The Quietly Evolving Standard of Care: Lessons from the Westfield Bondi Junction Inquest and the Modern Application of s 5O of the NSW Civil Liability Act 2002

This article was written by Ren Li for the Australian Health Law Bulletin.

Background

Joel Cauchi arrived at Westfield Bondi Junction on the afternoon of 13 April 2024. Earlier that day he had accessed his storage unit and then returned to the shopping centre with a knife in his backpack. Inside the shopping centre he moved through busy concourses before taking the knife from his bag. It was a large fixed‑blade with a dark handle and sheath. He held it openly and at 3:32 pm he began to attack shoppers without warning.The stabbing phase was brief and intense. In just under three minutes he had stabbed sixteen people. Six of them later died from their wounds.

As emergency calls flooded in, police used reports from witnesses and the shopping centre’s camera feeds to track his movement. They moved rapidly through the complex as shoppers were cleared from corridors and escalators. The offender continued to carry the knife openly while moving towards the upper levels.

NSW Ambulance was assigned at 3:36 pm[1] as calls reported multiple stab wounds and a moving offender. Treatment was assessed as adequate and appropriate, and expert evidence confirmed that none of the fatal injuries were survivable, so no pre‑hospital intervention could have changed those outcomes. NSW Ambulance is described as responding comprehensively and in a timely manner. The inquest commended NSW Ambulance paramedics and control centre staff for their courage, skill and commitment. [2]

Against this background, the inquest that took place (Bondi Junction Inquest) considered a narrower clinical point about tranexamic acid (TXA). After major trauma, some patients develop an acute clotting disorder associated with increased bleeding and higher mortality. In this context, TXA slows the breakdown of blood clots which stabilises bleeding. While inexpensive, easily supplied as a clear 10 mL intravenous solution, has a long shelf life at room temperature and is practical to carry on ambulances, it has not been routinely available for use by NSW Ambulance to date.

The inquest recorded that NSW Ambulance equipment was generally adequate apart from the absence of TXA for all paramedics, and identified clear utility in providing the drug to all road crews[3].  In fact, NSW Ambulance stated that TXA had already been endorsed for introduction and this change was in the process of being implemented.  The Coroner recommended, inter alia, that NSW Ambulance confirm the introduction of TXA as part of the standard products carried in NSW Ambulance vehicles[4].

TXA and its use in traumatic injuries: inquest findings

The NSW Health Emergency Care Assessment and Treatment (ECAT)  Traumatic Injury Protocol sets out the circumstances in which TXA is administered in the management of traumatic injuries. This protocol requires clinicians to give TXA as a single dose  in trauma patients with ongoing haemodynamic instability or signs of shock (within three hours of injury)[5].

The emergency physician expert witnesses at the Bondi Junction Inquest unanimously agreed the following:

1. TXA helps stabilise clots and can reduce bleeding in major trauma, particularly penetrating injury, but should not delay higher‑value actions at the scene.[6]
2. The use of TXA would not have altered outcomes for any of the deceased victims in this case – the fatal wounds inflicted were inherently unsurvivable.[7]
3. TXA has a role in trauma care in the context of pre-hospital decision-making at mass casualty scenes, but must not compete with time‑critical measures such as controlling obvious bleeding, moving patients out to definitive care, and avoiding on‑scene delays. In practical terms, if crews are able to administer TXA while these actions are being (or have been) taken, that is reasonable, but if treatment with TXA would slow those steps it should wait.[8]
4. At the time of the incident , only aeromedical teams carried TXA. Broader carriage to include ambulances is appropriate, provided training and clinical guidance reinforce the appropriate circumstances for its use. NSW Ambulance evidence aligned with this position: its Clinical Practice Committee had already endorsed statewide introduction, training packages and clinical guidelines had been developed, procurement was underway, and implementation of this change was anticipated from late 2025 to early 2026 subject to governance and supply.[9]

NSW Ambulance supported the Coroner’s recommendation that TXA be introduced as standard equipment across its fleet and confirmed that its implementation program was already progressing.

