Seven years after a Brisbane bus driver was killed by a Molotov cocktail, a coroner has found his attacker should not have been discharged from a mental health unit three months earlier.
Accountant Anthony O'Donohue lit a backpack containing a bottle of fuel and threw it at 29-year-old Manmeet Sharma, also known as Manmeet Alisher, while he was collecting passengers at Moorooka in Brisbane's south in October 2016.
Mr Sharma was immediately engulfed in flames, while the bus filled with thick black smoke. Fourteen passengers escaped with help from passers-by.
Mr O'Donohue was charged with murder, 14 counts of attempted murder and one count of arson before Queensland's Mental Health Court declared he was of unsound mind therefore not criminally responsible for his actions.
A psychiatrist told the inquest into Mr Sharma's death that Mr O'Donohue long believed he was being persecuted, but his mental illness became very severe in the six months before the attack on Mr Sharma.
Although other experts found Mr O'Donohue had delusional disorder, Dr Angela Voita diagnosed him with schizophrenia while treating him for five years at a high security unit.
The inquest heard he was discharged on August 1, 2016 and when he tried to make a further appointment on August 31, Mr O'Donohue was told he had been closed to the service.
Delivering his findings on Friday, State Coroner Terry Ryan said the decision to discharge Mr O'Donohue was "not satisfactory".
"However, that conclusion is reached with some hesitation knowing the benefit of hindsight," he said.
"Mr Sharma's death might not have occurred if different decisions had been made at different times in the course of his treatment."
But Mr Ryan said it could not have been predicted that Mr O'Donohue would have gone on to kill someone, "particularly in the manner that he killed Mr Sharma".
"Although he was a very unwell man, seemingly obsessed with revenge against his perceived persecutors, up until the point of his discharge ... Mr O'Donohue was the beneficiary of a compassionate response to his mental health needs which was very effective in keeping him and the community safe for over six years," the coroner said.
The Mental Health Court ordered Mr O'Donohue to be held in a mental health facility for at least a decade, despite Mr Sharma's family saying he should never walk free.
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