One of Auckland's most brutal murders will not have coroner's inquest, despite calls from a High Court judge for a "thorough examination" after questions were raised about the killer's mental health treatment.
Gabriel Yad-Elohim was found guilty of murdering Michael Mulholland over a defence of not guilty by reason of insanity following a High Court trial last August.
The delusional Korean-Japanese man with a history of mental illness delivered an estimated 90 blows to Mulholland's head and body after pulling him from the front door of the 69-year-old's Western Springs flat on September 26, 2017.
The graphic killing, which was filmed on CCTV cameras, came just three days after Yad-Elohim was released from the Auckland District Health Board's (ADHB) acute mental health facility, Te Whetu Tawera.
When sentencing Yad-Elohim to life imprisonment last September, Justice Gerard van Bohemen called for a "thorough examination" of what led to Yad-Elohim's release from the clinic.
"While it is not for this court to direct, I consider a thorough examination should be undertaken of the circumstances that led to your release from Te Whetu Tawera. I say that not withstanding the review that has already been carried out of your discharge," the judge said.
"I make no criticism of the management and staff of Te Whetu Tawera - they operate under difficult circumstances with finite resources. Nonetheless, the fact that you brutally killed a defenceless older man, days after being found to be suitable for release into the community, warrants external examination," he continued.
"It is particularly concerning that your condition has since been found to be considerably more serious than at the time of your release from Te Whetu Tawera."
When Yad-Elohim was asked if he had anything to say before the court's sentence was imposed on him he said: "I was mentally ill when the incident happened."
However, New Zealand's Coronial Services have declined to hold an inquest into Mulholland's death, which could have led to recommendations helping to prevent future tragedies.
In a May decision, released to the Herald today, Coroner Sarn Herdson said the matter was to be finalised after she reviewed a pathologist's report and an ADHB report of Yad-Elohim's treatment at Te Whetu Tawera.
"The report found, in summary, the fundamental decisions about [Yad-Elohim's] care and treatment were considered to have been appropriate for the way he presented and behaved with medical and nursing staff at the relevant time," Coroner Herdson said.
The report, which the ADHB refused to release publicly despite an Official Information Act request by the Herald, only came to light mid-way through Yad-Elohim's trial.
It was later released to the Herald by the High Court and said Te Whetu Tawera was under "considerable occupancy pressure" at the time which "contributed greatly to a hasty discharge".
"Overall the reviewers have not identified any substantial care delivery problems that may have contributed to the event prompting the review."
Some recommendations were made, which are being implemented, the ADHB has said.
Documents leaked to the Herald also showed doctors at the health facility were told to focus on discharging patients with a "one out, one in" policy.
Te Whetu Tawera was at full 58-bed capacity when Yad-Elohim was released.
Dr Peter McColl, the service clinical director at Te Whetu Tawera, said at trial the facility would have discharged Yad-Elohim sooner had suitable accommodation been found.
"It was a good discharge, it was well thought through ... This is what we do," McColl said.
"All the pieces were in place to follow up ... he was well, his symptoms had resolved. He no longer needed hospital-level care."
However, before Yad-Elohim's release a doctor noted that the patient, who has a history of meth use and non-compliance with taking medication, was "still" having hallucinations to kill.
But McColl told the court his colleague was "mistaken" and neither he nor his staff had "dropped the ball".
Mulholland's daughter earlier told the Herald that New Zealanders are being let down by the mental health sector and innocent people are paying for it.
"People do get it wrong, human error ... I don't blame the doctors for releasing [Yad-Elohim] early but I do blame that there shouldn't have been a need to release someone early," she said.
"My dad had never met that guy, there was nothing there, and now my dad is dead ... that guy should've [still] been in the hospital."
Mulholland's daughter has been fighting to have the ADHB release more information about her father's killer and said the case shows "a vast shortage of facilities" for mental health patients.
In a similar case, Colin Moyle was killed in 2007 by his former flatmate and Te Whetu Tawera patient Matthew Ahlquist.
Ahlquist was found not guilty of murder by reason of insanity.
Reviews of Ahlquist's case, including one by the Health and Disability Commissioner, detailed "evidence of unacceptably poor clinical judgment and practice by some medical and nursing staff''.
The Ahlquist review also showed a string of errors in his continuity of care, including his admission and discharge from Te Whetu Tawera.
"My brother's killer was prematurely discharged from the same mental health unit in 2007 and I believe nothing has changed," Colin's brother Graeme Moyle has told the Herald.
Despite there being no Coroner's inquest over Mulholland' murder, the case will be reviewed in the Court of Appeal.
The Herald revealed last year that Yad-Elohim's defence team, which now includes Auckland lawyer Phil Hamlin, is seeking to overturn his conviction.
A hearing date for the appeal is yet to be allocated.