A psychiatrist who treated the man behind a fatal stabbing rampage at a crowded Sydney shopping centre will be referred to health investigators after a coronial inquiry.

Joel Cauchi, first diagnosed with schizophrenia in his teens, was unmedicated and homeless when he stabbed 16 people inside Westfield Bondi Junction in 2024, killing six.

The New South Wales coroner said Andrea Boros-Lavack had provided 40-year-old Cauchi exemplary care over a long period, but failed to heed warnings from family that he may be relapsing, years before the attack.

This mistake was one of many that led to the tragedy, the coroner said, also pointing to a series of actions by police and shopping centre security.

Six people - Dawn Singleton, 25; Yixuan Cheng, 27; Jade Young, 47; Ashlee Good, 38; Faraz Tahir, 30; and Pikria Darchia, 55 - died during the attack in April 2024.

During a five-week coronial inquest that finished last May, the coroner heard from dozens of witnesses including doctors, police, survivors and the families of victims in a bid to unearth the events leading up to the attack and prevent such a tragedy occurring again.

On Thursday, Teresa O'Sullivan told the coroner's court that Boros-Lavack had provided personalised, consistent and compassionate treatment for Cauchi for many years after she first took him on as a private patient in 2012.

However, in late-2019 when Cauchi's mother raised concerns that her son was possibly relapsing, Dr. Boros-Lavack failed to take more active steps or to recognise the seriousness of the situation that was unfolding before her.

She said it was a major failing for the doctor to not do more to proactively urge Cauchi to resume his medication.

O'Sullivan's recommendation that Boros-Lavack be investigated by Queensland health authorities followed calls by some of the victim's families for such action.

Amidst the findings, the coroner recommended a public awareness campaign with the message of escape, hide, tell when there is a situation with an armed offender, alongside calls for improved mental health outreach services in New South Wales.

The inquiry has sparked debates around mental health treatment and public safety, as the community reflects on the failures that led to this tragic event.