A fatal fall through cracks of the mental health system

By TONY WALL

Auckland pensioner Tony Ellis was stunned to learn that his psychotic son had been released from a mental health unit only a few hours after he was committed, and before he had been properly assessed.

So he found out the name of the psychiatrist involved and wrote him an angry letter, asking why his 35-year-old son Paul had been allowed back to his Maraetai home.

Ellis, 68, told Dr Salman Kazim, of the Ti Aho Mai acute mental health unit at Middlemore Hospital, that he would hold him personally responsible if anything "unfortunate" happened.

Twelve days later Ellis was dead - bashed with a baseball bat after being stalked by his paranoid schizophrenic son.

The transcript of a desperate 111 call Ellis made from his Kaukapakapa home captured the terror of the attack.

Even as he pleaded for his son not to attack him, Ellis tried to convince him of his concern for his mental health. But the pleas had no effect and the transcript chillingly records the noises of the fatal attack.

South Auckland Health's handling of the case has been the subject of an inquiry for the Ministry of Health, conducted by Helen Cull QC. Her report is expected next month.

The Ellis family blames the unit and the system for the killing and hopes the inquiry will lead to changes in the Mental Health Act to stop such tragedies happening again.

This month Paul Ellis was found not guilty of murder by reason of insanity. Justice Tony Randerson said the death occurred in "tragic and probably wholly unnecessary circumstances".

The Weekend Herald has learned that Family Court judge Bernard Kendall discharged Paul Ellis from the unit 11 hours after he was committed, despite a psychiatrist's report expressing concern that he was a "significant" danger to himself and others.

After his release his behaviour became increasingly bizarre. His family pleaded with health professionals to have him re-committed - but there was no further contact until after the murder.

Judge Kendall would not discuss the case. Paul Ellis is now being held indefinitely as a special patient at the Mason Clinic in Pt Chevalier.

About 10 years ago, the toolmaker for Fisher and Paykel suffered his first delusional episode - thinking his parents were poisoning his coffee and putting bugs in his house - but he recovered without intervention.

In 2000 he married and his wife, Debra, noticed he was obsessed with the 19th-century German philosopher Friedrich Nietzsche and lyrics by Doors singer Jim Morrison.

Last year his behaviour became increasingly bizarre. In October he attended a personal development course known as a Life Seminar, which seemed to make him worse.

It was an intensive course with long hours, Debra Ellis told the Weekend Herald. "There was no let-up ... it was almost like brainwashing." Her husband became convinced that others on the course were trying to get inside his head, and bought a hat to stop the "imposters getting in".

She wonders why the seminar organisers did not spot his bizarre behaviour and seek professional help. Director Clive Lawrence would not discuss the issue with the Herald.

After the course finished Tony Ellis decided to get help, calling on South Auckland Health's community assessment and treatment team to have his son committed to hospital.

The team and a police officer went to Paul Ellis' home during the early hours of October 12, handcuffed him and took him to the Ti Aho Mai unit.

Paul Ellis was admitted at about 2am by Dr Alwyn Castelino, a psychiatric registrar, who took the view that the patient felt persecuted and that people were trying to get into his head to make him kill himself.

He was delusional, thinking he was Superman, and said he had been using cannabis and methamphetamines.

Dr Castelino said Paul Ellis was a significant risk to himself and others and needed to be detained under the Mental Health Act. The doctor then went off duty.

At about 3am a psychiatric nurse advised Paul Ellis of his rights, including being able to apply to a judge to review his committal under section 16 of the act. Paul Ellis said he did not want to be in the hospital and he wanted a review.

At about 11am a hearing was held before Judge Kendall, who was visiting the unit to hear other applications.

By law the judge had to consult the "responsible clinician" - Dr Kazim - but the Punjab-trained doctor, in New Zealand on a one-year temporary registration, had not had a chance to assess Paul Ellis because he was busy.

The unit was short-staffed and had exceeded its capacity of 45 patients.

