Police shooting inquiry zeroes in on psychiatric care of mentally unwell man

Vaughan Te Moananui was shot by police in Thames on May 4, 2015, following a clash on one of the Coromandel Peninsula town's streets.

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Vaughan Te Moananui was shot by police in Thames on May 4, 2015, following a clash on one of the Coromandel Peninsula town’s streets.

Whether a Waikato District Board of Health psychiatrist was negligent in caring for a mentally ill man shot by police on a suburban street in Thames has become the focus of the coroner’s lengthy investigation.

Vaughan Te Moananui, 33, was killed by police after a brief standoff on a Thames street around lunchtime on May 4, 2015, after he refused to put down the gun he was carrying.

The inquest into his death opened in October 2019, and following those earlier hearings, Coroner Michael Robb issued an interim ruling finding Te Moananui’s care inadequate.

However, more hearing time was required because the psychiatrist questioned Robb’s criticism of him.

The earlier investigation heard that Te Moananui had a long history of poor mental health, including schizophrenia, and had been admitted to psychiatric facilities several times. He had also been prosecuted for violent crimes when he was unwell.

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Risk factors identified at his most recent discharge from the Henry Rongomau Bennett Center in Hamilton, approximately a year before his death, included isolation, alcohol use, and lack of adequate medication.

He was advised to start a drug and alcohol program and be closely monitored, but this never happened.

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Instead, he moved out of his parents’ house, started living on his own, started drinking alcohol, and greatly reduced the dose of the antipsychotic he was taking because it made him sleepy.

Police conducted an extensive examination of the scene of the fatal shooting on Campbell St in Thames in the days after the incident.

Rebekah Parsons-King/Things

Police conducted an extensive examination of the scene of the fatal shooting on Campbell St in Thames in the days after the incident.

The psychiatrist, whose name has been redacted, approved the dose reduction because he felt Te Moananui was fine.

The hearing resumed with Dr. Rees Tapsell, director of clinical mental health services at the Waikato District Board of Health, being questioned by assistant coroner Andrea Twaddle.

Tapsell described caring for people like Te Moananui as “a difficult dance” for the team responsible for her ongoing care.

“The dance is often trying to encourage patients to take their medication and also to minimize the dose.

”[However] it’s impossible to do that without having a reasonable frequency of follow-up and further corroboration from others.”

Twaddle asked about a case where Te Moananui showed up to a meeting with his caretaker with a black eye, which should have been a big red flag that all was not well.

“A black eye is a concern,” Tapsell agreed.

“Would it be fair to say that the opportunity to engage with whanau was missed?” asked the interlocutor.

“Yeah, we all missed that opportunity,” Tapsell replied.

Previously, he said, “My expectation is that when a psychiatrist is worried about a patient, they will do more to get corroborative information from other sources.”

Matthew McClelland, QC, acting on behalf of the psychiatrist, also questioned Tapsell about the reporting lines and staffing levels of the 30-member DHB team of which his client was a senior member.

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McClelland said the focus shouldn’t just be on the psychiatrist, but on the broader situation and other people involved in your care.

Jacinda Hamilton represents the police at the hearing, while Arama Ngapo represents Te Moananui’s family.

More soon.

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