Warning: This story contains content some may find disturbing.
The family of a man who stabbed his grandmother to death had been frustrated trying to get him mental health treatment, a coroner has found.
Two or three months had passed since Tremaine Hati was seen prior to the fatal attack on 72-year-old Maria Morgan on 15 March, 2023.
Now, Coroner Ian Telford has determined that public interest would be served by this being investigatied by the Health and Disability Commissioner.
The Health And Disability Commissioner is a Crown entity responsible for resolving complaints about infringements of health and disability rights.
Hati, who had serious and long-standing mental health problems, had been staying with his grandmother in Ngāruawāhia.
It was about 6.35pm on the night in question when Morgan’s son and his daughter arrived for dinner, part of what was a weekly routine.
They left around 8.30pm, leaving Morgan and Hati alone.
Not long later, Hati’s sister messaged Morgan regarding a call she’d had with the mental health crisis team concerning her brother.
“This was the latest in a number of communications to mental health services,” Telford said, which reflected the family’s growing concern about Hati’s mental state.
About 9.15pm, Hati arrived at his sister’s home, which was about 800 metres from Morgan’s.
She noticed blood on his hands and abdomen and asked him what happened, but got no reply.
After asking a second time with no reply, she sent him inside to wash and called her mother, who suggested she contact police and the mental health crisis team.
After the call, she told Hati to get in the car and they drove to Morgan’s, where she saw a bloodstained butcher’s knife lying near the front entrance.
The front door was open and she saw Morgan lying on the floor with her head resting on a cupboard. She called out to her grandmother but got no response and called emergency services.
Police arrived shortly after and one arrested Hati, while another entered the home. The officer noticed Morgan slumped forward with her t-shirt saturated in blood.
Telford said it was immediately apparent she was dead.
Coroner Ian Telford (file photo).
Pool / Chris Skelton / Stuff
Pathologist Dr S Stables said Morgan had been stabbed multiple times, with wounds to the chin, left side of the neck, left shoulder, left arm, left chest, left hand and upper central abdomen.
The deepest of these had penetrated her chest and had gone through her heart. This was identified as the fatal wound.
Hati was taken into custody and charged with murder.
The court found, on the balance of probabilities, he was unfit to stand trial because of his mental condition.
But the judge also found that he’d carried out the acts and ordered he be detained as a special patient.
Telford said Hati’s first engagement with mental health services was his admission to a mental health unit in Whangarei in 2018 under the Compulsory Assessment and Treatment Act.
He reportedly responded well to treatment and was diagnosed with an unspecified psychotic disorder.
“After that he experienced a pattern of irregular but reasonably frequent admissions and readmissions, often involving compulsory assessment and treatment,” Telford said.
It was in January 2023 when Hati moved to Ngāruawāhia to live with his grandmother.
“It seems clear from the evidence that, at this time, Mr Hati’s compliance with his medication was sub-optimal and his behaviour was causing widespread concern to those around him.
“The family reported that their efforts to have Mr Hati seen by mental health services in the Waikato as frustrated and ultimately, he was not seen at the time of the offending, by which time two to three months had lapsed and during which he appears to have become increasingly unwell.”
Telford said Health New Zealand did a “learning review” which appeared comprehensive and was done in good faith.
But, he said while the report clearly identified a number of issues and contributory factors, “it’s less clear how those findings related to the actions taken following the event and to the recommendations arising from the review”.
“I therefore appointed counsel to assist the inquiry by, in the first instance, reviewing the file and canvassing the views of whānau.
“Having considered those views, and the circumstances of the case, I concluded that the public interest would be best served by referring the matter to the Health and Disability Commissioner, particularly given the number of services involved and the interconnected nature of their involvement and decision-making.”
Where to get help:
If it is an emergency and you feel like you or someone else is at risk, call 111.
Discussion about this post