The psychiatrist of the man who killed six people in a deadly stabbing rampage at a busy Sydney shopping centre has been criticised for failing to act on warning signs that his mental health conditions were deteriorating.

Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were killed by Joel Cauchi at Bondi Junction Westfield in Sydney’s east in April 2024.

Ten others, including a nine-month-old baby, were injured by the 40-year-old schizophrenic, who was experiencing psychotic symptoms.

On Thursday, coroner Teresa O’Sullivan found that while Cauchi’s psychiatrist Andrea Boros-Lavack made the right choice taking him off his antipsychotics in 2019, she then failed to follow up.

Boros-Lavack made “major failings” in not thinking that Cauchi’s psychotic symptoms had gotten worse, O’Sullivan found.

This was despite clear warning signs from his mother that he was hearing voices and writing notes believing he was under satanic control.

In her 831-page findings, O’Sullivan said Boros-Lavack did not then urge Cauchi to resume his medication and failed to provide the 40-year-old’s treating GP with enough information when she discharged him from her care.

However, O’Sullivan said the failings were not the sole cause of the mass stabbing, and in fact were one of a series of shortcomings.

O’Sullivan will refer Baros-Lavack to the Health Ombudsman of Queensland to review her care and treatment of Cauchi.

The 40-year-old was shot dead as he ran towards NSW Police Inspector Amy Scott, who was the first officer on the scene. The hero cop – who is battling cancer – was among those in Lidcombe Coroners Court on Thursday.

O’Sullivan commended Scott for her brave actions in facing Cauchi alone.

“They were extraordinary, calm, skillful and courageous and actions which clearly saved lives,” she said.

Inspector Amy Scott arrives at court for Thursday’s hearing. Photo: AAP

The shopping centre’s emergency evacuation alarm wasn’t activated until two minutes after Scott fatally shot Cauchi.

O’Sullivan found that the sole CCTV operator in the Westfield control room was not competent enough to handle the stressful situation.

She blamed management of security firms Scentre Group and subcontractor Glad, who should have been aware of the operator’s inexperience and made sure staffing was better.

Among O’Sullivan’s other recommendations are that the NSW government get advice on the decline of and demand for mental health outreach in the state. The state has also been advised to inquire about mental health resources and develop a timeline to to improve these services.

O’Sullivan also recommended the government promote the “Escape, Hide, Tell” slogan to encourage civilians to remain safe when an armed offender was in the loose.

-AAP