A mentally-ill woman's frenzied killing of a neighbour has led to a coroner suggesting the Mental Health Act be overhauled.
Diane White, 53, was found dead from head injuries in her home on January 19, 2010 after her next-door neighbour Christine Morris attacked her with a hammer.
Morris was later convicted of murder.
In a finding released today, Coroner Peter Ryan pinpointed a possible shortcoming in the Mental Health Act.
Under the Act, nurses may detain some patients until a medical practitioner examines the patient. But there is no provision for nurses to detain voluntary in-patients already subject to the Act.
Coroner Ryan said Section 111 of the Mental Health Act, which covered rights of detention, should possibly be reviewed to deal with in-patients such as Morris. The recommendation was directed at the Ministry of Health chief executive and the Director of Mental Health.
Morris made death threats before walking out of a Hamilton in-patient facility, where some staff felt powerless to stop her.
Years before, Morris was diagnosed with paranoid schizophrenia and borderline personality disorder. She was also profoundly deaf.
Coroner Ryan said it was a failure to let Morris out of the centre without ensuring she was accompanied. However, he also said there was no law allowing staff to physically restrain Morris.
A series of mistakes and misses preceded the murder but in some cases, agencies involved have since amended their processes or admitted fault.
In the days before murdering Ms White, Morris showed signs of extreme agitation.
On January 13, 2010, her 5-month-old son was placed in Child Youth and Family (CYF) custody. Morris admitted herself to Waikato Hospital's Henry Rongomau Bennett Centre soon after.
She believed Ms White was among those responsible for her child being taken away.
Police have already admitted they failed Mrs White. The Independent Police Conduct Authority last year highlighted multiple errors in their handling of the case.
Coroner Ryan said he agreed with those findings.
The coroner made no further recommendations to Waikato District Health Board, saying the board had made changes to reduce the likelihood of a similar event happening again.
Comment was being sought from the Ministry of Health.
By John Weekes
