A Coroner has made a swathe of recommendations demanding urgent changes to court processes following the death of North Shore teenager Christie Marceau in a bid to "reduce the chances" of similar "devastating" deaths in future.
The recommendations were aimed at the Ministry of Justice, police, Department of Corrections and Waitemata District Health Board after a number of inadequacies - mainly around deficits in inter-agency information sharing - were identified in the handling of the youth who stabbed Christie to death in her Hillcrest home.
Christie, 18, died on November 7, 2011 in her mother Tracey's arms on the deck of their family home.
Minutes earlier Akshay Anand Chand had forced his way into the house, chased Christie to the deck and stabbed her repeatedly in the head.
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Chand only stopped the frenzied attack when the knife bent to such an angle that he could no longer use it.
The Herald revealed that Chand was on bail at the time and facing serious charges of kidnapping, threatening and assaulting Christie two months earlier.
When released on bail Chand was ordered not to associate with, attempt to contact, or go anywhere near Christie or her home.
Judge David McNaughton also imposed a 24-hour curfew in place and ordered Chand not to leave his mother's house unless he was going to medical or legal appointments.
But just 32 days later Chand - who later admitted he had been planning the attack for some time - walked to the Marceau house armed with a hammer and kitchen knife and took Christie's life.
In October 2012 Chand was found not guilty of murdering Christie by reason of insanity.
An inquest was held in June last year and looked at the administrative process at the North Shore District Court in the lead up to Chand being bailed; police bail-checking processes and protocols and whether they were adequate; what Chand's mental health was before Christie's death and what information Judge McNaughton had available to him when he made the bail decision.
In her final report today Coroner Katharine Greig said the overriding purpose of the inquest was to establish the cause and circumstances of Christie's death and to make any relevant recommendations that could prevent similar incidents in future.
Her final report was released today and contained 10 strong recommendations that did in fact, highlight the failings the Marceau's wanted addressed.
"Christie's death has been a devastating loss for her family, whose lives are forever changed," Coroner Greig said.
"Christie's death and the circumstances around it shocked the nation.
"Following Christie's death her family spearheaded high profile public efforts to reform aspects of bail laws," she said.
"During this campaign, and since, images of Christie's smiling face have been published in the media regularly and her face is a familiar image to New Zealanders.
"The tragedy and futility of Christie's death, together with questions as to how Mr Chand came to be in a position where he could kill Christie, have continued to resonate and are a matter of strong public interest."
Coroner Greig's findings span 127 pages and relay what evidence was given by each witness at the two-week inquest as well as detailed recommendations.
The Marceau family were given a copy of the findings and spoke to the Herald soon after.
Tracey and Brian Marceau said they were pleased Coroner Greig had made such wide-ranging recommendations.
But, that was just a starting point.
Now, they called on the agencies involved to step up, improve and do their best stop anyone else suffering Christie's fate.
The recommendations include:
• When mental health reports are ordered by a District Court judge relating to a bail application, that their notes be made available to health assessors and that information will be considered in their final assessment.
• That police and the victim advisor service at the District Court develop a protocol identifying types of information that should be shared to enable them to work together more collaboratively - and that they exchange that information "on a nationally consistent and timely basis".
• That the victim advisor service review its processes for advising victims of crime who wish to provide their views to the Court on a bail application - and amend those processes if necessary.
• That the police, Ministry of Justice and Department of Corrections work together to ensure bail applications for serious offending are presented in a more "suitable format" and include full details of the proposed bail address and the occupants, as well as whether those occupants are willing to supervise defendants.
• That the North Shore District Court undergo an "in-depth review" of issues relating to document management including a review of the adequacy of electronic document management systems "particularly in relation to access, accuracy" and that any changes deemed necessary as a result are implemented nationally.
• That all district court processes are amended to ensure court takers record all relevant bail application information on the paper-based court file.
• That the Police Prosecution Service review its processes and, where necessary, amend them to ensure that they "maintain a robust procedure" to identify and monitor high-risk cases - and that the new process is "audited regularly" to ensure compliance.
• That the Waitemata DHB, police and Ministry of Justice work together to identify baseline documents throughout New Zealand that should routinely be provided to enable them to work "effectively" with offenders they are asked to attend or advise on; and agree which agency is responsible for providing those baseline documents to forensic court staff.
• That the police and DHB identify whether there are types of evidence held by police including job sheets or interview transcripts or videos, that would assist mental health assessors in preparing their own reports - and that a process is developed for such information to be shared before mental health assessments are carried out.
