Aftermath: Lessons from the Bondi Junction Inquest — A Turning Point for Mental Health Reform

On Saturday 28 February, the Australian Society of Psychiatrists (ASoP) hosted a landmark symposium at the Warrane Theatre, Museum of Sydney: Aftermath: Lessons from the Bondi Junction Inquest. Dr Pramudie Gunaratne is a true change maker whose leadership of ASoP is helping to drive a new, reform focused era in mental health care, elevating the voice of psychiatrists and strengthening national advocacy for better systems and outcomes. The hybrid event gathered leading psychiatrists, legal experts, policymakers, and people with lived experience to examine the clinical, systemic, and legal implications of the inquest — and to confront the uncomfortable reality that little has changed in 50 years.

A Mother’s Voice: A Voice of Integrity and Urgency

The symposium opened with a deeply moving address from Elizabeth Young, mother of Jade Young, who was killed in the Bondi Junction attack. Elizabeth spoke with extraordinary integrity about the devastating impact of her daughter’s death, and her words set the moral tone for the entire day. She called for urgent systemic reform — not in abstract policy language, but in the grounded truth of lived experience, loss, and the consequences of political inaction. Her message was simple: Australia cannot continue with a mental health system that leaves people unsupported until crisis — or tragedy — erupts.

Elizabeth also stressed that Australia continues to function as an unfederated system, where mental health funding, service access, and care pathways differ significantly across States and Territories, creating deep inequities that are felt most acutely in regional and rural areas.

The Truth We Don’t Want to Hear: Jonathan Harms on Systemic Neglect

One of the most compelling voices to follow Elizabeth Young’s profound and grounding opening was Jonathan Harms (CEO of Mental Health Carers NSW), whose clarity, conviction, and deep historical understanding of mental health reform brought a steady rationale perspective to the room. Jonathan articulated what many in the room felt but struggled to express: that nothing about the Bondi Junction findings is new, and the tragedy lies not in a lack of knowledge, but in a lack of action.

His message — that Australia has repeated the same recommendations across decades of inquiries, from the Richmond Report to the Burdekin Report and beyond — was delivered with calm precision but undeniable power, and it echoed the moving story Elizabeth Young shared as she reflected on Jade’s development and the milestones of her childhood and young adulthood against the backdrop of each report and inquiry that came and went without meaningful change.

Jonathan’s ability to connect policy failure with human impact gave weight to his call for genuine accountability and reform. He reminded us that carers and families are holding up a collapsing system, and that true change will only come when governments finally commit to implementing what has been known for over 50 years. His leadership on that stage was a steadying force amid tension, and his words resonated long after the panel ended.

Jonathan highlighted one of the most alarming structural failures in NSW’s mental health system: the complete absence of accountability embedded in law. Under Section 191 of the NSW Mental Health Act, any officer exercising discretion under the Act is protected from liability for injury caused — a provision which, as Jonathan put it starkly, means: “There is no liability for negligent mental health treatment in NSW.”

He warned that this legal vacuum has real and devastating consequences. In the five years before the Bondi attack, 50 people experiencing a mental health crisis were shot dead by NSW Police — a statistic he described as a red‑flag that something is fundamentally broken.

Richard Hendrie: A Powerful Voice for Humanity

Another standout voice of the day was Richard Hendrie, whose contribution brought a rare combination of lived experience and deeply grounded humanity. Richard spoke with clarity and compassion about how the current system reduces people to their diagnosis, explaining that individuals are too often viewed only through a clinical lens rather than as whole human beings shaped by family, community, environment, and personal history. He argued that mental health care must be rooted in human rights, not pathology — insisting that people are far more than the labels assigned to them. Richard also stressed the urgent need for innovation beyond medication driven models, calling for supports that address the full social ecosystem of a person’s life, including housing, employment, and meaningful connection. His message — that genuine reform requires seeing and valuing people in their entirety — emerged as one of the memorable themes of the symposium.