It is understood Dr Kazim's view was that it would be "very premature" to release him without a thorough assessment.

At the time Paul Ellis was calm and collected and answered eloquently when asked a series of questions. Before then he had never been admitted to hospital. Judge Kendall decided to release him.

After the hearing Dr Kazim told the unit's Mental Health Act administrator what had happened. The administrator told Dr Kazim he could start again and apply to have Paul Ellis recommitted under the act.

Dr Kazim spoke to Paul Ellis, but concluded that he did not seem mentally disordered and did not fulfil the criteria for a compulsory committal. However, he gave Paul Ellis Risperidone, an anti-psychotic, to take away with him. Dr Kazim is now living in the United States and is understood to be working for the Air Force.

Paul Ellis left Ti Aho Mai in a taxi. His family say that later he appeared "quite chipper, particularly as he had a certificate to say he was sane". But over the next two weeks his condition grew worse.

He did not take the medication regularly. Debra Ellis, who had just given birth to the couple's second child, had moved in with her parents in St Heliers and Paul Ellis began dumping rubbish in their drive. The police were called and a restraining order was taken out.

Police were also called when Paul Ellis deliberately drove his Harley Davidson in front of a vehicle and got knocked off.

On each occasion the family told police he had been released from a psychiatric unit and needed to go back.

Meanwhile, Tony Ellis was ringing the Ti Aho Mai unit and the community team that was supposed to be keeping tabs on his son, pleading with them to have him re-committed.

Dr Kazim received Tony Ellis' letter and called his home phone, but got an answer machine.

No one from mental health services had any further contact with Paul Ellis.

On October 18 he quit his job with Fisher and Paykel, which he had held for 18 years.

On October 25, the day of the killing, he got a V-shape cut out of his hair to match that of a Nazi general he had seen on a CD cover.

While driving along he saw the number plate JMO, which reminded him of Jim Morrison and in particular the song The End, with the lyrics "father, I want to kill you". He decided he had to kill his father "to stop all this madness in my life".

At 11.47 that night, Tony Ellis, barricaded inside his house, called 111. What followed was the stuff of nightmares. He said his son was outside and had told him to go and get his gun because he was going to kill him.

Tony Ellis spoke to the police operator for several minutes and armed himself with a baseball bat. He said he could hear knocking at the door. He then cried out that his son was inside the house - he had forgotten to lock the back door.

The police recording equipment picked up Tony Ellis' final pleas.

He said: "Paul ... no Paul ... please stay there ... I don't want to shoot you Paul. I've been trying to help you. I've always helped you ... no, I'm talking to the health people ... I tried to help you last time you had this ... I'm not going to shoot you Paul, that would be the last thing I would do ... Just stay there please."

Paul Ellis interjected: "Just [expletive] shut up and listen ... you or me because that's the way it is. Shut up and listen. It's either you or me. Go get the gun. It's either you or me."

Tony Ellis implored his son to think about his mother, who was in Australia on holiday at the time. This was followed by screams and banging noises, then a silence broken by the sound of the metal bat hitting the floor and Paul Ellis muttering.

Armed police arrived 10 minutes later and found Paul Ellis standing motionless near his father, spots of blood on his face. Tony Ellis was taken to hospital and died about three hours later of massive head injuries.

At the High Court trial, the director of the Mason clinic, Dr Sandy Simpson, said the Ti Aho Mai unit should have more thoroughly assessed Paul Ellis. He considered that if that had happened, Paul Ellis would have been detained.

Debra Ellis now visits her husband in the Mason Clinic three times a week with their children. She says he is back to his old self after a year of treatment, but is on antidepressants and has been suicidal at times, struggling to deal with what he has done.

"I'm sure it will upset him for the rest of his days - he was very close to his dad."

It is ironic, she says, that the mental health services "couldn't wait to get rid of him" when he first arrived - now they will have to spend years on his recovery.

"I'm angry with the system for letting him down but he's still a human being, he's still got a lot of those qualities I fell in love with."