Joel Cauchi's mother did not show up in the Crown Investigation to examine her son's life and the day her son murdered six people at a popular Bondy Junction Mall. But she often feels her presence in the form of notes she writes to the doctor or in conversation with the police.
One of the most compelling moments in the investigation was that Michele Cauchi, now in the mid-1970s, was filmed by police on a police officer.
She stood outside the neat home next to the blooming hydrangea, explaining her son (speaking multiple languages and having a college degree) that has been worsening since he stopped taking the medication. "Unless he does something violent, I don't know how we're going to get his treatment," she said.
These moments depict a picture of the mother struggling in Sisyphean to help her son (and then suffer from untreated schizophrenia). But she can only continue to push so far.
One of the people who provided painful evidence in the five-week investigation tells a similar story of doing their best in a “mistakeable system.” It crystallizes into a key point: The system is disappointing people in crisis, such as Cage.
Cauchi's attacks and their severity are rare.
However, the system failed to stand out on the slide after stopping taking drugs for drug-resistant schizophrenia, which is a familiar story.
The vision of Australia's mental health shelter that was demolished in the 1970s is to serve the community, but to support those in need.
But Queensland psychiatrist Professor Edward Heffernan told the program funding for investigating community services “never really followed” the shift.
Psychiatrists also told the survey that services have not kept pace with population growth. Meanwhile, psychological distress across the population is increasing, and substance abuse and other modern ways of stress make the situation worse.
Psychiatrist Ian Korbel, who is not part of the investigation, told Guardian Australia that he once worked on a mental health outreach team that will respond to people in the crisis. But the plan stopped operating in the mid-2000s.
Cobel said the team working in Sydney's eastern suburbs were used to inspect the homeless on the beach. Cage reportedly fell asleep there before the attack.
Cobel said the service's staggering pace led to the bucks to the police and the justice system. “They are in the punishment business,” he said. “They shouldn’t respond to it, but the health system has no resources to respond to it.”
Police are increasingly responding to this crisis.
The investigation learned that in New South Wales, police committed 40% of mental health incidents in 2022 compared to four years ago.
"We will always look at the police footage (these events). This may lead to allegations and because mental illness is effective, it is effective."
Morris works at the Mental Health Intervention Coordinator for the Queensland Police Department where the Queensland Police Department’s parents live. The day Cauchi’s mother talked to the police, they referred Joel to her character – helping people contact the health service – for follow-up inspections. But the official who held her role during her vacation missed the email. In the investigation, psychiatrists described the moment of getting Cauchi help as a “missed opportunity.”
Morris fought back tears and told the court that it was not a reflection of the officer's ability, but a direct consequence of insufficient resources. At least four people should work in that particular police district, she said.
One of the cruelest ironies of the problem of underresources is the IT-Moment that was missed in the blink of an eye during the investigation, and Morris said no one played her role when she asked this week. She couldn't find anyone to fill it back.
Matthew Morgan, an expert who teaches mental health responses at Catholic University in Australia, said: "The only person here who really blames this is the government. If they don't intend to invest in a proactive and responsive mental health system that can provide the community with 24/7 care … then stop with them."
Morgan recently conducted an analysis of Queensland's Crown Core Survey, which targets people shot by police with mental illness.
He said 24 people in the state have been fatally shot since 2008. “The state really failed them.
“There are only many sporadic treatment models, lack of follow-up care, and then the police are blamed for their crimes, sometimes fatal reactions to the situation.”
Since police spoke with Cauchi and his mother in January 2023, the investigation found several improvements in the crisis’s response.
Police can contact health professionals for advice on the incident and there are some common response modes where health care workers respond to the call together with police.
These changes - Peggy Dwyer noted in the review that attorneys who assisted the coroner have been conducted after multiple inquiries, internal police and government reports, and coronary investigations. All made similar suggestions: Health professionals should respond to mental health crises, not police, at least not alone.
The call to join the change is that their loved ones were shot dead by police while they were mentally ill. Jesse's mother, Judy Deacon, is Jesse's mother, Judy Deacon, who was shot and killed by police in 2023 in Glebe, who was Jesse's mother.
However, despite the recommendations, a joint response model has not been introduced nationwide. The leading model in NSW (called the Pacer) is only 20 of NSW's 57 police commanders.
During the investigation, Dewell asked Dr Brendan Flynn, Executive Director of the Mental Health Division of NSW Health: “Why are there no expanded pacemakers in NSW in NSW, when this report proved enough demand about four years ago?”
Flynn replied: "It's a resource issue. It requires new funding, which is mainly government."
Later Dewell asked: “Would we be at risk for being stuck here for another four years without more support?transparent
Flynn replied: “I hope that is not the case.”
Even if a version of the pacemaker is launched in NSW, more work is needed, Cobel said.
“In Australia, we have nowhere to go to mental health,” he said. “The worst thing about New South Wales is. It provides a 5% health budget for mental health.”
In countries such as England and Canada, "the number must be doubled at least", Kober said.
Investment in health services can save money in the long run.
Professor Olav Nielssen, a psychiatrist in Sydney, appeared before the investigation, and spoke about a supportive housing charity he worked for. It supports people who spin between hospitals, prisons and homeless departments.
He estimates that the cost of getting people in supported housing is one tenth of the cost of bounced around hospitals, prisons and other institutions. He said NSW has a 70-bed "plan" but there should be 1,000 beds to meet the demand.
Jade Young's mother, Elizabeth Young, who was the victim of the stabbing, appeared before the investigation and described the murder of her 47-year-old daughter as "a nightmare thing."
She also described it as a result of “years of neglect” in the mental health system.
“In my opinion, my daughter and five other people were killed by the accumulated number failures in a series of error-making systems.”