A potential shift in the standard of care and the applicability of Section 5O of the Civil Liability Act 2002 (NSW)

While TXA featured only briefly in the Bondi Junction Inquest, it has potentially wider consequences for paramedic defendants relying on section 5O[10] of the Civil Liability Act 2002 (NSW), (the  Act),  in trauma settings.[11]

Section 5B of the Act [12] sets out the basic test for negligence. It is essentially the statutory version of the common law test for breach of duty.  In simple terms, a person is only negligent if the risk was something they knew about or should have known about, it was more than trivial, and a reasonable person in their position would have taken steps to avoid it.  When deciding whether a reasonable person would have taken precautions, a court looks at factors such as how likely the harm was,  its potential gravity, how difficult or costly the precautions were, and the value or usefulness of the activity that created the risk.[13]

Section 5O  of the Act provides that a professional does not incur liability in negligence if their conduct was widely accepted in Australia by peer professional opinion as competent professional practice at the time the service was provided. Section 5O  effectively overrides the general principles of negligence under section 5B when its preconditions are satisfied, as it supplants the standard of care required.[14]

Over time, as TXA becomes embedded in ambulance protocols, it is likely that the judicial response to section 5O will reflect this change such that courts may treat it as the standard against which conduct is judged. A failure to carry TXA or to consider its administration where criteria are clearly met may be harder to defend. The lesson from Nemes v South Eastern Sydney Local Health District[15] (Nemes) is that section 5O turns on concrete proof of peer‑accepted practice, not aspirational policy.[16] Therefore, as TXA use becomes routine, it is likely that contemporaneous records explaining why it was given or withheld will become central to any defence.

While the written protocols will help with the transition, it is yet to be seen how they will be applied in practice by those on the frontline. Even with TXA becoming widely available on every NSW Ambulance vehicle, paramedics still need to exercise their professional judgment to decide whether it can be administered without delaying other time-critical measures.  In reality, making this clinical decision could be difficult in a time sensitive and chaotic scene. For example, penetrating trauma can involve concealed bleeding and rapid deterioration, while paramedics must also manage airway, breathing and circulation. Arguably, a missed or delayed dose of TXA could be due to other clinical priorities rather than a departure from competent practice. The question then becomes how, and in what circumstances, is the use of TXA determined to be “widely accepted in Australia by peer professional opinion as competent professional practice”.

Recent case law on section 5O in NSW

When a practice begins as a policy response and then evolves to  become part of routine clinical work, a  court will require evidence that competent peers widely accepted such practice at the time the care was provided. The recent NSW case of Briggs v Hillier[17] (Hillier) and Nemes [18] provide a useful reminder of how section 5O operates .

Section 5O focuses the inquiry on the manner in which the professional acted and whether, at the time, that manner was widely accepted by peer professional opinion as competent practice. The test is not for unanimity, as confirmed in both Hillier and Nemes.

The Supreme Court  of NSW, in Nemes, confirmed that a defendant can succeed under section 5O where expert evidence shows the conduct sat within a range accepted by a substantial body of peers at the relevant time. Therefore, a clinician or service may invoke section 5O if they can lead clear expert evidence that TXA was either administered when indicated , provided it did not delay time-critical measures, or alternatively was reasonably withheld.[19]

The Supreme Court of NSW in Hillier reinforced the abovementioned point that courts give real weight to contemporaneous materials and reconstruct the standard of care by reference to what was done at the time, not what might be preferred years later.[20] For ambulance services, this means that the quality of contemporaneous records and after‑action reports will be impactful if a section 5O issue were to arise.

s 5O displaces s 5B once engaged

The Supreme Court of NSW decisions in Hillier and Nemes illustrate the modern judicial approach to the application of section  5O of the Act, with the consequential displacement of section 5B[21]. In Hillier, Weinstein J held that section 5O of the Act applies as the exclusive standard of care once its preconditions are satisfied. The task is simply to determine whether the conduct was widely accepted in Australia by peer professional opinion at the time. If so, a court will not undertake any separate assessment under section 5B.[22] The judgment in Hillier characterises section 5O as a statutory standard rather than a defence and applies it across the negligence analysis (other than with  respect to failure to warn cases, to which section 5O does not apply). [23]In Hillier, peer professional opinion became the sole benchmark against which the defendant surgeon’s conduct was judged.

This suggests that once TXA becomes routinely available and governance around it has been implemented, disputes regarding its administration (or lack thereof) are also likely to  occur, with the possibility of competing expert views developing. The Supreme Court of NSW in Nemes ultimately decided on breach and causation without determining the 5O question, but it considered that the care provided would have been viewed as consistent with widely accepted practice despite the existence of dissenting expert evidence.[24]

The Supreme Court of NSW  in  Hillier adopted a similar approach in affirming that the availability of alternative acceptable options does not prevent a court from finding the conduct was widely accepted practice. Hillier  also illustrates that courts give greater weight to peers whose expertise aligns closer with the circumstances in issue, and that professional practice is assessed by reference to those with proximate experience rather than from generalised criticism.[25] This would be relevant to a developing clinical rollout where the practice may be emerging, but grounded in accepted reasoning among competent peer practitioners.

