'String of errors' in unit's care of patient

Scorched grass marked the spot where Colin Moyle was set on fire by Matthew Ahlquist in 2007. Photo / Herald on Sunday

The country's top health watchdog is investigating the Auckland District Health Board and a top psychiatrist over the treatment of a patient who followed through on threats to kill after being released from care.

Matthew John Ahlquist, 34, was found not guilty of the murder of Colin Edward Moyle on the grounds of insanity and sent to the Mason Clinic as a special patient.

Mr Ahlquist threw boiling water on Mr Moyle, 55, bludgeoned him with a spade and set him on fire at Mr Moyle's Auckland home in April 2007 because he thought he was "demonic".

Two expert psychiatrists later diagnosed Mr Ahlquist with paranoid schizophrenia and Justice Geoffrey Venning ruled he was not guilty by reason of insanity in December.

Health and Disability Commissioner Ron Paterson is investigating the care provided to Mr Ahlquist by the Auckland DHB and Dr Thom Rudegeair, the former head of the mental health clinic Te Whetu Tawera. Dr Rudegeair has since left the job.

The family of Mr Moyle complained to the commissioner after mediation with the ADHB failed.

Documents released to the Herald reveal "evidence of unacceptably poor clinical judgment and practice by some medical and nursing staff" in the care of Mr Ahlquist.

The reviewers suggest the unit got the balance wrong between the "recovery model" - which aims to help patients regain control of their lives and for which the unit has attracted praise - and risk management.

Other leaked documents reveal a string of errors in Mr Ahlquist's care. The report reveals he had been receiving psychiatric treatment since being diagnosed with schizophrenia, aged 23.

By 2004, he had been identified as being aggressive towards his parents, and the following year was admitted to Te Whetu Tawera under the Mental Health (Compulsory Assessment and Treatment) Act.

During his time at the unit he threatened to kill staff but a psychiatrist discharged him to the care of the homeless team.

By the end of 2006, Mr Ahlquist was transferred to St Lukes Community Mental Health Centre. The St Lukes psychiatrist, involved with him since his treatment began, wanted him to be detained and given anti-psychotic drugs, a diagnosis the homeless-team psychiatrist disagreed with.

In March 2007, Mr Ahlquist was readmitted to Te Whetu Tawera, where staff considered compulsorily detaining him.

The report says he told staff he wanted to kill somebody but then became guarded, insisting he made the statement because he was "off his head on painkillers". He was admitted informally but was not diagnosed as being psychotic and was discharged 12 days later after getting drunk in the ward.

Mr Ahlquist's family expressed their anger at the "inappropriate discharge", and a few weeks later Mr Moyle was dead.

A letter from Mr Paterson says his investigation will focus on the care Dr Rudegeair provided to Mr Ahlquist during the 12 days he was in Te Whetu Tawera before he was released.