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The Minns government has launched two urgent reviews into the state’s largest mental health hospital after learning that a man accused of stabbing three people, and another accused of killing two women in a car crash, had both absconded from its care.
Current and former staff at Cumberland Hospital fear nurses and security officers will become scapegoats for chronic understaffing and under-resourcing at the 261-bed hospital that admits some of the state’s most severe and complex mentally ill patients.
Setefano Mooniai Leaaetoa, 25, has been charged with murder and attempted murder after allegedly stabbing one person to death and severely injuring two others at a Merrylands grocery store on Tuesday. Leaaetoa had been an involuntary patient at Cumberland and escaped his escorts during a transfer to Westmead Hospital for medical care on February 7.
The day after Leaaetoa fled, another Cumberland patient, Luke Peter Francis, 31, absconded from one of Cumberland’s locked wards, Paringa, by allegedly threatening a nurse and swiping her access card, before stealing a car in Hurstville on Sunday. Francis had been released from prison on parole days earlier.
Francis was allegedly driving the stolen Toyota Camry when it crashed into another car during a police pursuit. Two women, driver Lee Casuscelli, 60, and her passenger, Maureen Crosland, 84, died at the scene. It is unclear whether substance misuse was a factor in the incidents.
Health Minister Rose Jackson initiated an urgent review into Cumberland’s security protocols, and NSW Health will conduct a review of Leaaetoa’s care with the assistance of an external senior psychiatrist.
Premier Chris Minns said Francis should not have been discharged after he absconded and had not returned.
Jackson told ABC News that in her view, police should have brought him back in if they had seen him, given that he was on parole at the time. “In this individual’s circumstance, we don’t have all the information,” she said.
Senior psychiatrist Anu Kataria, who resigned from Cumberland in January 2025, said it was common practice for an absconding patient’s status to be changed to discharged to comply with the Mental Health Act.
“Patients who are held involuntarily under the Mental Health Act have to have their status reviewed regularly, and their status updated accordingly,” Kataria said, adding this cannot be done if a patient is not present.
“Absconding is common,” said Nick Howson, a mental health clinical nurse consultant and the NSW Nurses and Midwives Association Cumberland branch delegate for mental health.
Cumberland staff would call local police “once a fortnight on average” about absconding patients who were a risk, most often to themselves, he said.
Staff immediately reported both absconding incidents to the police in line with protocols.
“We tell senior managers and executives that we need multiple staff for patients we know are high risk [for absconding],” Howson said.
“Quite often we get told: no, you can’t have a second escort. We don’t have the staffing for that, or we’re not paying overtime for that.
“Suddenly, they abscond, and the questions are: ‘What did you miss? What went wrong?’ When it’s generally quite obvious that nurses had concerns about this individual beforehand.”
In February 2025, staff warned that extremely unwell involuntary patients were waiting days on Cumberland’s locked wards to see a specialist at the height of the psychiatrist workforce crisis.
One staff member who spoke on condition of anonymity said the delays had led to agitated patients becoming violent, punching and kicking staff.
Senior psychiatrists who resigned from Cumberland in 2025 have been replaced by fewer, more junior, part-time psychiatrists.
Kataria said she was concerned that responsibility for the alleged stabbing and car crash victims would be erroneously placed on Cumberland staff, who do good work under challenging circumstances.
“Across the public mental health system, we have staffing shortages and bed numbers haven’t grown to match the demand,” Kataria said. “Staffing numbers don’t go up, and senior people retire or leave.”
Howson said the state government is refusing the union’s demand for staffing ratios of one nurse to three patients, despite chronic understaffing and overtime.
Cumberland patients held in seclusion, restrained
The last-resort practices of secluding and physically restraining patients are considered the canary in the coal mine for mental health units under pressure.
At Cumberland, patients were held in a seclusion room for an average of 14 hours and 7 minutes in January and June 2025, and for over 16 hours in the six months prior – more than three and four times the duration of NSW Health’s four-hour KPI target.
Cumberland Patients were physically restrained 108 times between January and June 2025 (6.5 restraint events per 1000 bed days) between January and June 2025, the latest available data shows.
Dr Ian Korbel, chair of the Royal Australian and New Zealand College of Psychiatrists’ NSW branch, said: “The vast majority of people living with mental health conditions are not violent. Suggesting otherwise contributes to stigma, increases fear, and can discourage people from seeking treatment and support.”
About 54 per cent of mental health admissions in NSW include “involuntary” care under the Mental Health Act.
Anyone needing support can contact Lifeline 13 11 14 and Kids Helpline 1800 55 1800.
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