The inquest, which began at Hamilton District Court this morning, heard there was a series of failings in the 33-year-old's care after he was discharged from a mental health ward at Waikato Hospital.
That included that Te Moananui's mother reported her son was drinking alcohol, which the senior doctor was unaware of because he wasn't reading all the progress notes being made by a key worker on the case.
The patient was relapsing and red flags not acted on included he had become isolated in the community, had reduced his medication for schizophrenia, not attended drug and alcohol treatment and not undertaken any psychotherapy.
Despite his discharge notes recommending these treatments, it appears none were organised for Te Moananui.
Giving evidence, Waikato DHB clinical director of mental health and addictions services Dr Rees Tapsell admitted there were missed opportunities by all of Te Moananui's healthcare workers when it came to listening to his whānau.
"Every single one of our clinicians ought to be engaging with the family of those in our care."
Regarding the progress notes - information added to Te Moananui's patient file every time he met with a key worker - the psychiatrist's lawyer Matthew McClelland, QC, challenged a suggestion his client had not been reading them.
However, Coroner Robb pointed out the psychiatrist admitted as much in the first inquest.
"It's not possible to follow every single note that every single key worker writes about every single patient, it's just not possible," the psychiatrist is recorded as saying in 2019.
The court heard Te Moananui turned up to an appointment a month before his death with a black eye but how he suffered the injury was not followed up.
McCelland pointed out the psychiatrist was managing 120 patients at the time.
He said the psychiatrist was an authority on the anti-psychotic medication clozapine, which Te Moananui was taking, he was involved in research and had worked internationally.
The doctor was well-regarded and was still contacted by colleagues for advice, McClelland said.
He quizzed Tapsell on the fact the DHB previously rated the psychiatrist highly but after Te Moananui's death, said his conduct fell well below expectations and that he provided an unsatisfactory standard of care.
"I think that more could have been done by the key worker," Tapsell replied. "I think more could have been done by the responsible clinician."
McClelland said more could have been done by the whole team and Tapsell said this was the focus of the first inquest, which McClelland was not involved in.
"I expected that there were other things that weren't done that could hand should have been done, by members of the team and by the service itself," Tapsell said. "Including myself."
The Coroner said the reason for the focus on the psychiatrist was because of his response to the original findings, which were critical of the doctor.
"I understand his concern that he is now the subject of this resumed inquest but he is not the exclusive subject of my inquiry."
The night before his death, at his home in Kopu near Thames, Te Moananui shot a man in the foot.
The Independent Police Conduct Authority found two police officers were justified in shooting Te Moananui.
It said at the time of being shot, Te Moananui was pointing a rifle at them and they feared for their lives.
The authority said he had told a family member that he wanted to "go out like a gangster, giving Thames something to talk about".
The inquest continues.
