Coroner's twin tragedy hope

The Auckland coroner, Mate Frankovich, ended his inquest into the deaths of Lachlan Jones and Malcolm Beggs yesterday, saying he hoped to produce "some salutary solution" to prevent a repetition of the events that led to the suicide-murder.

He concluded the eight-day inquest after Eugenie Laracy, acting for the Beggs family, made a brief closing submission calling for a change in direction of Waitemata Health's culture.

"In some ways this was a disaster waiting to happen."

She was commenting on the case which scrutinised events of the 12 months leading to last August 30 when the schizophrenic Jones, in community care, hacked to death his flatmate, Malcolm Beggs, before gassing himself.

She said there had to be change in a system that left people in the community living with or caring for the mentally ill, vulnerable through the actions of "professionals who have decided that is where [the mentally ill] should be."

For Waitemata Health, Adam Ross expressed condolences to the Beggs and Jones families.

"We can say till we are blue in the face that an inquest is not about apportioning blame but the worthies of the fourth estate and the public do not necessarily see it that way."

Mr Ross referred to argument during the inquest about whether Mr Beggs should have been told he had a mental health patient living in his home. But Waitemata Health psychiatric staff had no perception that Jones was a risk so they had nothing to pass on to Mr Beggs, Mr Ross said.

He said Waitemata Health's role with Jones was as relevant in the tragedy as his family background, the role of Auckland Healthcare, Jones' friends and the way he chose to lead his life.

The case involved an individual who was unpredictable and an illness which was particularly difficult to treat.

"One should be slow to conclude there have been any causal effects from anything that was done or not done in this case."

Earlier, in cross-examination of Dr Ian Goodwin, an Auckland Healthcare specialist in suicide and self-mutilation cases, Eugenie Laracy said Mr Beggs had been forced to retreat from his house as a result of Jones' actions.

Dr Goodwin said that if Mr Beggs had voiced his concerns about Jones to the Community Assessment and Treatment Team West (CATT) it might have given the team a clue to what was going on.

Before the deaths, he said, the team knew Jones had a job, a home and a social life.

"What they didn't know was that Lachlan was in his room pumping weights. He was not communicative ... It sounds like a scary individual. I don't think the CATT team was aware of that."