Joel Cauchi’s mother didn’t appear before the coronial inquest examining her son’s life and the day her son murdered six people at a popular Bondi Junction shopping centre. But her presence was often felt, taking shape in the form of notes she had written to his doctor or in a conversation with a police officer.
One of the most striking moments of the inquest was when Michele Cauchi, now in her mid-70s, was filmed via body-worn video camera on a police officer.
She was standing outside her tidy home next to blooming hydrangeas, explaining how her son – who spoke multiple languages and had a university degree – had been deteriorating since he stopped taking medication. “I don’t know how we’re going to get him treatment unless he does something drastic,” she says.
These moments painted a picture of a mother engaging in a Sisyphean struggle to get her son – then living with untreated schizophrenia – help. But she could keep pushing only so far.
Person after person who gave painful evidence at the five-week inquest told a similar story of doing their best in a “fallible system”. It crystallised into a key takeaway: the system is letting down people in a crisis, like Cauchi.
‘The state has really just failed them’
Cauchi’s attack and the severity of it was a rare occurrence.
But the system’s failure to pick up on his slide after he stopped taking his medication for treatment-resistant schizophrenia is sadly a familiar story.
Psychiatrists who appeared as experts before the inquest said the vision when mental health asylums in Australia were dismantled in the 1970s was for community services to instead support those people in need.
But Queensland psychiatrist Prof Edward Heffernan told the inquiry the planned funding for community services “never really followed” the shift.
Psychiatrists also told the inquest that services hadn’t kept pace with population growth. Meanwhile, psychological distress was increasing across the population, and patterns of substance abuse and other modern stressors had made things worse.
Ian Korbel, a psychiatrist not part of the inquest, tells Guardian Australia he once worked in a mental health outreach team that would respond to people in crisis. But that program stopped running in the mid-2000s.
Korbel says the team that worked in Sydney’s eastern suburbs used to check the beaches for people experiencing homelessness. Cauchi was reportedly sleeping rough there before the attack.
Korbel says the faltering of services has resulted in the buck passing to police and the justice system. “They’re in the punishment business,” he says. “They shouldn’t respond to this, but the health system isn’t resourced to respond to it.”
Police are increasingly responding to such crises.
The inquest heard that in New South Wales, police responded to 40% more mental health incidents in 2022 compared with four years earlier.
Sen Sgt Tracey Morris told the inquiry: “We will always look at [those incidents] from a policing lens. That may lead to charges and them going through the court system when [it’s] effectively because of the mental illness.”
Morris works as the mental health intervention coordinator in the Queensland police district where Cauchi’s parents live, in Darling Downs. The day Cauchi’s mother spoke to police, they referred Joel to her role – which helps people link in with health services – for a follow-up check. But the officer acting in her role while she was on leave missed the email. This moment to get Cauchi help was described by a psychiatrist at the inquest as a “missed opportunity”.
Fighting back tears, Morris told the court this was no reflection on that officer’s capability, but a direct consequence of under-resourcing. At least four people should be doing her job in that particular police district, she said.
One of the cruelest ironies of that under-resourcing issue came during the inquest in a blink-and-you-might-have-missed it-moment, where Morris said no one was covering her role while she was at the inquest for the week. She couldn’t find anyone to backfill it.
Matthew Morgan, an expert in policing mental health responses who lectures at the Australian Catholic University, says: “The only people really to blame here is the government. If they’re not going to invest in a proactive and responsive mental health system that can provide the community around-the-clock care … then the buck stops with them.”
A recent report Morgan co-authored analysed Queensland coronial inquests into people fatally shot by police while experiencing a mental illness.
Twenty-four people have been fatally shot in the state since 2008. There is a clear patten, he says. “The state has really just failed them.
“There’s just lots of patterns of sporadic treatment, lack of follow-up care, and then the police get blamed for their criminalising and sometimes lethal response to such situations.”
‘Years of neglect’
The inquest heard there had been multiple improvements in crisis response since police spoke to Cauchi and his mother in January 2023.
Police can connect with health professionals to get advice on incidents, and there are co-response models where healthcare workers respond to call-outs alongside police.
Those changes – as Peggy Dwyer, counsel assisting the coroner, pointed out in the inquest – have come after multiple inquiries, internal police and government reports and coronial inquests. All make a similar recommendation: health professionals should respond to mental health crises, not police – at least not alone.
Joining calls for this change are families whose loved ones have been shot dead by police while they were suffering a psychosis. One of the loudest recent voices has been Judy Deacon, the mother of Jesse, who police shot dead in Glebe in 2023 after reports he was self-harming.
But co-responder models have not been rolled out nationwide, despite recommendations to do so. The leading model in NSW, known as Pacer, operates in just 20 of NSW’s 57 police commands.
During the inquest, Dwyer asked Dr Brendan Flynn, the executive director of the mental health branch of NSW Health: “Why has there not been an expanded Pacer across NSW where sufficient demand is demonstrated, when this report came out almost four years ago?”
Flynn responded: “It’s a resourcing issue. It would require new funds, and that’s a matter primarily for government.”
Later Dwyer asked: “Is there a risk that we just then get stuck here for another four years where there’s no rollout of more supports?”
Flynn replied: “I hope very much that’s not the case.”
Even if a version of Pacer were rolled out across NSW, Korbel says, more work needs to be done.
“Nowhere in Australia do we fund mental health as we should,” he says. “NSW is the worst. It gives 5% of its health budget to mental health.”
Korbel says that figure “would need to be doubled at least” to match similar programs in countries such as England and Canada.
Investment in health services can save money in the long term.
Prof Olav Nielssen, a Sydney-based psychiatrist who appeared before the inquest, spoke about a supported housing charity he works at. It supports people revolving between hospital, prison and the homeless sector.
He estimated the cost of having people in supported housing was a tenth of what it would otherwise cost having them bouncing around a network of hospitals, prisons and other institutions. He said NSW had “plans” to have 70 of these beds but that there should be 1,000 to meet the need.
Elizabeth Young, the mother of Jade Young, a victim of the stabbings, appeared before the inquest and described her 47-year-old daughter’s murder as the “stuff of nightmares”.
She also described it as the result of “years of neglect” within the mental health system.
“It seems to me that my daughter and five others were killed by the cumulative failures of numbers of people within a whole series of fallible systems.”
