Vaughan Te Moananui – seen here holding a grandchild – was shot by police in Thames in 2015. A final coroner’s report raises serious concerns about the help he received from mental health services before his death (File photo).
Support received by a man with serious mental health and alcohol issues before he was shot dead by police in Thames in 2015 has been heavily criticised in a coroner’s final report.
Coroner Michael Robb’s conclusions on the highly complex case of 33-year-old Vaughan Te Moananui are outlined over 72 pages.
The former Waikato District Health Board (DHB) has apologised to Te Moananui’s whānau for deficiencies in care provided.
Te Moananui was discharged from Waikato Hospital’s Henry Rongomau Bennett Centre in 2014 to be compulsorily cared for in the community, where he was expected to be free of alcohol and illicit drugs.
However, there was subsequently a deterioration in his mental health, heavy use of alcohol, medication reduction issues, and ultimately a convoluted series of events, including Te Moananui shooting a man in the leg and other “unusual” behaviour.
Te Moananui was then shot by Waikato Armed Offenders Squad members after telling them to shoot him, advancing towards them and raising a rifle their way. He was transported to hospital, but died.
Robb’s report said the “single greatest failing” in the case was a lack of monitoring of Te Moananui by his unnamed community mental health team key worker between November 2014 and his death the following May.
Also, an unnamed, overseas-qualified psychiatrist – who had only been in New Zealand a fortnight when he was assigned the case – faced criticism for his efforts on Te Moananui’s behalf.
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Rebekah Parsons-King/Stuff
Vaughan Te Moananui was shot by police on a street near his sister’s house in Campbell St, Thames. (File photo)
On Te Moananui’s compulsory community care, Robb said: “A crucial aspect of that community care was support and monitoring with the view to identifying and managing any risks of Vaughan becoming acutely unwell.
“Vaughan had a history of both harming others and attempting to take his own life when acutely unwell.”
If the community team’s monitoring and support proved ineffective “this was a contributing factor in Vaughan’s ultimate deterioration and… a contributing factor in his death”.
Robb said an “individual shortfall in monitoring” had been identified but there needed to be a team responsibility to manage high needs patients such as Te Moananui.
He acknowledged an update from the former DHB about ongoing efforts to improve community care of patients.
But he also noted Te Moananui’s care would have been assisted by clear identification of him as someone who was “complex and high risk”.
“There did not appear to be a process for separating him out from other patients” who may not have had his risks and other attributes, Robb said.
In his view expectations of community team members needed to be prescriptive to cover such things as discharge requirements (for example, a drug and alcohol programme), identification of individuals at high risk of becoming acutely unwell, and oversight of key workers by a lead clinician/psychiatrist.
On the issue of whether a return to compulsory hospital care would have prevented Te Moananui’s death, Robb said he was showing no signs in early April 2015 of problems that would have legally justified this.
The coroner also advocated what he called “healthy scepticism” in assessing individuals.
“While psychiatrists are experts in evaluating individuals face-to-face, there are limits on this based on the individual’s willingness to be candid.”
Robb acknowledged his recommendations could add “strain” to the time of psychiatrists and key workers.
But the Government had signalled extra funding for mental health “and I hope this will extend to entities…resourcing mental health care”.
“Whether this occurs in a practical sense is as yet unclear.”
The coroner stressed Te Moananui was a man well-loved and deeply missed by his whānau.
“His whānau continue to grieve and to struggle with the circumstances of his death.”
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