Sydney hospitals where nurses are expected to be prison guards
Rare murders by psychiatric patients are a predictable outcome when mental health facilities are expected to act as prisons for people diverted from the criminal justice system, a senior Sydney psychiatrist has said.
The use of Section 19b orders, which allow judges to detain people who may be mentally ill or disturbed for evaluation and referral to mental health facilities, has become a lightning rod for failures in the state’s mental health system.
Mooniai Leaaetoa, 25, accused of stabbing one man to death and seriously injuring two others at a store in Merrylands, and Luke Peter Francis, 31, who allegedly killed two women in a car crash during a police pursuit, were under Section 19b orders for allegedly escaping from Cumberland Hospital, sources in the mental health system said.
Francis allegedly pressured a nurse and stole her access card to escape the facility. Health Minister Rose Jackson has launched an urgent review of Cumberland’s safety protocols and NSW Health will conduct a review of Leaaetoa’s care.
The number of defendants referred in lower courts for mental health or cognitive impairments increased from 2,215 between October 2019 and September 2020 to 3,428 between October 2024 and September 2025, according to NSW Bureau of Crime Statistics and Research data.
Forensic psychiatrists said Section 19b of the Mental Health and Cognitive Disorders Judicial Provisions Act is also used for non-violent, vulnerable people whose psychiatric conditions have worsened due to inadequate community mental health services and lack of resources.
Forensic psychiatrist Dr. “These terrible cases showed how stressed the system is in managing patients at higher risk,” said Christina Matthews.
UNSW Co-Professor of Psychiatry Matthew Large said: “While the murder of a stranger by a mentally ill person is always surprising as well as shocking, such an event was foreseeable.
“Over the years, the number of Section 19b patients transferred from the criminal justice system to public mental health units has increased, as has the severity of the events leading up to this.
“Increasingly, we are expected to treat these patients with the same level of security afforded to some inmates.”
Judges knew that if they sent someone to prison, they would wait several days to see a psychiatrist, “so they quite understandably sent them to Cumberland and our other state hospital mental health units,” Large said.
How common is it for mental health patients to run away?
Around 200 mental health patients have been admitted so far in the 2025/2026 financial year (about one percent of patient admissions).
Proportion of patients escaping in NSW:
- 0.23 per 1000 bed days from the mental health unit,
- For accompanied leave, it is 0.28 per 1000 bed days.
At Cumberland Hospital (which treats the most seriously ill and complex patients), the escape rate is:
- 0.75 per 1000 bed days from hospital,
- 0.23 per 1,000 bed days while on accompanied leave.
Source: NSW Health
As a result, he said, two groups of patients ended up in the same wards: “The first is the patients who are very disturbed, often under the influence of methamphetamine, and are removed from the justice system after various forms of punishment. [alleged] crime. “These patients are being kept in custody.”
The latter group, and the majority of patients, are so ill, law-abiding and rarely dangerous that they need patient-centered, recovery-focused, trauma-informed care in the least restrictive way possible, he said.
“This combination leads to wards that can be unpredictable, frightening and sometimes even dangerous,” Large said. “Hospital staff, mostly nurses, are well-trained and caring, but they are not guards.
“Public mental health services need to be better built and staffed to provide both care and custody for all who come.”
A Sydney psychiatrist with experience in the forensic system said not all people in Section 19b orders were violent but appeared in court for alleged minor offenses because of their worsening mental illness.
“They are not guilty,” they said. “There are all kinds of people in Section 19s, including women and non-violent people, and it is appropriate that they be removed from the justice system.”
They said the clear benefits of diverting people from the justice system included reduced recidivism rates.
Matthews said there is recognition, especially among judges, that opportunities are being missed to provide appropriate care for mentally ill people in prison.
He said hospitals face difficulties treating people in Section 19bs, but they are more therapeutic than being transferred to prison.
Chief executive of the Australian Association of Psychiatrists, Dr. Pramudie Gunaratne said “the problem is not the patients” but “the system under pressure where we can actually do more harm than good”.
“When we bring together people with very different clinical manifestations in overstretched units, we create conditions in which therapeutic care becomes secondary to risk management.” [and] no one gets the level of care they truly need.
“Alongside someone experiencing acute psychosis or substance withdrawal, there may also be a young woman presenting with severe depression who is not eating or drinking.
“It’s too large a clinical spread to manage in a single setting, especially in a locked ward.”
Gunaratne said the problem stemmed from a wider crisis: “We are failing to provide adequate community support for the 58,000 people in NSW who are living with serious and complex mental illnesses and are slipping between the cracks.”
The Bondi Junction attack inquiry recommended more community outreach and specialist teams, particularly where mentally ill people leave care.
Giancarlo de Vera, CEO of mental health consumer advocacy organization BEING, said prevention and early intervention are crucial.
“If we invest in the right mix of support, particularly community-based care, which is currently lacking, we will significantly reduce fatal incidents like the one at Merrylands.”
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