The exposure of failures leading to a terrifying shopping mall mass killing has piled pressure on authorities to avoid such an incident happening again.
Joel Cauchi, 40, armed himself with a hunting knife and was experiencing psychotic symptoms when he killed six people and injured 10 others in April 2024.
Jade Young, 47, Dawn Singleton, 25, Ashlee Good, 38, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were slain at Bondi Junction Westfield in Sydney's east.
On Thursday, coroner Teresa O'Sullivan released her findings about the shortfalls that led to the tragic event.
This included a major failure by Cauchi's psychiatrist who neglected to follow up properly after he had ceased taking antipsychotics.
The coroner also identified more systemic issues such as difficulties in tracking those with mental illness who did not have housing and insufficient psychiatric guidelines around un-prescribing patients from medication.
The coroner imposed 23 separate recommendations directed to the NSW government, NSW Police and other official bodies.
The Royal Australian and New Zealand College of Psychiatrists committed to following the coroner's suggestions about strengthening mental health treatment and care.
“We must be clear: under-resourced, fragmented systems increase the likelihood that vulnerable people fall through the cracks with significant consequences for them, their families, and the wider community," said college president Astha Tomar.
The NSW government has been urged to improve mental health outreach services and accommodation offerings for those without housing.
Premier Chris Minns stopped short of making any promises, saying the government would carefully consider the recommendations.
"We will now ... work to implement measures that strengthen our mental health system and community safety."
Scentre Group - which was criticised for leaving a less-than-competent security officer unsupervised in the CCTV control room at the time of the attack - also did not commit to following Ms O'Sullivan's suggestions.
Instead, a spokesperson said the company would review the inquest report and that safety was the highest priority.
NSW Police Commissioner Mal Lanyon took a similar line, saying the force still had to conduct a comprehensive review of the coroner's findings.
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