The Coronial inquest continues at the Wellington District Court. Photo / File
The Coronial inquest continues at the Wellington District Court. Photo / File
An over-stretched mental health sector and police failings have been at the forefront of the Coronial Inquest into the violent death of Glen Collins.
The inquest is taking place this week in front of Coroner Brigitte Windley in Wellington.
Collins was stabbed to death in an unprovoked attack at his partner's Upper Hutt home in September 2018 by David Charles Gilchrist.
Gilchrist plunged a 20cm stainless steel blade into the back, neck and torso of Collins who died at the scene despite efforts by neighbours to save his life.
Gilchrist, who had a long history of psychotic illness, including violent behaviour, was subject to a compulsory treatment order in the community and was off his anti-psychotic medication when he attacked the father of two.
He was charged with Collins' death but found not guilty by way of insanity in the High Court at Wellington in March 2019.
Windley commenced today's proceedings in the Wellington District Court with an acknowledgement of the family and friends of Collins who have been present for the inquest's duration.
"It's important to acknowledge the unwavering presence of Mr Collins' family and friends and your commitment to this process."
Police and mental health professionals who have taken the witness stand this week have spoken about a mental health system under extreme pressure.
Gilchrist had been reported missing to the Whangarei police by the Northland District Health Board on August 30. Less than a month later he murdered Collins in a frenzied attack.
The handling of that file, and subsequent investigation into Gilchrist's location, has since been deemed inadequate, admitted by a police staff member on the witness stand this week.
"The Northland police did not take timely and sufficient steps to locate Nathan Gilchrist," the witness said.
The file landed in the inbox of a staff member who was on annual leave, the file had not been reassigned and a risk assessment of Gilchrist couldn't be carried out.
The witness admitted that there was an issue around pursuing missing person files and that from time to time there wasn't sufficient priority placed on missing person files from the Northland police.
She said these failings have assisted in showing where police need to make significant amendments in their processes.
Lack of inquiry into Gilchrist's whereabouts, despite the man committing petrol drive-offs as he made his way down the country, hindered police In locating a man who was deemed dangerous.
Police admitted that tracking his bank records had helped locate him in the past and if that was a path taken then the police would have been able to locate Gilchrist sooner.
Coroner Brigitte Windley acknowledged the "unwavering presence" of Glen Collins' family in court today. Photo / Supplied
Another witness from the police said she had taken Gilchrist into custody the night before the murder after his registration brought up the multiple petrol drive-offs when searched in a police database NIA.
His status as a missing person was flagged, as well as a notice for carrying knives and his previous history of violent offending.
The witness said Gilchrist didn't present as "mentally disordered", and he told the constable he wasn't missing. He claimed he was in Wellington seeking legal advice to stop taking his medication.
Mental health triage service Te Haika was called, who then contacted the Crisis Resolution Service at Wellington Hospital.
A witness from Te Haika said they were advised by the CRS to tell police they could take Gilchrist to the emergency department, but because he did not present unwell, and was resisting his medication, the constable was under the impression he did not want assistance.
CRS denied this was what they advised and said they requested more information from Te Haika at the time. The nurse said if they had known Gilchrist was under the Mental Health Act he would have been given a high priority to be seen that night.
The missing persons alert was cleared and Gilchrist was released on bail to appear on the petrol drive-off charges. Northland police were notified of his whereabouts but failed to pass the information on to the DHB who had reported him missing in the first place.
The court heard there was a failure of communication at a number of steps, and at every step there can be instances where services across the board could have done better.
Earlier in the week Windley said the inquest would bring a range of emotions, but that it was not about blame or findings of liability.
She said the hearing was about establishing the facts and accountability to reduce the chances similar circumstances could result in another family having to endure such an ordeal.