Staggering Funding Inequity

At the symposium, Professor Patrick McGorry was quoted saying that mental health expenditure sits at around $183 per person, compared with approximately $2,500 per person spent on Defence — a striking illustration of how profoundly underfunded mental health remains. To place this in context, publicly available data shows that all government mental health expenditure in 2023–24 totalled $14.5 billion, equating to roughly $552 per person; however, this figure combines both Commonwealth and state/territory funding, making it not directly comparable to a federal only estimate. By contrast, recent Defence budgets and international datasets consistently place Australia’s per capita defence spending in the range of $2,000–$2,500 per person, depending on the year and methodology — broadly reinforcing the stark imbalance McGorry highlighted between national investment in defence versus mental health (AIHW, 2026; SIPRI, 2024).

Recurring Themes Throughout the Symposium

The symposium revealed that the challenges my daughter Amber faces are shared widely across the mental health system, with deeply entrenched failures emerging repeatedly throughout the day’s discussions. Speakers highlighted severe resource shortages — including inadequate housing, limited psychosocial supports, gaps in physical healthcare, and a 25% psychiatrist vacancy rate — alongside persistent stigma, particularly toward conditions such as bipolar disorder and Schizophrenia, which we have experienced first-hand in both community settings and Emergency Departments. Multi disciplinary care, described as the gold standard, remains largely inaccessible; similarly, case management is almost non-existent, leaving families to coordinate complex care on their own. There is also little continuity of care, with Amber having to retell her story each time she sees a new registrar, compounding trauma. The system’s heavy reliance on medication — despite the significant side effects Amber has endured — reflects a lack of comprehensive, person centred alternatives. Bed shortages, overwhelmed Emergency Departments, and long waits for inpatient care further expose the system’s fragility; at one point, after more than 16 hours in ED, we were simply sent home due to no availability. Even inpatient units can be harmful, as Amber’s distressing three month stay for Clozapine titration demonstrated. Structural barriers persist too, from limited bulk billing to the absence of Medicare items that support collaboration with carers. Although we are fortunate to have an excellent GP, the pressure on primary care still leaves little room for the depth and time required for complex mental health needs. Overall, the themes of the symposium reflected a system under immense strain — one that too often leaves individuals and families to navigate its gaps alone.

Systemic Failures: A Call for Accountability

The inquest made painfully clear that Joel Cauchi, the perpetrator of the Bondi Junction attack, had no follow up or monitoring after discontinuing Clozapine — a medication known to require rigorous oversight because of its risks and because relapse rates after cessation can reach as high as 90%. Despite repeated concerns raised by Joel’s mother, there was no coordinated plan, no active monitoring, and no responsible service holding clinical oversight. His case illustrated, in a devastating way, how people with severe mental illness are routinely left to navigate a fragmented and overstretched system on their own. Instead of receiving assertive outreach, multidisciplinary support, or continuity of care, Joel became yet another person who fell completely through the cracks.

Where to From Here?

The conclusion was unequivocal: This system cannot be “tweaked” — it must be rebuilt. The mental health system in Australia is not under strain — it is structurally incapable of delivering the care people need. We already know what needs to be done. We have known for decades. The question is no longer what the solutions are. It is whether we finally have the political and moral courage to implement them.

For families like mine — for Amber — this is not theoretical. It is our daily reality. And it is long past time for change. For me, the panel discussion during the final part of the day highlighted one of the deepest barriers to achieving meaningful reform: We cannot fix a fragmented system if we continue to fragment ourselves. Real reform will only be possible when clinicians, people with lived experience, families, carers, policymakers, legal experts, NGOs, and government leaders work together with humility, shared purpose, and a commitment to genuine partnership. That is the only way forward.

Sharon Grocott
Wayahead CEO

Sources:

Australian Institute of Health and Welfare (AIHW) (2026), Expenditure on mental health related services, 2023–24. Available at: https://www.aihw.gov.au/mental-health/topic-areas/expenditure (Accessed: 2 March 2026). [sipri.org]

SIPRI – Stockholm International Peace Research Institute (2024), SIPRI Military Expenditure Database. Available at: https://www.sipri.org/databases/milex (Accessed: 2 March 2026