The man accused of attempting to murder two Australian National University students was reported missing to police just two minutes before the first emergency call.
Alex Leonard Ophel, 24, was arrested after allegedly stabbing two female students with a knife and hitting two men with a frying pan during a terrifying incident at the university on Monday afternoon.
Police said they were made aware he was missing when staff from Gawanggal Mental Health Unit - where Ophel was staying - called triple zero at 2.45pm.
The first emergency call about the alleged attack near Fellows Oval was received two minutes later at 2.47pm, police said.
Canberra Health Services would not comment when asked when staff were made aware Ophel was missing.
The directorate told The Canberra Times that when a Gawanggal patient cannot be found the procedures state staff should, in order: attempt to the contact the person or their next of kin, and search the immediate area.
Then, "dependent on risk to themselves and others, ACT Police are contacted for assistance," a spokesperson said.
Canberra Health Services declined to comment when asked if mental health staff followed this procedure after Ophel went missing.
They said an upcoming review into the incident is expected to "examine all relevant matters".
ANU chancellor Julie Bishop said this week the attacks occurred at 2.40pm on Monday and Ophel was taken into police custody at 2.51pm.
"In other words, it was 11 minutes from the time of the attack to the time the man was taken into custody," she said on the Today program.
The incident at the ANU occurred in the same week ACT Minister for Mental Health Emma Davidson spoke about how recommendations for changes to the Dhulwa Mental Health Unit were progressing.
She said the facility was "on its way" to becoming a safer environment due to the work of Canberra Health Services staff.
The board overseeing the recommendations from the independent inquiry were satisfied with the progress of most the recommendations.
However, it said "further work was required" to meet the intent of a recommendation around leave.
The inquiry into Dhulwa last year noted there were concerns that guidelines for approving leave for patients in Dhulwa and Gawanggal mental health units were "unnecessarily prescriptive and, if strictly applied, could lead to unintended consequences and consumer frustration".
The report said "every effort should be made to ensure patients are not subjected to disappointment or frustration in relation to anticipated leave where such cancellation is avoidable".
The Canberra Times is not suggesting a connection between any policy changes and the circumstances of the alleged attack on Monday.
The inquiry heard from patients and other stakeholders who said there was a lack of clarity around the circumstances in which somebody's leave could be cancelled.
"The inquiry recognises that, on occasion, leave must be cancelled for the safety of consumers and others but recommends that such decisions are made by appropriately qualified senior clinicians, are not made arbitrarily, and are made for valid clinical reasons," the report said.
The ACT chief psychiatrist is undertaking a review into the circumstances around the ANU incident.
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