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Source: ONE News -
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A psychiatric patient's compulsory treatment had "inadvertently lapsed" six months before he killed a man in his Auckland home, according to district health board information.
An analysis of 216 "serious or sentinel" events reported to the Director of Mental Health in 2007, included reference to the case of Matthew John Ahlquist, 33, who last December was found not guilty on the grounds of insanity of murdering Colin Moyle in Sandringham in May 2007.
Moyle was bludgeoned with a spade before being set alight.
A High Court judge found Ahlquist to be insane and ordered him detained as a special patient at the Mason Clinic in Auckland.
The court was told Ahlquist killed Moyle, 55, because he believed he was controlling him and he was convinced he was demonic.
An Auckland District Health Board summary of the Ahlquist case, released among other documents by 21 DHBs on Sunday, lists various failures.
It said his Mental Health Act status had inadvertently lapsed about six months prior to the homicide.
But a review of the Act's administration in community mental health centres had since been completed and a new system implemented.
The DHB's review of the case also found that:
- General adult services were not resourced or configured to provide inpatient secure or intensive assertive community rehabilitation.
- Communication between general and forensic services was inadequate.
- Auckland DHB was unable to access sufficient expertise to deal with the drug abuse associated with psychosis.
Deputy director of mental health Charles Hornabrook says he is unable to talk about this specific case, but when someone is placed under the Mental Health Act, they retain legal rights to dispute it.
There is a sequence of review dates when legal opinion is sought to challenge a clinician's perspective and if review dates are not met, the Act could lapse, he says.
"Our goal with this sort of reporting, both from the DHBs and the ministry is to be transparent and accountable ... about what did and didn't occur, with the hope that services will improve," he says.
Of the 216 reported events for 2007, the latest year for which data is available, 176 involved deaths and of those 85 were reported as suicides.
Waitemata DHB clinical director Murray Patton, speaking on behalf of the DHBs, says mental health staff do a difficult job in often trying circumstances, and are committed to providing the best possible health care.
"Unfortunately high levels of morbidity and mortality are associated with serious mental illnesses, even with the best treatment. Mental health problems can be complex and chronic," he says.
"Some people experience mental illness on and off throughout their lives, and this may go hand-in-hand with a range of medical conditions, addictions or social problems that contribute to their distress.
"The reality is that not all deaths or injuries are preventable or the result of error."
