At the time of Joel Cauchi's deadly stabbing attack in April 2024, a lone security guard overseeing Westfield Bondi Junction's CCTV control room had stepped out for a toilet break.
She returned one minute into the 40-year-old's attack and had to play catch-up as six people were killed and 10 others injured before Cauchi himself was shot dead by NSW Police Inspector Amy Scott.
As an inquest into the tragedy continued on Monday, swift moves taken by Scentre Group, which owns the Sydney shopping centre, were welcomed.
"Scentre have obviously been ahead of the game in this," said UK security and policing expert Scott Wilson.
"All I can do is praise them."
The changes include stab-proof vests for security guards, an updated CCTV control room for faster emergency alerts and further training for centre staff about what do to in case of an armed offender.
Mr Wilson acknowledged that security guards on the day did well to protect shoppers and, in some cases, actually ran towards danger.
However, he told the NSW Coroners Court that flaws within the centre's CCTV control room impeded the response.
The sole control room operator - who cannot be named for legal reasons - had to figure out what was going on and did not know how to react under pressure, Mr Wilson said.
She only spoke to a triple-zero operator 10 minutes after the incident occurred, having been left on hold for six minutes, the inquest was told.
In audio of that call played to the inquest, the guard said there was an armed offender within the facility and that shots had been fired.
"Do you know if anyone's been injured there?" the operator asks.
"We're not aware," the guard replied.
She then changed her answer, saying three to four people had been injured and two people stabbed.
In court, Mr Wilson called this response "inadequate".
"It was just all mixed up and it should have been a lot clearer," he said.
He said the call may have suggested the attacker had used both a gun and a knife.
Mr Wilson said he could not believe the security guard was unaware of the extent of the casualties by the time she made the call.
"She must know she's dealing with multiple victims of a stabbing," he said.
He also questioned why she remained in the room instead of being replaced by someone more competent as the emergency and its aftermath unfolded.
This was despite obvious deficiencies in her knowledge being flagged before the attacks. Further training had been scheduled.
"If you've not got faith in her, why leave her in that room?" Mr Wilson asked.
She should have also quickly activated the centre's emergency display system to let customers know to "Escape, Hide, Tell" because of an armed active offender, he said.
Grilled by barrister Adam Casselden SC, representing security sub-contractor Glad Group, Mr Wilson denied the standards he expected guards to work under were "unreasonable".
Glad employed many of the security staff at Westfield on the day, including the officer in the CCTV control room.
Mr Wilson also praised the quick response by NSW Police and NSW Ambulance.
He suggested better communication between the two agencies however, and said they should have formed a joint command post together when they arrived at the scene.
Cauchi was experiencing psychotic symptoms at the time of his stabbing spree after being diagnosed with schizophrenia as a teen.
He had been successfully treated with antipsychotics for decades before his private psychiatrist formed a plan to wean him off the medication.
By mid-2019, he was not taking any more medication, and by early 2020 he had stopped seeing a psychiatrist regularly after moving from Toowoomba to Brisbane.
The inquest continues on Tuesday.
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