Joel Cauchi had been forgotten by the mental health system when he armed himself with a 30-centimetre long knife and rampaged through Sydney's Bondi Junction Westfield on Saturday afternoon on April 13, 2024.
Six people were killed and 10 others were injured before the 40-year-old was shot dead by police.
As an inquest into the events commenced on Monday, counsel assisting Peggy Dwyer SC said Cauchi had visited a Brisbane GP in January 2021 for a report to get a gun licence.
He claimed he was interested in firing a pistol at a local gun range but did not want to purchase a firearm.
In that single consultation, the doctor found Cauchi was a "fit and proper" person and recommended that Queensland police grant the licence, Dr Dwyer said.
While the force sent over a "statement of eligibility", no further steps to get a proper licence were sent.
"That is very, very fortunate," Dr Dwyer told the court.
Earlier she described the 40-year-old's web browsing history before the attack as "distressing".
"Mr Cauchi was preoccupied with weapons, with violence and with mass killing," she told the NSW Coroners Court.
This interest in death and murder included searches for serial killers and mass killings both in Australia and overseas including the Columbine High School shooting in 1999.
Notes on his phone included references to planning a strike at a mall while armed with a knife, the court was told.
The searches showed a man who was seriously unwell and who was far from the support of his parents, Dr Dwyer said.
Expert psychiatric evidence would show that Cauchi was "floridly psychotic" when walking through the Westfield, Dr Dwyer said.
The notes in his phone were far removed from how the 40-year-old appeared while he moved through the shopping centre and did not prove any actual motive, she told the court.
Dr Dwyer described how Cauchi went from victim-to-victim, and how bystanders rushed to help those wounded or assist paramedics or police.
Dawn Singleton, 25, Ashlee Good, 38, Jade Young, 47, Pikria Darchia, 55, Yixuan Cheng, 27 and security guard Faraz Tahir, 30, were all killed.
The stabbings started around 40 seconds after the sole security guard in the centre's command post decided to go to the bathroom.
This meant there was no one actively monitoring the 40-year-old's movements via the CCTV network for about a minute before the officer returned.
Security officers also issued the wrong type of alert, telling customers to evacuate instead of warning them that an armed offender was on the loose.
That alert, which flashed up on signage within the shopping centre, was only activated after Cauchi had been shot and killed by the first officer on the scene Inspector Amy Scott, Dr Dwyer said.
An "extremely loud" alarm also hampered communication between emergency responders on the ground.
Dr Dwyer described how confusion between security guards, police officers and paramedics on the scene caused suspicions that a second, ultimately non-existent attacker, was in the mall.
This meant the area was declared a "hot zone" after Cauchi was shot dead which barred ambulance officers from entering the scene.
Fortunately, all victims had been assessed and treated by paramedics at that time, Dr Dwyer said.
Inspector Scott's exemplary actions meant any further tragedy was avoided in spite of this confusion, she told the court.
Dr Dwyer said that Cauchi had been diagnosed with schizophrenia as a teen and had been successfully treated for over 18 years while he lived in Toowoomba west of Brisbane.
However by June 2019, he had ceased taking anti-psychotic medication despite his mother raising concerns of a possible relapse.
His decision to move to Brisbane in March 2020 right at the onset of the COVID pandemic saw his psychiatric sessions cease and his condition deteriorate until the tragic events in Bondi Junction.
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