Joel Cauchi stands on the nature strip outside his parents’ tidy Queenslander home in Toowoomba, waiting for the police.
On this day in January 2023, Cauchi is friendly and calm. He tells one of the officers: “I just would like to record a crime, if that’s OK.”
The footage, captured by police body-worn cameras and played this week in a coronial inquest, makes for a striking comparison with the images of Cauchi 15 months later when he roamed Westfield in Bondi Junction with a 30cm blade, stabbing six people to death and injuring 10 others.
In the 2023 footage, Cauchi has a cordial chat to Sen Const Matthew McDonnell. Cauchi explains he has called the officers to his parents’ home to make a complaint over his dad stealing his “collector’s items” knives. Cauchi says he’s not sure why his dad took the knives – he’s tried to negotiate with this dad, but his dad is “not willing” to give them back.
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His mother, who stands closer to the house next to blooming hydrangeas, tells the other officer her version of the story. Cauchi’s weapons are “pigging” knives, she says. His 75-year-old dad took the knives away because Cauchi has been “in a rage” and hearing voices.
“When he’s on medication he’s a totally different person,” Cauchi’s mother can be heard telling the officer in body-worn camera footage. “He doesn’t know he is sick.”
“I don’t know how we’re going to get him treatment unless he does something drastic.”
On 13 April last year, something drastic did happen. Cauchi fatally stabbed Ashlee Good, 38, Jade Young, 47, Yixuan Cheng, 27, Pikria Darchia, 55, Faraz Tahir, 30, and Dawn Singleton, 25, before he was fatally shotby police inspector Amy Scott.
This week the coronial inquest into the attack heard Cauchi’s voice for the first time – and about earlier chances to intervene that were not taken.
Of the five Queensland police officers who appeared before the inquest this week, two had responded to Cauchi’s call for help the day he alleged his dad stole his knives.
They were each asked by senior counsel assisting Peggy Dwyer SC if they agreed with a psychiatrists assessment that this moment was a “missed opportunity”. They all did.
“There was no signs he was a threat to himself or others but I believe it warranted further intervention,” McDonnell, who spoke to him that day, told the court on Monday.
At the time, Cauchi was not medicated for his schizophrenia, the court heard. He had been weaned off medication by a psychiatrist and was meant to be monitored – but wasn’t.
McDonnell emailed a police officer known as the mental health intervention coordinator, or MHIC, explaining the interaction and asked for a follow-up. But the officer, who was acting in the MHIC role at the time, forgot to follow up after becoming caught up with another job.
On Tuesday, Sen Sgt Tracey Morris – the officer who had been away at the time and is normally the sole MHIC for a region of 220,000 residents – cried when asked about her colleague, Sen Const Peter McDiarmid, missing the email.
“His oversight of [that] email is devastating and is not indicative of him as an officer or how he performed my role,” she told the court.
Asked by Dwyer if McDiarmid might have missed the email due to a lack of resources, Morris said: “Absolutely.”
Morris explained how that was an ongoing issue hampering her work, and told the court there should be three full-time staff to deal with the workload. She also told the court she struggles to find officers to backfill her role while she’s away. While at the inquest this week, she could not get anyone to cover her.
If the officer had followed up, Morris said police would have looked up his past interactions with police and also potentially linked him up with health services after a follow-up conversation with the Cauchi family.
But the police were also upfront while giving evidence about their limitations to respond to such incidents and poor resourcing in the health sector.
Morris told the court that such people were increasingly dealt with by police because they had nowhere else to turn and that was a problem.
“We will always look at it from a policing lens,” Morris said during her evidence. “That may lead to charges and them going through the court system when [it’s] effectively because of the mental illness.”
Dwyer said that a change to the Queensland Mental Health Act was “shaping up as a significant recommendation” – specifically, bringing it in line with NSW where police can request an emergency assessment for someone if they are threat to others, not just a serious threat to themselves.
