A coroner who investigated five deaths in the Wellington region has made dozens of recommendations about the mental health care provided to the people responsible.
Each of the accused had a history of mental illness and four were found not guilty by way of insanity, while one was unfit to stand trial. Photo: RNZ / Rebekah Parsons-King
The recommendations are wide reaching, covering community care, resourcing and police practices.
Coroner Michael Robb has today made public his findings into the deaths of five people in 2015 and 2016.
There are heavy suppression orders on each case, but the coroner says he released the findings together to highlight common threads, such as whether the people responsible for the deaths should have been in compulsory care.
In each case the person responsible has a history of mental illness. Four were found not guilty by way of insanity and one was unfit to stand trial.
One person fatally stabbed another person and injured others; one fatally stabbed one person and wounded another with a hammer; one fatally stabbed a person; one fatally struck a person in the head; and one fatally strangled and stabbed a person.
The coroner has found gaps in the care provided to all five people responsible for the deaths, and has recommended improvements.
The recommendations are aimed at several organisations, including Capital and Coast District Health Board and police.
They include improvements to the transfer of care of patients between organisations; better information sharing, so crucial background information is not lost; and increased resourcing.
In a statement, Capital and Coast District Health Board mental health, addiction and intellectual disability service executive director Karla Bergquist said the service had implemented "significant system improvements" since the deaths.
That included implementing recommendations from a 2016 external review.
"The service is committed to meeting the recommendations of the coroner and to monitoring and reviewing outcomes related to those recommendations," she said.
"It is important to note that the majority of people with a mental illness will never commit a violent act, and are more likely to be victims rather than perpetrators of violence."
The Capital and Coast and Hutt Valley district health boards acknowledged the extensiveness of the coroner's inquiries.
In some cases, where there was earlier police involvement, Coroner Robb noted that it was important for officers to still follow normal procedures in conducting interviews and recording incidents for matters involving mental health.
Mental health and community service manager Inspector Brett Callander said police were reviewing the coroner's findings and considering his recommendations.
"Every 24 hours police respond to around 100 calls involving a person having a mental health crisis," Callander said.
"Mental health-related crisis and distress calls to police are complex and vary in severity; often involve people who have not committed a criminal offence; and require co-ordination of cross-sector services to respond appropriately."
In recent years police had improved the way they managed co-ordination with sector services to ensure people in mental distress and crisis received the right help at the right time, he said.
In March 2020, a "co-response team" began operating in Wellington to help people in mental distress. It is made up of staff from Wellington district police, Wellington Free Ambulance and the Capital and Coast District Health Board.
"The [team] is an innovative approach that enables a health-led response as the preferred option for addressing emergency mental health-related calls. The team is dispatched to both police and ambulance emergency mental health-related calls, responding in the same vehicle," Callander said.
"Where possible, the team delivers timely and co-ordinated mental health care at home or in the community.
"They also consider other factors contributing to the person's mental distress, such as housing, employment, income, alcohol and-or drug issues, and link the person to appropriate services."
An independent evaluation of the team's trial, by the Otago University department of psychological medicine, found it had benefits, including less use of the powers of the Mental Health Act and less reliance on emergency departments.
"The agencies involved are now considering the findings with a view to determining the next steps, both in Wellington and nationally."
Callander said other work in recent years included improved training for emergency communication centre staff, so relevant calls are transferred to a mental health triage line.
It was staffed by nurses who had access to some clinical records, and provided faster and more appropriate help.