In any given situation, some paramedics may decide that TXA can be appropriately administered, while others may reach the opposite conclusion. On the above considerations, either response may be considered competent in the context of the specific circumstances.

Finally, it is clear that section 5O of the Act turns on contemporaneous professional judgment rather than hindsight[26]. The Bondi Junction Inquest treated real-time decision-making as the touchstone, such that the outcome was not relevant to an assessment of decisions made[27].

In summary, given the ongoing rollout of TXA, including training of road crews, drug availability, and evolving field practices, it is reasonable to conclude that a single, uniform approach has not yet been established. Once TXA is routinely available and in regular use, the focus will shift to whether paramedics prioritise TXA or other treatment tasks on a case-by-case basis, or adopt strict adherence to a fixed protocol. Finally, the adoption of similar TXA protocols by ambulance services in other Australian jurisdictions is likely to provide guidance on what constitutes widely accepted practice in comparable systems and circumstances.

A practical response

As a practical approach, frontline paramedics ought to ensure TXA is available, understand the indications and limits, and document reasons for administering or withholding it in light of scene priorities.  Consistent, practical training in TXA use will further support confident adoption and effective application in the field.

Further to the need for documentation discussed earlier, a standardised checklist may assist paramedics to document the clinical basis for their decisions. Where TXA is administered, the record should note the indication, such as suspected haemorrhagic shock or penetrating trauma, elapsed time from injury, confirmation that administration did not delay higher‑value tasks such as bleeding control or extrication, the dose, route and time of administration, and the details provided at handover to the receiving emergency department to avoid duplicate dosing. Where TXA is withheld, the record should state the reason, including whether administration would have delayed time-critical steps, whether criteria for administration were not met, or whether the time window had expired – with these decisions understood against the realities of scene hazards, limited crews, and competing clinical pressures.

Contemporaneous notes concerning indications, timing, scene conditions, and the absence of delay to higher‑priority steps will provide evidence that the decisions taken on the day reflected peer‑accepted practice for the purposes of section 5O at the time the care was provided and in the context of the specific circumstances.  A concise record of scene conditions, clinical triggers, decision making and handover would allow the sequence of priorities, and the basis on which the paramedic acted, to be understood. Clear after‑action notes that also identify the guidelines, protocols and training then in force, including any transitional constraints during rollout, would further anchor the account in the professional practice that existed at the relevant time and support the application of section 5O.

For ambulance services, policy and training should continue to emphasise that TXA is an adjunct, not a substitute for rapid bleeding control and evacuation. Clear protocols, accessible action cards, and regular exercises that rehearse the sequencing of TXA within time‑critical care will help align practice across road crews.

Conclusion

The Bondi Junction Inquest is illustrative of the potential influence of coronial findings on the standard of care expected in the context of a claim in negligence. Any paramedic who relies on section 5O may see a standard shift after an inquest. The law will treat the new practice as part of the competent baseline against which future conduct is judged. The adoption of TXA illustrates how a clinical adjustment, prompted by an inquest and supported by uncontroversial expert consensus, might quickly become part of ordinary practice in a frontline setting.

Interstate practice will also be relevant to what becomes widely accepted and to this point, the Queensland Ambulance Service already publishes a detailed TXA protocol[28], setting out eligibility criteria and dosing requirements for its use in trauma. However, none of this creates a blanket duty to give TXA.

The Supreme Court of NSW decisions in Hillier and Nemes confirm that section 5O of  the Act displaces section 5B once engaged, reminds us that unanimity is not required, that multiple reasonable clinical pathways may all meet the standard, and that the enquiry is fixed to the state of practice at the time rather than to the ultimate clinical outcome. They also highlight the evidentiary value of contemporaneous documentation and the weight courts place on responsible, profession‑specific peer opinion.

Although incremental clinical developments like this can occur across many health professions, the Bondi Junction Inquest offers us an opportunity to observe how real‑time changes in practice may influence expected standards of care in the civil liability arena.  This coronial finding simply provides a clear and timely example of the process in motion.

