The Royal Australian and New Zealand College of Psychiatrists (RANZCP) acknowledges the NSW Coroner’s findings into the tragic events at Bondi Junction on 13 April 2024, and accepts the recommendations directed to the College. 

Our thoughts remain with the families of those who lost their lives, the survivors, first responders, clinicians, and all those impacted by this tragedy. 

The College notes the Coroner’s findings highlight fragmented service delivery, prolonged disengagement, gaps in continuity of care and insufficient integration across mental health, primary care, justice and community safety systems. These weaknesses are not isolated and represent sector-wide structural risks within the mental health system framework.

RANZCP President Dr Astha Tomar said the College was committed to implementing the Coroner’s recommendations and working with governments and partners to strengthen psychiatric training, service delivery frameworks and cross-sector coordination. 

“This tragedy has laid bare the critical fault lines in the mental health system. When provision or continuity of care in the public health system beaks down, the risks do not disappear – instead they accumulate with devastating consequences,” Dr Tomar said. 

“We acknowledge the recommendations relating to the RANZCP and will work with authorities in New South Wales, Queensland, and the Royal Australian College of General Practitioners to implement them in ways that are clinically sound, person-centred and system-wide in impact.

“Public safety depends on a well-functioning health system. Once a person has been out of treatment for years, the predictive and preventive capabilities of any individual clinician are inherently limited. Without system-level mechanisms for follow-up, outreach and coordinated care, or even access to care, risk becomes a system responsibility, not an individual one.” 

The College stressed that medication management, including Clozapine prescribing and deprescribing, must be guided by contemporary evidence, specialist oversight, and structured follow-up. 

“We remain committed to supporting psychiatrists and GPs with up-to-date, evidence-based guidance in the treatment of schizophrenia and other serious mental illnesses, including complex prescribing decisions that require careful monitoring and continuity,” Dr Tomar said.

Evidence presented during the inquest reinforced longstanding sector concerns that Australia’s mental health system lacks reliable mechanisms to detect, re-engage and support individuals with severe mental illness who disengage from care — particularly across state borders and between private and public systems.

"This case demonstrates a high-risk pattern the system is not designed to manage well – long term disengagement, cross-jurisdictional movement, and absence of coordinated follow-up from public health systems. Without reform, these gaps will continue to create avoidable risks,” Dr Tomar said.

“We must be clear: under-resourced, fragmented systems increase the likelihood that vulnerable people fall through the cracks with significant consequences for them, their families, and the wider community.”

RANZCP is calling for urgent whole of system reform with properly resourced community mental health teams, assertive outreach for people who disengage from treatment, stronger cross-state information and care coordination mechanisms, integrated health-led crisis responses, workforce expansion and specialist service capacity and clearer shared-care frameworks between psychiatrists and GPs.

“People living with serious mental illnesses need sustained, coordinated, specialist-supported care and not episodic contact between overstretched services or clinicians,” Dr Tomar said. 

The College urged media and public discussion to reflect the complexity of mental illness risk and system responsibility.

“We encourage careful, evidence-informed public discourse that examines systemic drivers alongside individual clinical care, rather than drawing conclusions that may unintentionally misrepresent how risk is assessed and managed in practice.”

The RANZCP will continue to work with governments, health departments, justice agencies, and community partners to implement these recommendations and accelerate system reform.

ENQUIRIES: For more information, or to arrange an interview call Dishi on +61 437 315 911 or email media@ranzcp.org.  

The Royal Australian and New Zealand College of Psychiatrists is a membership organisation that prepares medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises governments and other groups on mental health care. For information about our work, our members or our history, visit www.ranzcp.org.

In Australia: If you or someone you know needs help, contact Lifeline on 13 11 14 or www.lifeline.org.au or the Suicide Callback Service on 1300 659 467 or www.suicidecallbackservice.org.au.

In New Zealand: If you or someone you know needs help, contact Lifeline NZ on 0800 543 354 or www.lifeline.org.nz or the Suicide Crisis Helpline on 0508 828 865 or www.lifeline.org.nz/suicide-prevention.