Photo: RNZ
The Chief Victims Advisor is calling for a Royal Commission of Inquiry into forensic mental health facilities after it was revealed a man who was ruled insane after killing someone two decades ago has killed again
.
RNZ has revealed a man who was made a special patient under the Mental Health Act after his first killing was recently found not guilty of murder by reason of insanity for a second time, after killing someone he believed was possessed.
Releasing a person into the community after they have been designated a special patient requires the sign off of the minister of health, the attorney general and the director of mental health. The man was released more than a decade ago, and later had his status changed to being a patient under the Mental Health Act.
At the time of his second killing, he was subject to a Community Treatment Order.
RNZ is unable to publish details regarding either killings as the decision to lift name suppression has now been taken to the Court of Appeal, meaning the man and his victim can not be identified until the appeal has been determined.
Chief Victims Advisor Ruth Money told RNZ the case was "my worst fear", adding she felt "physically sick" when she read the article today.
"It's pretty hard to see how this could be any worse."
Money wants an "urgent review" for any patient who has had their status changed.
"Clearly something is seriously wrong with how these people have chosen to re-classify their status," she said.
"It's getting to the point where we need a Royal Commission to find out what's happening in these facilities."
Ruth Money. Photo: Stephanie Creagh Photography
Money said there would be many patients who had the correct classification.
"But at this point I don't think the public can have any faith that the allocations or the classifications have been done safely.
"We have got people killing members of the community who have been classified by the senior people in mental health as safe, clearly we have a significant problem because the community wasn't safe."
Mental health patient Elliot Cameron pleaded guilty earlier this month to murdering Faye Phelps at her Christchurch home in October last year.
Nearly three years ago, in June 2022, Hillmorton Hospital forensic mental health patient Zakariye Mohamed Hussein stabbed Laisa Waka Tunidau to death as she walked home from work. Hussein was on community leave at the time of the killing.
RNZ revealed earlier this week that Phelps, and others who employed Cameron to do their gardening, were unaware he was actually a mental health patient who had been living at Hillmorton Hospital for many years.
After RNZ's story about Cameron, Money wrote to director of mental health Dr John Crawshaw.
In her email - seen by Phelps' daughter - Money wrote she was "both extremely concerned and outraged" to read about Phelps' death.
"This is not the first time it has happened, but it needs to be the last."
Money said she wanted to understand what support was being offered to Phelps' family, what he was doing to expedite the reports, and what support was being offered to Waka Tunidau's family.
She also asked when the investigation of Canterbury District Mental Health Services - launched after Tunidau's murder - was going to be released.
Money told RNZ she was "very concerned" from a victim's perspective about the "systemic issues" around victims of mental health patients.
"This isn't the first innocent death at the hands of someone from this mental health facility, and it seems that we are waiting an inordinate amount of time for reports that have been promised that could have prevented unnecessary assaults."
She wants Health New Zealand to commit to timelines so that the families are updated.
"They need to be transparent with the care that is being offered to the families, but also the staff in these institutions. And importantly, there needs to be an urgent and long, lasting review and change so that this doesn't happen again," she said.
"How many more people need to die? How many more victims do we need to create before systemic change happens? This must be prevented at all costs."
In a statement to RNZ, Dr Crawshaw said he had replied to Money's email, and offered an opportunity to meet and discuss broader issues relevant to both their roles.
He said reviews specific to serious events were undertaken by Health New Zealand.
Dr Crawshaw's report investigates wider concerns about the mental health service provision in the Canterbury district of Health New Zealand.
He said the investigation looks into the service at a systemic level: its general and clinical governance, its resourcing and overarching care model.
"All of which take some considerable time to review, analyse and report."
The broader review was scheduled to be completed mid-year, he said.
'Multiple checks and balances' - minister
In a statement, Minister for Mental Health Matt Doocey said he had been "very clear that we can and must do better to improve mental health and addiction outcomes and services in New Zealand".
"Within mental health there is a range of services available that are focused on addressing the mental health and addiction issues that many people face. In addition, we have specialised forensic services who provide rehabilitation to special patients, with the aim of protecting the public and keeping patients safe.
"As a result of rehabilitation, special patients may progress to a point where it is appropriate for their legal status to be reviewed. Before this occurs, there is a transition period where the person remains a special patient but is granted progressive community leave with clinical supervision and family or wider support. If the patient is progressing well, they may be granted extended periods of approved leave. Leave may have specific conditions applied regarding treatment required, or activities or movement in the community."
Doocey said there were "multiple checks and balances in place when it came to special patient decisions.
"These include the Director of Mental Health who gives advice and a recommendation, the responsible clinician and in some instances the Special Patient Review Panel and the Mental Health Review Tribunal. It is only at the end of this process that a person's status as a special patient may be reviewed. A change in status will only be granted if specified criteria, including public safety, are met.
"Even when a person is changed from special patient status, they will usually progress to being a patient where care is provided under compulsory treatment orders. These orders are regularly reviewed. These are long standing processes used for many years and aligned with approaches used in countries similar to our own."
He said the Mental Health Bill currently before Parliament would set out a new approach to the decision-making around change of status from special patient.
"If passed, the Bill will establish a Forensic Review Tribunal responsible for determining long leave, reviewing the condition of these patients, and determining changes in legal status.
"Any serious incident, particularly where someone is tragically killed, is a cause of very serious concern. That is why it is important that investigations and reviews are triggered and recommendations for changes to services are acted on."
Labour mental health spokeswoman Ingrid Leary told RNZ it would be "inappropriate" to comment on either the Cameron case or the case involving the man found insane twice as they were each subject to review processes.
"I would expect the reviews to look at systems and information gaps to see whether existing processes were followed and whether there are systems gaps that need to change.
"Like everyone else, I want to ensure cases like this don't happen again and will keep close eyes as the reviews evolve."
Leary said it was "premature" to suggest a full review into the mental health system.
"While these cases are harrowing and deeply unfortunate it's important to allow the review process to occur and respond appropriately rather than taking a knee-jerk approach which might not actually lead to the best and whole solution based on all the evidence."
Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
