Vaughan Te Moananui holding his first grandchild, who he got to spend five months with before being shot by police. Photo / Supplied
By Belinda Feek, Open Justice multimedia journalist, Waikato
After a drawn-out, seven-year battle to hold those accountable for failing her brother, Genevieve Simpson-Te Moananui has finally been able to grieve.
On Tuesday night, reading Coroner Michael Robb's findings into the death of her brother Vaughan Te Moananui, she cried for the first time since he was shot by police.
There was relief at having some closure. But, there is also frustration about the level of care her brother received after leaving Waikato Hospital's Henry Rongomau Bennett Centre in 2014.
"I always maintain he was set up for failure because he came out with no wraparound support," she told Open Justice.
"Even though it's wrapped up, I've still got a lot of anger with me because there were so many missed opportunities and common sense didn't prevail in any of the team ... all his early warning signs were there."
Te Moananui suffered mental health difficulties from a young age. He was eventually diagnosed with schizophrenia, anti-social personality disorder and alcohol and poly substance abuse.
After spending time in the centre he moved in with his parents in their alcohol-free home.
When he moved out six months later, things began to deteriorate.
In May 2015 the 33-year-old was shot by Waikato Armed Offenders Squad members after pointing a gun at police.
Shortly before then Te Moananui had traded his motorcylce for a firearm and in the last 48 hours of his life he began drinking heavily.
He became increasingly disturbed and attacked the steering wheel of his car with a tomahawk before firing his gun in his driveway. He then got into a struggle with an associate and shot him in the leg, but refused to let the injured man and his partner leave to get help.
On the morning of his death Te Moananui paranoia increased. He went to his sister's house and kept drinking. He began quoting passages from the Bible, speaking in tongue, removing clothing, doing the haka and telling his sister he wanted to be shot by police.
The police were eventually called and he was shot after pointing his gun at them.
'The single greatest failing'
After a series of investigations, one of which saw the officers who shot him cleared of any wrongdoing by the Independent Police Conduct Authority, and a "frustrating" three-year inquest, the whānau finally have some form of closure but say they continue to have grave concerns about the lack of accountability by a psychiatrist in charge of his care at the time.
"I don't think I'll ever have full closure with the doctor not accepting [their] part," said Simpson-Te Moananui.
Coroner Robb noted the psychiatrist wasn't proactive enough during his four assessment hearings before his death, but ruled a key worker's lack of contact with Te Moananui was "the single greatest failing".
"Most importantly Vaughan and his whānau were let down by this, but so too was the psychiatrist in that information necessary for assessing Vaughan was not gathered."
On release from HRBC, staff noted Te Moananui's risk factors were alcohol abuse, becoming isolated, and not taking his medication, but in the five months leading up to his death, those warning signs were not being monitored by his care team.
He was appointed a community health treatment team which encompassed a key worker who liaised with him, an occupational therapist, psychologist and psychiatrist.
A month later, in May 2014, a psychiatrist noted there were no clinician notes on his file despite his extensive mental health history and also "there appears to be no wrap around follow-up care by the community team".
He also noted there was no relapse prevention plan and no updated risk management plan.
Te Moananui was appointed a new psychiatrist, who is only referred to as X in the Coroner's findings.
During each of the four assessments with X, Te Moananui told the psychiatrist that he had reduced his medication, from 200mg to ultimately 50mg in April 2015. Each time X signed it off.
Psychiatrist X hadn't read progress notes by other members of the care team including one two months before Te Moananui's death from the key worker that there were "rumours" he had been begun drinking again. The "rumour" was in fact from Te Moananui's mother who knew he was drinking.
Coroner Robb noted Te Moananui had been stable and coping well prior to X taking over and from when he took over in July 2014 through to November 2014, "had essentially been frequently monitored by his psychologist".
"That matters that I note from the evidence are that psychiatrist X did not have a relationship and rapport with Vaughan that led to candour and openness."
Two expert psychiatrists who gave evidence at the inquest were critical of that failure, as well as him not contacting Te Moananui's family.
"Even if he had not read the progress notes, he should have asked Mr Te Moananui about his drinking culture during [his last assessment] on April 2, 2015," one expert said.
They also noted it was important the psychiatrist knows whether a patient was being followed up in the community and, if a patient was going to reduce their medication of their own accord, "that should indicate close monitoring both by the psychiatrist and key worker".
Psychiatrist X defended his actions throughout the inquest, at one point stating that the key worker had invited Te Moananui's mother to an appointment adding "I can't think what else could have been done".
"I do not accept the psychiatrist's evidence that he in any way genuinely sought the attendance or contribution from Vaughan's whanau from November 2014 through to his death," Robb said.