Footnotes

[1] Inquest into the deaths at Westfield Bondi Junction on 13 April 2024 Executive Summary –  https://coroners.nsw.gov.au/documents/bondi-junction-inquest/findings/Inquest_into_the_deaths_at_Westfield_Bondi_Junction_Summary.pdf Paragraph 398

[2] Above n 1, at  at paragraph 408

[3] Above n 1, at  at paragraph 415

[4] Inquest into the deaths at Westfield Bondi Junction on 13 April 2024, Above n 1,  List of Recommendations – Recommendation 15

[5] NSW Health, Emergency Care Assessment and Treatment (ECAT) Protocol – Traumatic Injury (A12.3, July 2024) pg 5–7   https://aci.health.nsw.gov.au/ecat/adult/traumatic-injury

[6] Inquest into the Deaths at Westfield Bondi Junction (Coroners Court of NSW, 5 February 2026), Inquest Findings,Volume 3 at 9.158 https://coroners.nsw.gov.au/documents/bondi-junction-inquest/findings/Inquest_into_the_deaths_at_Westfield_Bondi_Junction_Volume_3.pdf

[7] Above n 1, at  [9.157], [9.162], [9.129]–[9.132]

[8] Above n 1, at  [9.158]

[9] Above n 1, at  [9.156], [9.159]–[9.160], [9.171(h)–(i)]

[10] Civil Liability Act 2002, (NSW) 5O   Standard of care for professionals

(1)  A person practising a profession (a professional) does not incur a liability in negligence arising from the provision of a professional service if it is established that the professional acted in a manner that (at the time the service was provided) was widely accepted in Australia by peer professional opinion as competent professional practice.

(2)  However, peer professional opinion cannot be relied on for the purposes of this section if the court considers that the opinion is irrational.

(3)  The fact that there are differing peer professional opinions widely accepted in Australia concerning a matter does not prevent any one or more (or all) of those opinions being relied on for the purposes of this section.

(4)  Peer professional opinion does not have to be universally accepted to be considered widely accepted.

[11] Victoria: s 59 Wrongs Act 1958 (Vic); Queensland: s 22 Civil Liability Act 2003 (Qld); Western Australia: s 5PB Civil Liability Act 2002 (WA); South Australia: s 41 Civil Liability Act 1936 (SA); Tasmania: s 22 Civil Liability Act 2002 (Tas)

[12] 5B   General principles

(1)  A person is not negligent in failing to take precautions against a risk of harm unless—

(a)  the risk was foreseeable (that is, it is a risk of which the person knew or ought to have known), and

(b)  the risk was not insignificant, and

(c)  in the circumstances, a reasonable person in the person’s position would have taken those precautions.

(2)  In determining whether a reasonable person would have taken precautions against a risk of harm, the court is to consider the following (amongst other relevant things)—

(a)  the probability that the harm would occur if care were not taken,

(b)  the likely seriousness of the harm,

(c)  the burden of taking precautions to avoid the risk of harm,

(d)  the social utility of the activity that creates the risk of harm.

[13] Above n 12 at (1)–(2)

[14] See generally discussion in Briggs v Hillier [2025] NSWSC 1021.

[15] Nemes v South Eastern Sydney Local Health District [2025] NSWSC 418

[16] Civil Liability Act 2002 (NSW), Subsection 5O(1),

[17] Briggs v Hillier [2025] NSWSC 1021

[18] Nemes v South Eastern Sydney Local Health District , Above n 15.

[19] Nemes v South Eastern Sydney Local Health District Above n 15, at [39]

[20] Briggs v Hillier, Above n 17 at [455-456], [461]–[466] and [474]–[475]

[21] This position is likely to be reflected in the mirrored provisions in other states and territories.

[22] Nemes v South Eastern Sydney Local Health District, Above n 15, at [425]–[426]

[23] Nemes v South Eastern Sydney Local Health District, Above n 15,  at [469]–[478]

[24] Nemes v South Eastern Sydney Local Health District, Above n 15,  at 38-39

[25] Briggs v Hillier Above n 17, at 455

[26] Briggs v Hillier,  Above n 17,  at 427-428

[27] Inquest into the deaths at Westfield Bondi Junction on 13 April 2024,Inquest findings, Above n  6,  at 8.224 in relation to CPR

[28] Queensland Ambulance Service Drug Therapy Protocols: Tranexamic acid – policy code DTP_TRXA_0924 https://www.ambulance.qld.gov.au/__data/assets/pdf_file/0031/219379/DTP_Tranexamic-acid.pdf