NSW officials have promised a security review after confirming the driver charged over a police pursuit that ended in two deaths on Saturday had fled Australia's largest mental health facility on February 8.
Another Cumberland Hospital patient absconded on February 7 before allegedly mounting a murderous stabbing spree on Tuesday.
Advocates say the state's grossly underfunded mental health system is too focused on waiting for a crisis before initiating treatment.
Greater focus must be given to community support to prevent people being left in positions where they are held for treatment against their will, the head of a mental health consumer group says.
"The supports people need when they leave facilities like Cumberland aren't there," BEING chief executive Giancarlo de Vera told AAP.
"They're not getting the support in the community in order to thrive and not do things that are tragic in nature."
The state's most vulnerable patients were being let down by a broken system, NSW opposition mental health spokeswoman Sarah Mitchell said.
"Two escapes from the same mental health facility in just 24 hours is not a coincidence, it is a sign that something is seriously wrong within the system," she said.
Luke Peter Francis reportedly fled the western Sydney hospital four days after he was released from prison on parole.
The 31-year-old was an involuntary resident at the hospital when he fled, according to the mental health minister.
Francis was accused of threatening a nurse and taking an access card before escaping, Rose Jackson said.
She blamed police for not returning him to the hospital, even though his status had been changed from "absconded" to "discharged".
"I don't know why he wasn't brought back in if he was indeed mentally disturbed and he was also on parole," Ms Jackson told ABC Radio.
She has launched an urgent review into Cumberland Hospital's security protocols.
Police said they had attempted to locate each man, but they declined to comment further while matters were before the courts.
The local health district said it was "deeply distressed" by the incidents and would undertake a formal review, including an external senior psychiatrist, into the care and treatment of the patients and security protocols at the hospital.
"NSW Police are notified when a patient absconds from mental health care, as they were in both of these cases," a spokesperson from Western Sydney Local Health District said.
"The safety of our patients and staff is a priority."
On Saturday, Francis allegedly stole a car and led police on a 40-minute pursuit before crashing into a car in Camden South.
Teacher and charity director Lee Casuscelli, 60, and her passenger Maureen Crosland, 84, died when the stolen car illegally crossed into the intersection and struck their vehicle.
Francis is in custody facing a charge of aggravated dangerous driving occasioning death and will appear in court on February 26.
His escape happened a day after Setefano Mooniai Leaaetoa also absconded from Cumberland Hospital.
The 25-year-old was arrested on Tuesday after allegedly killing one person and injuring two others in a stabbing attack in Merrylands.
Leaaetoa is believed to have run from a health transfer vehicle while being moved to Westmead Hospital, NSW Health confirmed on Wednesday.
He has been charged with murder and attempted murder.
Ms Jackson previously conceded the mental health system is grossly underfunded.
BEING, the Black Dog Institute and other advocates have for years demanded increased public expenditure to reflect mental health making up 15 per cent of the total disease burden.
The inquest into the Westfield Bondi Junction mass stabbing attack found multiple problems with NSW's mental health system, including the need to improve outreach and accommodation services.
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