Five people were killed by five mentally-disordered people in Wellington over a period of 18-months. Photo/123rf
Five people were killed by five mentally-disordered people in Wellington over a period of 18-months. Photo/123rf
Four people were stabbed to death and another fatally bludgeoned after five mentally-ill people slipped through the cracks of the country's mental health system.
The tragic and unconnected events all played out in Wellington during 2015 and 2016, leaving behind a trail of lost lives, grief-stricken families, mentally-ill people struggling to cope with having killed someone and a score of questions, including – could these homicides have been prevented?
It's a question Coroner Michael Robb has explored in-depth during his inquiry and inquest into each of the five deaths over recent years.
The findings, released today, consider the offenders, four of whom were found not guilty due to being insane at the time they killed and the fifth being found mentally unfit to stand trial, the victims, and the harrowing killings.
Equally critical, if not more so, the reports examine how these people, who were receiving help from a range of providers with most being under the umbrella of Capital and Coast District Health Board (CCDHB), became so unwell that they were capable of killing and what changes can be made to reduce the risk of deaths occurring in similar circumstances in the future.
Across all inquiries, he identifies broadly common features, and a number of flaws within the mental health system, with many caused through under-staffing and various other resourcing issues.
All of the offenders appeared in the High Court at Wellington with four being found not guilty by reason of insanity, and one being found mentally unfit to stand trial. Photo/Georgina Campbell
Based on his findings, Coroner Robb has provided an extensive range of comments and recommendations, many of which are summed up in the stories below that delve into each of the five tragedies.
Names of the offenders, victims and their families have all been changed and their genders concealed to reflect non-publication orders.
A good deed turned fatal for Kelly when they invited Lee into their home for the night.
The next day, Kelly was strangled and stabbed multiple times at the hands of Lee who was suffering psychotic delusions at the time.
The two were known to one another and Kelly had checked Lee out of respite accommodation for the night of February 13, 2015, to mark a special occasion.
A text sent by Kelly to a family member at 11.25am the following day was the last anybody would hear from them.
Kelly was well-regarded within their community and described as intelligent and educated. Their death has forever changed the lives of those who knew and loved them, the findings read.
What led to Kelly's death began almost a year prior, when Lee attempted suicide in July 2014 and was hospitalised with an anoxic brain injury.
Lee was treated in Wellington Hospital before being discharged to a private rehabilitation provider which specialised in acute brain injuries.
Kelly sent a text to a family member at 11.25am on the day they were killed. That was the last anybody heard from them. Photo/123rf
They remained at the rehab facility until October 2014, when they were discharged and moved into a flat with strangers.
Over the following months, Lee struggled to live independently and was eventually moved into a respite accommodation facility, which operates under the umbrella of a private company.
Two psychiatrists said Lee was suffering from a mental illness that arose from the brain injury with a cognitive deficit, mood disturbance, and psychotic symptoms. Their mental state declined at a rapid speed.
Kelly maintained regular contact with Lee during this period, visiting them and, on occasion, taking them away from the facility for short periods of leave.
Tragically, the support Kelly provided eventually turned deadly.
ISSUES
• No entity took responsibility for Lee or put in place daily support following discharge from rehabilitation
• It took months to identify how best to address Lee's deterioration
• Handover of Lee's care was to a GP rather than back to the DHB
• A brain injury specialist and/or rehabilitation specialist should be included in the discharge plan in cases similar to Lee's
• Better handover protocol implemented between public and private health providers
• An appraisal undertaken to determine whether ACC-funded providers are offering comprehensive treatment and rehabilitation services for traumatic brain injuries
• Legislative changes to the Accident Compensation Act 2001 around disentitlements for self-inflicted personal injuries and suicide
ONE DEAD AND FOUR WOUNDED
Grayson was at the hospital being assessed by the crisis team when they pretended to take an antipsychotic pill given to them.
They were released from ED shortly after and when they arrived at the home of people known to them, Grayson grabbed a knife from the kitchen and ran into the bathroom.
When Alex, one of the people at the home, chased after them, Grayson fatally thrust the knife into Alex's heart, and stabbed another person who was also present.
Grayson had pretended to take an antipsychotic pill only hours before they went on to kill. Photo/123rf
Grayson then ran from the bathroom, stabbing a nine-year-old in the stomach and another person in the shoulder before leaving the house for the neighbours.
When the neighbour answered the door, Grayson sunk the knife into their chest with such force that the handle broke away from the blade.
Alex was 67 when they died on July 1, 2015. They are remembered as a much-loved and committed parent and grandparent.
Grayson had a long history of mental illness and had stopped taking their antipsychotic medication, due to side-effects suffered, about three months before killing Alex.
On the morning of the homicide, Grayson had been sent home by their employer due to their mental state.
The then-25-year-old had become acutely unwell and was seen later in the day by their GP.
While at the doctor's, Grayson was aggressive and showing psychotic symptoms. The doctor gave them antipsychotic medication, which Grayson refused, and arranged to have them taken to the hospital for a psychiatric assessment.
During the assessment, Grayson was again unwilling to take the medication, and at first pretended to, only for the tablets to be found at the bottom of the cup.
