Almost two years after a schizophrenic man fatally stabbed six people in a suburban shopping mall, those left behind will learn what went tragically awry.
Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were killed by Joel Cauchi at Bondi Junction Westfield in Sydney's east in April 2024.
Ten others, including a baby, were injured by the 40-year-old, who was experiencing psychotic symptoms.
Cauchi was shot dead as he ran towards NSW Police Inspector Amy Scott who was the first officer on the scene.
After overseeing an often heart-wrenching five-week inquest, coroner Teresa O'Sullivan will deliver a swathe of findings and recommendations on Thursday.
She has been asked to examine shortfalls in the response by security guards, police and ambulance.
The 77 seconds between when the first and final victims were stabbed meant at least one life could have been saved if the alarm had been triggered earlier, the inquest earlier heard.
The incident turned security guards' worst fears into reality, United Workers Union spokesperson Nicholas Richardson told AAP.
While guards had been pushing for more engagement from companies and clients, there hadn't been huge steps to make that happen, he said.
The coroner will determine if more could have been done in treating Cauchi when he lived in Toowoomba, Queensland, and afterwards when he moved to Brisbane.
The 40-year-old had stopped taking antipsychotics before the move and did not find another psychiatrist in the state capital.
He was homeless at the time of the Westfield attack.
Australian Society of Psychiatrists executive director Pramudie Gunaratne hoped the recommendations would be a "turning point" towards genuine mental health reform.
"What we saw on that day was a young man who was seriously unwell but left in free fall without mental health support for four years," she told AAP.
"The most gut-wrenching thing about all of this is that even after such an incredible tragedy, little seems to have changed."
The families of the victims have also asked Ms O'Sullivan to examine any shortfalls in media coverage of the incident.
