Doctors at Auckland's acute mental health facility are told to focus on discharging patients when at maximum capacity, a policy which led to the brutal slaying of an innocent pensioner, leaked documents reveal.
In an exclusive interview with the Weekend Herald, the victim's daughter also says New Zealanders are being let down by the mental health sector and innocent people are paying for it.
The Mental Health Adult Service Escalation Plan for occupancy at Auckland District Health Board's (ADHB) Te Whetu Tawera (TWT) shows a clinic wide policy of "one out, one in" when the beds are full.
It is the scenario doctors faced when releasing Gabriel Yad-Elohim, before he went on to murder Michael Mulholland just three days later on September 26, 2017.
Yad-Elohim, a delusional Korean-Japanese man with a history of mental illness, delivered an estimated 90 blows to the 69-year-old's head and body after pulling him from the front door of Mulholland's Western Springs flat.
The leaked plan shows the various levels of risk associated with the number of patients at the clinic - green being the best and purple the worst.
Lead clinicians, clinical team leaders, clinical coordinators and the pharmacy team leader are alerted to "58 Purple: very high risk" by at least 8.15am whenever the unit's 58 beds are all occupied.
A 9.45am meeting is also held where staff "prioritise and decide discharges and transfers", while no overnight or weekend leave is granted to any patients.
Clinical consultants then "cancel all non-urgent work to focus on discharge, until Te Whetu Tawera is out of purple".
After hours, the clinic's duty manager will phone the on-call consultant for any patient releases with the "aim of reducing occupancy (1 out, 1 in.)".
"No admission until after a discharge is completed, i.e. no going over numbers," the policy reads.
It also shows funding can also be accessed for motel accommodation for up to one week to facilitate discharges for patients.
Mulholland's daughter, who has been fighting to have the ADHB release information about her father's killer, says the case shows "a vast shortage of facilities".
"People do get it wrong, human error ... I don't blame the doctors for releasing him early but I do blame that there shouldn't have been a need to release someone early," she says.
A jury found Yad-Elohim guilty of murder in August over a defence of not guilty by reason of insanity.
"My dad had never met that guy, there was nothing there, and now my dad is dead ... that guy should've [still] been in the hospital," Mulholland's daughter told the Weekend Herald.
During a heated cross-examination at the trial, Dr Peter McColl, the service clinical director at Te Whetu Tawera, said the facility would have discharged Yad-Elohim sooner had suitable accommodation been found.
"It was a good discharge, it was well thought through ... This is what we do," McColl said.
"All the pieces were in place to follow up ... he was well, his symptoms had resolved. He no longer needed hospital-level care."
However, before Yad-Elohim's release a doctor noted the patient, who has a history of meth use and non-compliance with taking medication, was "still" having hallucinations to kill.
But McColl told the court his colleague was "mistaken".
Yad-Elohim self-presented at Auckland City Hospital's emergency room on September 17 before later being admitted to his mental health ward.
"Te Whetu Tawera is a pretty acute place, everyone there is pretty ill," McColl testified.
Mulholland's daughter says the process which led to her father's death can't keep happening and called for more mental health care funding to increase occupancy levels.
"We're actually being let down by the mental health sector and innocent people are paying for that," she says.
"I didn't feel sorry for Gabriel, but [he was] definitely let down to a point where this shouldn't have happened."
Graeme Moyle's brother Colin Moyle was also killed by a former patient at Te Whetu Tawera when, in 2007, Matthew Ahlquist beat him to death with a spade before setting him alight.
Ahlquist was found not guilty of murder by reason of insanity.
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 showed errors in his continuity of care, including his admission and discharge.
Graeme Moyle says he has "suspicions" about how mental health units are managed when they reach max occupancy, and worries discharged patients also end up in the prison system.
"Funding is a big thing," he says.
"If there is a serious lack of beds they obviously need the funding for more beds ... To have a policy like that to perhaps pick the least sick person to discharge shows that you need more beds."
An external review of Yad-Elohim's treatment also came to light during the trial.
It was commissioned after Mulholland's murder and showed some of Yad-Elohim's medical notes were "misleading".
However, McColl said neither he nor his staff had "dropped the ball".
The Weekend Herald has requested and been denied a copy of the review from the ADHB.
An ADHB spokesperson said no changes had been made to the occupancy plan at Te Whetu Tawera as a result of the review.
"Overall the reviewers have not identified any substantial care delivery problems that may have contributed to the event prompting the review," the spokesperson quoted the review.
However, the reviewers did make "a number of recommendations", which are being implemented.
Yad-Elohim was sentenced last month to a life term behind bars and a minimum period of imprisonment of 13 years by Justice Gerard van Bohemen.
The judge also called for a "thorough examination" of what led to Yad-Elohim's release from Te Whetu Tawera.
"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," Justice van Bohemen said.
The Weekend Herald understands Yad-Elohim's legal team are preparing an appeal.
Warren Pay, jailed for murder, is now free after being re-sentenced for manslaughter.