Eventually, Grayson appeared to have taken a single tablet and was allowed to leave the hospital. It was hoped they would later take a second, but blood results would reveal that they had in fact not even taken the first.
Jamie left the address and Taylor went into the house to find Morgan dead by the Christmas tree.
Jamie's family and other supporters had reached out for help but they felt abandoned. Photo/File
Moments prior to the December 6, 2015, homicide, Jamie and Morgan, who were known to one another, sat together in the lounge at Morgan and Taylor's home.
Jamie left to retrieve a knife from the kitchen and then returned to fatally wound Morgan.
Morgan, 55, was described as a "wonderful" spouse to their childhood sweetheart, and a "perfect" parent.
Psychiatric assessments have determined Jamie suffered from a psychotic illness and was acutely unwell at the time of the violent event.
They had struggled with taking their antipsychotic medication for some time and leading up to the killing of Morgan, had stopped taking it completely.
Jamie lived an isolated life and was described as guarded and someone who struggled to communicate.
Their family and supporters had tried to get them help but were left with the impression, from their GP, police, and mental health services, that nothing could be done unless Jamie "did something major".
ISSUES
• Jamie was discharged from the CMHT to their GP with no plan to manage their new medication
• Responsibility for Jamie's care fell exclusively on the GP
• Jamie had no mental health monitoring within the community
Ashley, 66, was a resident at the same boarding house, run by a Trust, that Tyler was staying at.
Ashley has been remembered as adventurous, spontaneous, romantic, kind and generous.
Tyler had come to the attention of police before he went on to kill. Photo/File
In the months preceding the March 30, 2016, killing, Tyler experienced a period of relatively stable mental health, coping independently in the community with the support of a CMHT.
However, by mid-January 2016 they had stopped taking their antipsychotics and had come to the attention of the police.
Following an assessment, Tyler, who has chronic schizophrenia and has been described as a difficult person to manage, was found to be psychotic and became subject to a compulsory inpatient hospital care order.
After a month in care, they were discharged from the hospital to a night shelter - with no money, no community mental health care in place, and a Google map to show them where to find a mental health facility if needed.
The next day Tyler went to the facility and was assessed by a crisis team.
This led to their immediate return to hospital where they remained until early March 2016 when they were then discharged to the boarding house.
While in the community the Team for Assertive Community Treatment (TACT), under CCDHB's Mental Health, Addiction, and Intellectual Disability Service (MAIDS), was responsible for Tyler's mental health care.
What followed was the series of bizarre behaviour, and on March 29, 2016, information about their actions was provided to their TACT case manager.
But neither the police nor the care manager had any direct contact with them.
The following day, Tyler arrived at the TACT facility, spoke briefly with a staff member and then returned to the boarding house.
• A compulsory inpatient order should have been made to return Tyler to care
RECOMMENDATIONS
• It should be established whether supported accommodation is needed and the accommodation, and funding, is in place before a patient is discharged
• Better resourcing around areas of inpatient care, the number of psychiatrists, time availability for completion of detailed clinical records and treatment plans, supported accommodation and intensive community support
• Comprehensive care plans should be formulated and include baseline wellness and how that determination was reached
• Clinical records should be fully documented with anticipation care may be transferred to another health professional who has no prior knowledge of the patient
Robin, 38 at the time, phoned the police and spoke of having stabbed someone, telling the operator that the person was "not okay".
That was an understatement. Jessie, 37, was dead.
Jessie married her partner only months before they were killed. Photo/123rf
Jessie had married their partner in February 2016 and has been described as gentle, caring, empathetic, supportive and always thinking of others.
Robin, for the most part, had lived a life without mental health issues.
But as a result of events that began in 2012, causing Robin an immense amount of stress, that quickly changed.
Their sleep significantly deteriorated and they became mentally unwell. In 2015, they suffered a psychotic episode, suffering from specific delusions of a consistent theme.
The delusions led to Robin being psychiatrically assessed and receiving psychiatric care, initially from a crisis team, then from a CMHT.
Robin was prescribed antidepressant and antipsychotic medication and their sleep quickly improved and psychotic symptoms resolved.
By mid-2015, they were believed to be in remission from what was at that time considered a brief and one-off psychotic episode.
Robin stopped taking the antipsychotics in October 2015, and saw a psychiatrist for the final time in November 2015.
Thereafter, the only contact Robin had with a mental health professional was with a CMHT care manager.
In February 2016, Robin reported a return of the delusions but the information wasn't escalated and no further assessment by a psychiatrist was arranged.
• Poor clinical documentation and care expectations
RECOMMENDATIONS
• Training of care managers in identifying psychotic symptoms and the significance of reemergence of symptoms
• If a person who has previously suffered from psychosis has a recurrence of a psychotic symptom, they should be assessed by a psychiatrist
• If a person has suffered a psychotic illness or episode, they should not be discharged from the CMHT without a psychiatric assessment and detailed handover to a GP
• Sufficient allocation of time and psychiatric resources and training should be provided to psychiatrists to ensure full documentation of an individual's diagnosis and care plans
