Five mentally-unwell people went on to kill. A number of flaws in the mental health system have since been identified. Photo/File
Five mentally-unwell people went on to kill. A number of flaws in the mental health system have since been identified. Photo/File
"Heartbreaking" and "absolutely avoidable".
Those are the words an unmistakably frustrated Shaun Robinson, Mental Health Foundation chief executive, used to describe five unconnected but equally tragic homicides by five mentally-ill people.
"What makes me most angry is that this is total system failure in terms of responding to people's mental health needs," Robinson told Open Justice.
"Mental health has been ignored and under-resourced for decades in this country – in fact, it's never been adequately accepted or the scale of the issue acknowledged or a proper, compassionate, humane and effective response put in place and this is the worst end of the daily tragedies that result from that neglect."
Inadequate documentation of patients' history and care plans, and inadequate transfers of patients between health providers was also highlighted.
Shaun Robinson, Mental Health Foundation chief executive, said the deaths were avoidable. Photo/Supplied
Based on his findings, Coroner Robb – who made clear that violent acts by mentally-ill patients are very rare - has made a significant number of recommendations.
Hutt Valley and Capital and Coast DHBs, which provide health services in the area the homicides occurred, have welcomed the findings.
Chief executive for the Wellington DHBs' Mental Health, Addiction and Intellectual Disability Service Karla Bergquist said changes have taken place within the service since the homicides.
"The service has implemented a number of significant system improvements since these events occurred, including the successful implementation of recommendations identified in an external review in July 2016.
"The service is committed to meeting the recommendations of the Coroner and to monitoring and reviewing outcomes related to those recommendations."
A Ministry of Health spokesperson praised the efforts that had taken place to improve care within the service, and acknowledged the findings of the Coroner's report.
"To help address workforce shortages across the mental health and addiction sector, Budget 2019 is investing $77 million over four years in mental health and addiction workforce development."
But while Robinson appreciates the Government's intent, he said it's not enough.
The failures are not just that of the public health services, or the staff delivering the services.
Robinson said they are just one piece of a very big puzzle.
Other factors include meagre community support, mental health crises falling on police to deal with, inadequate emergency housing and inadequate income.
"Every aspect of the system that should be there to support people when they are struggling and really vulnerable is just not there."
However, since the 2017 mental health and addictions inquiry, He Ara Oranga, Robinson said there is more acknowledgment of the scale of the issue – a scale that reveals 20 per cent of New Zealand adults every year will have a significant episode of mental distress, according to Ministry of Health figures.
"Everything the Government has done has been good. It's just so far it's nowhere near enough and has not been systematic enough," he said.