However, Sen Const Hope Porter, who spoke to Cauchi’s mother the day of the January 2023 incident, told the court Cauchi did not appear to be a threat to himself or others.
“The way Joel presented and the way he spoke and the way he was at the time, like he was well-dressed, he looked after himself … he was living with his parents, he spoke well, you can tell he was educated,” Porter reflected.
“He didn’t spend his entire life crazy. He was a high-functioning human being and then he wasn’t. And I don’t know where that decline happened.”
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Insp Bernard Quinlan, the manager of the vulnerable persons group for Queensland police, who gave evidence at the inquest on Tuesday, said police were “not equipped with the skills and knowledge” to respond to mental-health crises alone.
“It’s a no-brainer for me that there should be responses that are health-led that can go out and assist people when they need help,” he said.
Dwyer read to Quinlan the expert opinion of a psychiatrist who reviewed the body-worn footage, which showed police’s interaction with Cauchi when his father took his knives away. The expert determined Cauchi was “certainly psychotic” and in her view qualified for “compulsory admission” for a mental-health assessment.
Asked if that would be the benefit of having a specialist in mental health attend call-outs alongside police, Quinlan said: “I couldn’t agree more.”
The court heard that the day after Cauchi reported his dad had stolen his knives, he went to a camping store and bought a new knife.
Later in the week, the coronial inquest moved from Cauchi’s history to the day of his attack, a busy Saturday at the mall. It specifically examined the response of security guards, one of whom was fatally stabbed, and what they knew as Cauchi began his rampage.
The coronial inquest heard a public emergency announcement warning customers was not issued until 17 minutes after Cauchi killed his sixth and last victim, and 14 minutes after Scott had already shot him dead.
When the alarm was activated, which the court heard was the wrong alarm for the situation, Brett Simpson, the first responding paramedic, recalled for the court it was so loud that: “It was both a physical and mental impairment to basically every activity that was taken inside the shopping centre.”
Two security guards gave evidence about how the confusing and delayed communications resulted in the slow response from guards, with the radio channel line busy with “chatter” – making it difficult to send and receive information.
Much focus in the inquest’s second week was given to the guard in charge of the room with CCTV, with the court hearing concerns were raised about her ability to do the job. When Cauchi began to attack people, she was in the bathroom and not monitoring the 700 CCTV cameras.
The guard, who cannot be named for legal reasons, had refresher training in the weeks leading up to the incident, but trainers had flagged she was “not getting better”.
A manager of the security firm was asked by counsel assisting on Friday what he thinks of the suggestion that guards “should have done more in terms of confronting the armed offender”. He responded that as soon as they knew it was an armed offender they should have raised the alarm and tried to get people to safety.
He told the court that the security guards earn between $26 and $28 an hour.
Another guard who cannot be named for legal reasons told the court about how his first instinct when he saw Cauchi’s victims on the ground was to grab privacy screens.
Asked by Sue Chrysanthou SC if he got the privacy screens because bystanders were filming the victims, the man said he didn’t recall noticing that. Chrysanthou is acting on behalf of some of the families.
“I saw kids around, that was my main concern,” the man explained.
“I’m a father, so I saw those kids and I knew just a glimpse would be traumatising,” he said.
When he began to perform CPR, he heard Scott fire the shots that killed Cauchi. But in the confusion of the moment, thought he was being shot at.
Concluding his evidence on Thursday, he read aloud a note he had written about the ongoing impact, saying only two of his colleagues have been able to return to full-time work.
“Not everyone understands the fear and chaos we faced,” he told the inquest. “Many [security guards] showed great courage performing CPR and taking people to safety as best [they] could.”
“We go through training and it’s good training but when the scenario actually happens you’re in flight-or-fight mode, and it’s just survival instinct.”
“I wish we did better, I wish we did different.”
The inquest, scheduled for five weeks, continues.
In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, call or text Mental Health America at 988 or chat 988lifeline.org.