A psychiatrist who treated the man behind a fatal stabbing rampage at a crowded Sydney shopping centre will be referred to health investigators after a coronial inquiry.

Joel Cauchi, first diagnosed with schizophrenia in his teens, was unmedicated and homeless when he stabbed 16 people inside Westfield Bondi Junction in 2024, killing six.

The New South Wales coroner said Andrea Boros-Lavack had provided 40-year-old Cauchi exemplary care over a long period, but failed to heed warnings from family that he may be relapsing, years before the attack.

This mistake was one of many that led to the tragedy, the coroner said, also pointing to a series of actions by police and shopping centre security.

Six people - Dawn Singleton, 25; Yixuan Cheng, 27; Jade Young, 47; Ashlee Good, 38; Faraz Tahir, 30; and Pikria Darchia, 55 - died during the attack in April 2024. Ten others, including Good's baby, were injured in the three minutes before Cauchi - who was suffering a psychotic episode - was shot dead by New South Wales (NSW) police inspector Amy Scott.

The coronial inquest, which heard from dozens of witnesses, aimed to uncover the events leading up to the attack and to prevent such a tragedy from occurring again. Coroner Teresa O'Sullivan found missed opportunities for intervention by police and a lack of adequate care led to the devastating outcome.

She recommended that the psychiatrist, Boros-Lavack, be investigated by Queensland health authorities due to family calls for accountability. Additionally, the coroner cited systemic issues with mental health outreach services and emphasized the need for the NSW government to enhance support for individuals with mental health challenges.

Furthermore, O'Sullivan criticized some media coverage, indicating that it exacerbated existing trauma for victims' families, while also praising emergency services for their rapid response during the crisis.