Recommendations were also made around improvements to regional forensic psychiatry services including better information collecting, recording and sharing and ensuring services lined up with court forensic staff guidelines.
THE FULL REPORT WILL BE AVAILABLE ONLINE FROM 6PM TODAY.
Coroner Greig expressed her "deepest condolences" to the Marceau family.
"Christie was young, vibrant and deeply loved by her family," she said.
"Christie was intelligent, caring, compassionate and joyful.
"She loved her family and her friends.
"Her life was cruelly cut short just as she was embarking on adulthood."
How the agencies responded
After the findings were released the Herald sought comment from the agencies at the centre of the recommendations - the police, Ministry of Justice, Department of Corrections and Waitemata District Health Board.
Ministry of Justice chief executive Andrew Bridgman said his agency would be "reviewing" the coronial findings and "welcomed" the "detailed consideration of the issues".
"We want to do all we can to ensure our policies and processes are best practice and will be working with other agencies involved in the criminal justice system," Bridgman said.
"As the coroner noted, in recent times the implementation of the Criminal Procedure Act and changes to the Bail Act have changed the way the courts manage cases.
"The District Court is now one court and a range of changes are being made to ensure consistency across all court locations."
National manager of the Police Prosecution Service Superintendent Gary Allcock
acknowledged the findings.
"Police will take time to review the Coroner's findings and consider the recommendations that have been made," he said.
"Police recognise the profound impact of this tragedy on the family and friends of Christie and the important role police prosecutors play in the court process advocating on behalf of victims. "
Allcock added that the prosecutors involved in Chand's court case remained "valued members" of the police.
"Police staff involved in the investigation and prosecution of Christie's death are not immune to the tragedy of this case," he said.
"Nothing can change the fact that the person responsible for this tragedy is Akshay Chand.
"It was the actions of this man that killed Christie."
Chief District Court Judge Jan-Marie Doogue also weighed in.
"The findings of the Coroner's inquest into the death of Christie Marceau highlight the risk created by information gaps in the criminal justice system and expose where some of those gaps are, especially around the quality of information that is placed before judges," she said.
"To make sound, safe decisions that protect people from further harm, judges need as much information as possible.
"We rely on everyone across the system to capture that detail to the best of their ability and bring it to the court's attention.
"This inquest has demonstrated the value of thorough, evidence-based inquiry for dispelling rumour and unfair speculation, and for shedding light on the complexity of the interdependent processes in the system which formed part of the backdrop to Christie's death."
She said the quality of information available to judges in bail hearings concerned he.
"District Court judges have led an initiative to provide judges considering bail applications in certain types of violence cases with a pack that gathers together all information about a defendant held across various police and court files, and including victims' views," she explained.
"The Ministry of Justice has helped us trial these 'Judge's Packs' successfully in four regions and judges are eager to see them rolled out nationwide.
"While these sorts of initiatives improve judges' knowledge, they cannot eliminate risk completely.
"Risk factors include those arising out of mental disorder where accurate clinical diagnosis may not always be possible."
Judge Doogue said the findings also "underscore" the importance of good quality court administration and support services for both the people affected by crime and decision makers.
"District Court judges are determined to play our part; we owe it to all parties involved in criminal proceedings, and the communities which the District Court serves, especially victims and their families – families like the Marceaus."
The Waitemata DHB said it "accepts the findings and recommendations".
"We hope the finalisation of this process brings some comfort to Ms Marceau's family and friends," said a spokesperson.
"Following the death of Ms Marceau the DHB commenced an investigation which included an external review of the DHB's role in providing mental health care and advice to the court.
"The review documents were provided as part of the coronial process and are accurately reflected in the findings.
"Coroner Greig has made four recommendations in respect of the DHB with regard to its forensic mental health services and work with justice and police around court processes and procedures.
"A number of the recommendations are based on work the DHB had already undertaken following the internal review.
"Waitemata DHB will continue to work with police, Justice and DHBs nationally to implement the further recommendations of the Coroner."
Corrections deputy national Commissioner Leigh Marsh also acknowledged the findings.
"Ms Marceau's death was a tragedy and we extend our deepest sympathy to her family and friends.
"Coroner Greig made one joint recommendation for Corrections, the Ministry of Justice and police to consult on ensuring that simpliciter bail applications for serious offences, and where a 24 hour curfew is proposed, are provided to the court in a suitable format.
"We've accepted this recommendation and we are committed to working with our justice sector partners to ensure that public safety is at the forefront of decision-making."