The brother of a man bludgeoned and burned by a mental health patient has praised a judge's call for a review of the same district health board involved in a similarly brutal killing.
Graeme Moyle's brother Colin Moyle was killed by his former flatmate Matthew Ahlquist in 2007 after being beaten with a spade and set alight.
Ahlquist was found not guilty of murder by reason of insanity.
He was a patient at Te Whetu Tawera, Auckland District Health Board's (ADHB) mental health unit.
As was Gabriel Hikari Yad-Elohim, who just days after being released from the facility in September last year murdered Michael David Mulholland.
Yad-Elohim, who was found guilty of murder despite his defence also seeking a verdict of not guilty by reason of insanity, was sentenced yesterday in the High Court at Auckland.
Justice Gerard van Bohemen gave him a life term behind bars and a minimum period of imprisonment of 13 years, but called for a thorough examination of what led to Yad-Elohim's release from Te Whetu Tawera.
"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 then at the time of your release from Te Whetu Tawera."
Today, Moyle said he saw a number of similarities between the care of Ahlquist and Yad-Elohim.
"Both had a long history of mental illness and each had been in and out of psychiatric care," he said.
Yad-Elohim, who was also a meth user, had been admitted three times to mental health services in Auckland - first in 2009 for five weeks, and again in late 2014 and into 2015 for 10 weeks before last year's admission.
He also received care in Sydney. While in Australia he was convicted of assaulting a nurse.
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.
"I am very pleased someone of Justice van Bohemen's statue has finally recognised the need for independence when investigating these types of cases," Moyle said.
"My brother's killer was prematurely discharged from the same mental health unit in 2007 and I believe nothing has changed."
He said an independent, publicly available report would highlight "similarities and systemic failures".
"I have been raising this issue for a long time and have recommended establishing an agency similar to the Independent Police Conduct Authority to carry out inquiries into homicides and suicides by patients receiving mental health intervention."
During Yad-Elohim's, specifically when Dr Peter (William) McColl, the service clinical director at Te Whetu Tawera was cross-examined, an external review of Yad-Elohim's treatment first came to light.
It was commissioned after Mulholland's murder and completed by a clinical director from Northland and nurse director from Christchurch.
Its existence shocked everyone in the court involved in the trial, except McColl.
It showed the medical notes kept on Yad-Elohim were "misleading".
However, McColl testified neither he nor his staff had "dropped the ball".
McColl admitted a shortage of beds had contributed to the decision to release Yad-Elohim, who murdered Mulholland outside his Western Springs flat with an estimated 90 blows to his head and body.
The top doctor called the release from Te Whetu Tawera a "good discharge" and said Yad-Elohim "no longer needed hospital-level care".
The Herald has requested a copy of the review from the ADHB but was refused a copy for privacy reasons.
However, an ADHB spokesperson said the reviewers "have not identified any substantial care delivery problems that may have contributed to the event prompting the review".
But several recommendations made were being implemented, the spokesperson said.
"How are we to have confidence in this report if they refuse to disclose its contents even in a redacted format," Moyle said.
The Herald has also requested the review under the Official Information Act.
Moyle was critical of the system whereby DHBs initiate their own inquiries.
"There is no independence, no transparency, no involvement of victims or their families and crucially, in most cases, no publication of their findings," he said.
"The only way the public can be assured that these inquiries are fair, robust and transparent is for a true independent body to carry them out."