Missed drug test before second killing sparks mental health system review. Photo / RNZ
By Sam Sherwood of RNZ
A mental health patient was not drug tested on the day he committed his second killing because the staffer believed he was “acting cagey”, his father alleges.
The man was subject to a compulsory treatment order at the time, which meant drug screening occurred on a voluntary basis.
But if he failed the test, the clinician would then need to assess whether the patient should be recalled to hospital.
RNZ earlier revealed the 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.
RNZ is unable to publish details regarding either killing because of an appeal against name suppression that is due to be heard by the Court of Appeal.
RNZ has obtained a copy of a letter from the man’s father to the presiding judge.
The man’s father alleged that on the day his son killed for a second time, he was supposed to be drug tested.
“He turned up for the appointment but was not tested because the staff member said that he was acting cagey and she didn’t want to make him feel like he was being picked on.”
“This is a so-called health professional who observed unusual behaviour from a person with severe mental health issues, and they didn’t do anything about it. She didn’t test him and basically allowed him to leave. A few hours later [he killed again].”
The man said his son told him he had to go have a drug test, “so he was expecting it, but nothing came of it”.
The man’s second killing “could and should have been prevented,” the father says.
“How can someone who has previously killed another person be able to remain free when the warning signs are right there for all to see?”
In the weeks leading up to the second killing, the man’s mental health was “rapidly declining”, a judge earlier said. He was admitted to a mental health facility following an altercation with a relative.
About a week later he was released. He was having relationship problems and was using cannabis.
Five days after he was released from the mental health facility, he stabbed someone to death.
In his letter, he said his son had mental health issues “for most of his life”.
“I have attended countless appointments and meetings relating to [him] and his treatment, and I have full knowledge of the process, his medication and its effectiveness, the downsides, and how he has responded over the years.
“I have met his doctors and psychiatrists and have a good understanding of the mental health system, what services are provided, and some of its failings.”
He discussed his son’s admission to a mental health facility before the second killing when his mental health “deteriorated”.
He said the staff should not have released his son.
The second killing was “predictable if anyone bothered to look at the warning signs and do something about it,” he said.
“Predictable in the sense that [he] was on a downward spiral. Maybe not predictable with the exact date and time, but the warning signs were there for the health professionals to see. To use their judgment and training and to actually do something about what they saw instead of just letting it go because it gets too hard for them.”
He said the health system was “not aggressive enough to make decisions”.
“For more than five years, I visited [him] every night in one of their institutions, so I know full well what goes on inside the walls. There are more questions than answers. The health system had [him] in their custody and released him. A health professional saw [him] on the day he killed [again], described him as being cagey, did not do the blood test, and let him go without doing anything. How? Who is accountable? How can someone who has previously killed another person be able to remain free when the warning signs are right there for all to see?”
RNZ put the allegations regarding the drug test to both Health New Zealand and the Ministry of Health.
Health New Zealand (HNZ) said an external review of the care the patient received leading up to their alleged offending was in progress. They did not comment on the allegations.
In most situations, screening for substance use occurred on a voluntary basis and could include individuals subject to detention under the Mental Health Act on compulsory treatment orders, an HNZ spokesperson said.
“However, screening is very much part of an individual treatment/care plan where interventions may be put in place in the event of a positive result or refusal to be tested.”
Director of Mental Health, Dr John Crawshaw, said in a statement in circumstances like these, an independent review was triggered to investigate the incident and make recommendations for changes to services and for those recommendations to be acted on.
A review was underway.
“The claim of reported drug use and delays in drug testing would be most appropriately investigated by the independent review commissioned by Health New Zealand.”
In relation to drug testing, a Ministry of Health spokesperson said screening for substance use occurred on a voluntary basis and could include individuals subject to detention under the Mental Health Act on compulsory treatment orders.
“Screening is very much part of an individual treatment/care plan, where interventions may be put in place in the event of a positive result or refusal to be tested.
“For further background, it also depends on whether the person is on an inpatient order or a community treatment order. If the testing is part of a condition of leave on an inpatient order, it can result in the leave being cancelled. If the person is on a community treatment order, the responsible clinician would then need to assess whether there is enough concern to direct the patient to be treated as an inpatient. It’s important to note that this applies to people under ordinary Mental Health Act orders, and there is a separate process for special patients.”
Mental Health Minister Matt Doocey said any serious incident, particularly one where someone was killed, was a “cause of very serious concern”.
“That is why it is important that reviews are triggered and recommendations for changes to services are acted on. My focus is on ensuring agencies involved are putting in place the necessary changes to help prevent these incidents occurring again.
“There is an external review under way, and it would be my expectation that this review will cover the care this person received leading up to the incident.”