Robb accepted X's submission that a reduction in medication wasn't in itself harmful, however he noted it needed to be combined with close monitoring - which didn't happen.
Waikato DHB serious event review found psychiatrist X should have been having appointments with Te Moananui every two weeks, not every three months.
Coroner Robb issued draft findings after the first part of the inquest in 2019, which the DHB responded with seven changes including a new triage system for referrals and an updated orientation for new staff.
Coroner Robb found the failure by the support team to identify Te Moananui's "ultimate deterioration" was a contributing factor in his death.
He found there was no process for separating Te Moananui out, as someone who was complex and high risk, from others who were not.
He listed multiple recommendations including that while a key worker might physically carry out monitoring, it should be overseen by the psychiatrist, identifying who are the client's close contacts and that a psychiatrist must review progress notes and discuss them with the client.
The DHB responded it regarded those as 'fundamental and known by anybody" registered as a consultant psychiatrist but that it would consider outlining them in its new staff orientation.
Psychiatrist X said resourcing didn't allow him time to review progress notes, that it was the key worker's role to provide him with information about Te Moananui and that it wasn't his role to supervise him.
In his final assessment with Te Moananui in April, X also didn't comment on a bruised eye he'd suffered after falling off his motorbike while drunk, missing an opportunity to discover his alcohol abuse.
Instead, the psychiatrist said he was doing well each time he saw him, no issues were raised with him, that he was being seen weekly and the key worker was regularly in touch with his whanau and employer.
"Clearly those things were not correct," Coroner Robb said, adding he was just as uninformed as the key worker.
Coroner Robb also recommended emergency departments and mental health teams share information, but after investigating, the DHB said it didn't have the resourcing to do the work given the "numerous" presentations to ED by mental health patients.
Although Te Moananui told his sister he was going to die and he wanted to be shot by police, Coroner Robb ruled that his death was not self-inflicted, instead, he was "irrational, beyond reason, and likely acutely unwell".
A Waikato DHB/Te Whatu Ora Waikato spokesperson said there had been considerable change and development of mental health services in the Waikato over the past seven years and lessons from this event have been implemented during that time.
"The approach today is to develop a more joined-up delivery of services with providers collaborating to create wraparound care."
'If he did a good job my brother would still be alive'
Although Coroner Robb found the key worker mainly at fault, Simpson-Te Moananui believes the psychiatrist was just as culpable and is disappointed they are allowed to keep working with vulnerable people.
"At no time did [X] accept any of the criticism of the evidence in front of us. [X] only saw Vaughan four times and it was quite brief."
She felt the psychiatrist was more worried about protecting their own name and reputation and hasn't stopped to reflect or admit there was room for improvement.
"[There was] no kind of apology, nothing, we're just left with [X] did a shit job and [X] accepts no responsibility for it."
She believes that if the psychiatrist "did a good job my brother would still be alive".
Simpson-Te Moananui hopes lessons have been learned but said the Government needed to address the "mental health crisis" before it could prevent another tragedy from happening.
It needed to be more specific with its allocation of funds and instead fund initiatives like Mike King's 'I Am Hope'.
"I'm thinking whoever is managing the money has no idea where the money needs to go because it's not reaching the communities where it needs to be going.
"There's too many people getting paid too much money and not doing any of the mahi that needs to be done on the ground floor."
She accepted Te Whatu Ora Waikato was making changes but said it was hard when they couldn't retain or attract staff.
The incident had torn the family apart.
"The failures in the mental health system didn't only steal my brother's life but the domino effect knocked our entire whānau down.
"It was a massive impact on everybody. It's torn relationships between whānau members and it's really exhausting...I feel relieved it's finally kind of over, but it's not over.
"We start the grieving process now I suppose.
"[Tuesday] night, reading the findings, was the first time I've cried since Vaughan died because just finally having some form of closure but I don't think I'll ever have full closure with the doctor not accepting [their] part."
She was now almost the same age as her brother - who now has three grandchildren, while his two sons are aged in their 20s.
"I always think how he would be, missing out on his sons, and he has three granddaughters now."
Simpson-Te Moananui said it was also a battle to find a lawyer to represent them at the inquest, eventually finding Arama Ngapo of NL Lawyers after being turned down by 21 others.
"Twenty-one didn't want to go against two Government agencies plus the fact he was shot by AOS and he had a gun on him put them off even more I think, but Arama has been really good."
As for the findings, she felt the key worker and psychiatrist had the same level of responsibility although the psychiatrist was more senior and should've been prompting the key worker about his progress.
"The key worker was obviously way too lax in his approach. He wasn't proactive in his approach to look for Vaughan who was a high-risk person of becoming unwell.
"It's disappointing, it frustrates me."