again? The answers may not fully come with the coroner’s findings in December. For now, the system stands on trial as much as any single person—flaws exposed, in hopes that remembering is itself a form of protection.

Even before the first witness took the stand, the mood inside the Sydney courtroom hinted at the lingering trauma over April’s Bondi Junction massacre. There were white-knuckled hands on tissue packets and sidelong glances exchanged between families who may never cross paths otherwise. The violence—swift and incomprehensible—still hangs over them. In three minutes, six people were killed and ten others wounded, and now, their loved ones sit here tracing the threads that led to that afternoon.On the defensive was Dr Andrea Boros-Lavack, a psychiatrist with nearly a decade of treating Joel Cauchi—a man later described as “floridly psychotic” at the time of the attack. The inquest, intended to untangle systemic failings, quickly sharpened to a point. Barrister Sue Chrysanthou, speaking for several families, wasted little time, “She failed, we say, to take into account the signs and symptoms that he was exhibiting...” Her words, sharp with grief, landed in the hush like stones on ice. The subtext was unmistakable: someone should have connected the dots before it was too late.At the same time, the psychiatrist’s lawyer, Mark Lynch, argued that expecting faultless foresight of such tragedy is unrealistic. “He decided for himself—‘I’m not going to take those anymore,’” Lynch observed of Cauchi’s medication. His tone, while measured, had an edge—a reminder that professionals are not omniscient, that adults sometimes fall beyond the reach of even the most vigilant care.But that logic, for many in the gallery, was cold comfort. As the coroner’s court grappled with the uncomfortable realities of chronic mental illness, families stared at unanswered questions. Why did signals of Cauchi’s deteriorating health go unheeded? Several references were made to his transient life between states, his struggles with homelessness, and the gaps opening in the web of care just wide enough for him to slip through.One especially uneasy moment came when Dr Boros-Lavack speculated, in a now much-criticized remark, that Cauchi’s violence might have been powered by fury and misogyny, not only psychosis. Counsel assisting, Peggy Dwyer, described the statement as “shocking,” and it clearly stung. Lynch, Dr. Boros-Lavack’s barrister, countered swiftly, labelling the questioning itself “grossly unfair.” But the families, already feeling the weight of things unsaid, were not mollified.Security measures at the shopping centre became a second flashpoint. CR1, the control room operator on duty, stood at the centre of a heated debate. Described as “not sufficiently trained or equipped,” she had reportedly faced the chaos alone. For the Tahir family—Faraz Tahir was the security guard who lost his life—this detail was unbearable. Their lawyer, Lester Fernandez, stated plainly, “Scentre Group and Glad Group should never have allowed CR1 to work in the control room alone and unsupervised.” Those words triggered ripples of frustration throughout the room.Of course, the pace and brutality of the attack meant even the strongest security measures might not have staved off every loss, or so argued Dean Jordan, representing the Scentre Group. “The practical reality,” he said, “is that even the most robust security measures... will not be able to completely prevent all active armed offender attacks.” Muffled, uncomfortable agreement met this line, but no one left convinced that nothing could have been improved.It was clear by day’s end that this inquest is not just about apportioning blame. The coroner is poised to recommend a raft of changes: stricter guidelines for discharging psychiatric patients, a revamp of security protocols, even a fresh look at how the media discusses mass violence. The mention of bravery awards indeed came as a kind of balm—names like Inspector Amy Scott and Ashlee Good, who stood between strangers and harm, drew the first gentle nods and tears from family members in hours.Ultimately, nothing promised in this courtroom can restore what was lost. The ultimate question, unspoken but everywhere: how do we bind up the wounds of something like this—and what must change so it cannot happen again? The answers may not fully come with the coroner’s findings in December. For now, the system stands on trial as much as any single person—flaws exposed, in hopes that remembering is itself a form of protection.