First lessons learned in the wake of a mass killing

Quick thinking, cool heads and courage prevented a violent mass stabbing becoming much worse despite missteps in its aftermath.

It has been over a year since Joel Cauchi launched an unprovoked three-minute knife attack on weekend shoppers in Sydney that shocked a nation.

The 40-year-old was shot dead by police after his April 2024 rampage at Westfield Bondi Junction but only after he had killed six victims and injured 10 others, including a nine-month-old baby.

As an inquest into the tragedy wraps up its first week, the NSW Coroners Court has heard multiple revelations about what happened and what went wrong.

The court was shown dramatic CCTV footage of the moments just before NSW Police Inspector Amy Scott fired at an armed Cauchi as he ran at her on the mall's air-bridge.

The court heard the then-homeless man was "floridly psychotic".

Diagnosed with schizophrenia as a teen, Cauchi had been successfully treated while living with his family in Toowoomba, near Brisbane.

However, his mental condition deteriorated after he ceased taking anti-psychotic medication in 2019.

He was also cut off from psychiatric sessions after moving to the state capital in early 2020.

By the time of the Westfield rampage, Cauchi was "completely detached from the mental health system," counsel assisting Peggy Dwyer SC said.

Police seized his phone after the incident, uncovering disturbing web searches that had shown a preoccupation with killing, serial killers, weapons and death since at least 2022.

Officers also found a number of notes on his phone indicating rudimentary planning for an attack including to "check out malls and also where to run".

Despite this, Dr Dwyer said there was no direct evidence for any motive.

Detective Chief Inspector Andrew Marks, the officer-in-charge of the investigation, said there was no evidence Cauchi adhered to terrorist or extremist ideology, nor had he specifically targeted women.

"From the start of his attack, he moved very quickly and he appeared to attack people that were not ready, didn't know what was happening," he told the inquest.

What is clear from the evidence is that the actions of Insp Scott saved many lives.

The officer was the first to arrive and decided to enter the mall alone at 3:37pm without waiting for backup.

Pushing aside nausea and a realisation she could be about to die, she pursued Cauchi through the mall for 85 seconds before he turned and ran at her with the knife.

Flanked by shoppers she'd moments earlier ushered behind her, she fired three shots.

Two hit Cauchi and he fell onto the ground 6.5 metres in front of her.

Insp Scott told the court she sought to eliminate the threat despite overwhelming odds against her.

"You're looking at a 60 to 70 per cent chance of non-survival and that's if you're partnered up and vested up, and I was neither of those," she said.

Witnesses repeatedly gave thanks to the hard work of police and paramedics who put themselves in danger to help others that tragic day.

The efforts of shoppers and mall staff were also recognised after they came together to whisk the vulnerable from danger or administer first aid to the injured.

This included French nationals Damien Guerot and Silas Despreaux who attempted to fend Cauchi off with bollards.

"That day, as tragic as it is, it gave me faith in humanity, restored some faith in humanity and the goodness of people," Insp Scott said.

A number of unfortunate missteps, mistakes and plain bad luck also impeded the response to Cauchi's attack.

In an outstanding coincidence, the mall's CCTV control room was unmanned at the moment he stabbed his first victim.

The room's sole security officer went to the bathroom 40 seconds earlier and did not return for 105 seconds.

By that stage, Cauchi had attacked eight individuals, three whom later died.

This stroke of bad luck impeded the initial response by security guards in the mall, forcing them to play catch-up.

An emergency alert telling shoppers and staff what to do was only issued after the 40-year-old had been shot.

It was also the wrong alert for such an attack, telling people to evacuate rather than "escape, hide, tell" due to an armed offender.

Emergency alarms turned on after Cauchi had been stopped were "extremely loud" and impeded communication between police and paramedics, the inquest was told.

The firm that owns Westfield, shopping mall giant Scentre, told the inquest its alarms had been tested and complied with Australian standards.

Dr Dwyer noted that these communication issues did not affect the outcome because of Insp Scott's swift actions.

"If (Insp Scott) had not been on the scene so quickly, there's a real possibility Mr Cauchi's attacks would have continued unabated for a further period," she said.

The duty officer leading the Special Operations Team - a specially trained team of paramedics used for high-risk situations - was also not informed of the attacks and only learned of it "by accident" chasing up another matter.

Essential personal protective equipment like ballistic helmets and vests used by the specialist paramedics was stored at a central repository instead of on-site with officers around Sydney.

This meant it took longer than required to get this crucial equipment to Bondi Junction.

There was also confusion and miscommunication around a potential second offender, leading to NSW Ambulance assistant commissioner Brent Armitage declaring the mall a "hot zone" around 4.30pm.

This meant paramedics were barred from entering the complex.

The call was made despite police knowing by about 4pm there was only one offender and he had been shot.

But it did not affect any medical outcomes as all victims had already been removed from the mall.

Critical care paramedic Chris Wilkinson said he arrived just after 4pm but was barred from entering by police.

He described feeling frustrated by what was happening.

"I felt inadequate being forced to stay on the outside when I thought people may be passing away on the inside," he told the court.

A joint tactical command meeting between police, ambulance and security staff only took place at 5.30pm.

An international security expert is expected to tell State Coroner Teresa O'Sullivan this was much too late.

The inquest, continuing on Monday, is due to run until the end of May.