The brutal killing of Lorraine Royal at the hands of her mentally ill stepson did not get a lot of publicity and was marked down as another tragic, unavoidable death.
But now the families of both the victim and the killer have spoken out to 20/20, saying the death could, and should, have been prevented.
And they are being backed by a police officer who was involved in the case.
The first police officer on the scene was greeted with the killer saying: "I'm telling you...that is Satan down there."
Jessie Moore believed he was doing the work of God by killing Satan. "If I can clean my hands I can communicate with him a lot better, just because there's blood from Satan all over them," Jessie told the officer.
He was recorded as saying he was "only doing what Jesus told me to do" just minutes after he had bludgeoned and strangled Royal to death under an Otaki bridge.
Moore's family and the police tried to help and they all say Royal's death was completely avoidable.
"It was preventable if the mental health people had done their job properly...we wouldn't have to live every day knowing that our brother is not with us, and that, that lady who we loved and cherished as part of our family is not here either," says Jesse's sister Kerry.
Royal's brother John and his wife Debbie say she was let down by a system meant to protect her and she is dead because nobody listened to their warnings abut Moore.
"No one listened so the judicial system failed. And I believe someone has got to be accountable for it," says John.
And former police detective Chris Siscely agrees, saying there was no need for her to die.
"This was just a totally preventable homicide from my point of view," says Siscely.
Jessie's family had seen the danger signs and two weeks before the killing they knew something was badly wrong.
"What he was doing was not normal and he needed to be told that and he needed medication to help him," his sister Lana says.
The family knows bipolar. Moore has a strong family history of the disorder - a disease marked by mood swings and bizarre beliefs. His sisters Lana and Kerry both suffer from it, so when their law-abiding brother's whole personality changed, they knew just what was happening.
"He went overly religious, his moods were elevated - typical behaviour of a bipolar. If you've got any experience at all you should be able to detect those things straight away," says Kerry.
Jessie's father Graham called mental health services and said his son needs an assessment - saying he has bipolar or a similar thing and is dangerous with it.
"I gave them the history of the family," says Graham.
But Jessie wasn't given a mental health assessment and continued his slide into psychosis. He was seeing Satan everywhere.
One night he boiled over into violence and tried to kill a friend. He went to his workmate's place and talked to him and then attacked him.
Jessie smashed him in the face with a cup and then beat him severely around the head, while also trying to strangle him - all the time saying to him that he was possessed by Satan. His victim required about 20 stitches.
A delusional, ranting, Jessie Moore was arrested for assault and in the police cells was warning people that the world was going to end at midnight.
"To me the bells were ringing, the lights were flashing and big arrows were pointing and saying hey, we need a full assessment here," says Siscely.
Mental health assessments are the job of the district health board - in the case of Otaki that's Capital Coast Health.
Jessie's dad Graham says he rang mental health and told them that what he had warned them about had actually happened.
But Jesse wasn't a priority for the mental health crisis team and they never assessed him.
Board mental health head Murray Patton says because they were dealing with other calls at that time, they decided the case was less urgent.
"Mr Moore was in a safe place, he was asleep, he was going to remain in custody overnight," says Patton.
This decision meant Jessie's first-ever contact with a health professional wasn't until the next day before court when he had calmed down and met the court-appointed nurse.
Graham says if he had been seen that night there "wouldn't have been a shadow of a doubt in their minds". He says to see someone days later, even hours later can be too late.
In his bail assessment notes forensic justice liaison nurse Chris Norris said Jessie said he was obsessed by the bible and that God was speaking to him. He recalled the attack on his workmate as a power struggle between good and evil.
But he was judged to be calm, remorseful and probably not a danger.
"It amazes me that somebody can go in and talk to somebody for 15 or 20 minutes in the cells, like a mental health worker, and decide that perhaps this person doesn't have to go in for a full psychiatric assessment even though he's just tried to kill his workmate, even though he said he's possessed by Satan," says Siscely.
The police strongly opposed bail for Jessie, saying his motive was irrational and fanciful, had used a weapon, attempted to strangle his victim and armed himself with two more weapons before he was arrested.
But Jessie was granted bail by Judge Lovegrove after he concluded that on the basis of the assessments Jesse was no longer a risk.
To his family's horror, Jessie was sent home with a psychiatric assessment booked for several days later.
"I just figured that he would be getting some medication and going through the same processes we did, having you know, the mental health coming to us and sitting us down and assessing exactly what state of mind we are in at that time. Not giving us a bunch of sleeping tablets, or telling us to go home and sort it out ourselves," says Lana.
Later that same night, Jessie killed Lorraine Royal - taking her to the Otaki Bridge and according to Siscely either dumping her over the rails or through the rails before "dragging her down underneath the bridge".
"He was telling us not to touch the body - that she had been possessed by Satan," says Siscely.
The police officer recorded Jesse saying: "Yes...praise the lord...this is the big kahuna... I've caught him."
Siscely says it became increasingly obvious that they were dealing with a serious mental illness.
The high court agreed and last year Jessie Moore was found not guilty of murder by reason of insanity. He is now getting the care he needs as a special patient at Porirua Hospital.
His family says the treatment has made him more like his old self. But what they, and Lorraine's family, want to know is why was it so hard to get Jesse help when he first needed it - why did things have to go so tragically wrong?
They ask who is going to be made accountable and how many times a life has to be taken before something is done to ensure it doesn't happen again?
Meanwhile, no one is saying sorry. When questions were raised, the chief district court judge backed the bail decision made by Judge Lovegrove and a just-released coroner's report lays the blame at nobody's feet.
Capital and Coast District Health Board's head of mental health also stands by the decisions his team made about Jessie's treatment.
"I don't believe on the basis of the information that I have about how he was presenting at that point in time that many other people would have made a different decision," says Patton.
The board also stands by the mental health nurse who assessed Jessie before court. He's still in the same job - still doing mental health assessments at Porirua court.
"I think he did an extremely thorough job. Made a good assessment, took a number of things into account in making that assessment," says Patton.
While he concedes that Jessie's obsession with the Bible and the attack on his workmate suggested a disorder or some sort, "they were not in themselves necessary features that require detention or incarceration".
The health board says the court should have had more background on Jesse and they have worked to improve their communications. But if it happened again, Jessie would still have been recommended for bail.
"Those decisions were weighed quite carefully by the staff member particularly involved at that point in time, and made what then and now seems to have been a reasonable decision. That there was a tragedy that followed we can't pin it to that decision that was made at the time," says Patton.
That has upset Lorraine Royal's family, as well as the lack of any recommendations by the coroner. To them, it means no one will ever be held accountable for what happened to Lorraine and to Jessie.
"It paints a really uneasy picture, the lack of accountability," says John, adding that he doesn't have any malice against Jessie and is just "sorry that the system let him down".
That's something both families agree on. Jessie's sisters say they're living proof of how Jessie could have been living today if he'd been treated in time.
"It's unbelievable that this happens, and it doesn't just happen to us, it's happened to lots of families, and when is it going to stop, that's what we want to know," says Kerry.
As for Jessie himself - he will be staying in the forensic hospital for a long time.