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Police could have prevented death, independent report finds

28 February 2013

Police could have prevented death, independent report finds

Police could have prevented the death of Diane White, the Independent Police Conduct Authority has found.

On Tuesday 19 January 2010, Police were told that Christine Judith Morris, a mental health patient at the Henry Rongomau Bennett Centre in Hamilton, had escaped after threatening to kill her next-door neighbour, Diane Elizabeth White.

Later that day Police found Mrs White dead in her home. She had been killed by Ms Morris.

The Independent Police Conduct Authority today released its independent investigation into the death of Mrs White. The report concluded that Police had the information and the ability to prevent the death of Mrs White if they had responded appropriately.

Summary of Events
On the morning of Tuesday 19 January 2010, Police were notified by fax and telephone that Christine Judith Morris – a 40-year-old profoundly deaf patient at the Henry Rongomau Bennett Centre in Hamilton with a serious mental health illness – was missing after climbing over a fence at about 10am. Immediately before escaping she had threatened to kill her next-door neighbour, Diane Elizabeth White, 53.

The fax sent from the Henry Bennett Centre at 10.09am was not received by Police until 11.04am, because their fax machine was out of service until just before 11am and messages were not diverted. The Henry Bennett Centre nurse followed up the fax with a telephone call to the Hamilton Police Station but received no response. She eventually called 111 at about 11.07am and spoke to the Police Northern Communications Centre (NorthComms).

At 11.13am two Police officers were dispatched to Ms Morris’s address. They were unable to find her, but spoke briefly with Mrs White as she mowed her lawn, and advised her to call Police immediately if she saw Ms Morris. The officers then left.

Shortly afterwards, at 11.30am, Police received a second call from the Henry Bennett Centre advising that Ms Y, who lived near Ms Morris, had reported that Ms Morris was with her and was making threats to harm Mrs White. A NorthComms dispatcher mistook the information from this call as a repeat of the information from the first call, and subsequently no officers were dispatched to Ms Y’s address to apprehend Ms Morris.

At 12.19pm Ms Y called Police advising that Ms Morris had just left her address. After a few minutes Ms Y reported that Ms Morris had returned with blood on her face. Officers were again dispatched to find Ms Morris. They discovered that Mrs White had been attacked and killed in her home with a blood-stained hammer found nearby.

Police quickly located Ms Morris and took her into custody. She later pleaded guilty to the murder of Mrs White, and on 2 April 2012 was sentenced to life imprisonment with a minimum non-parole period of 10 years.

The Authority’s investigation considered whether Police complied with relevant law and policy during this incident, specifically in relation to the initial missing person notification; the handling by NorthComms of each of the three calls; and the Police response to the calls.

The Authority also looked at whether arrangements between Police and the Ministry of Health regarding missing mental health patients were satisfactory.


Police had the information and the ability to prevent the death of Mrs White if they had responded appropriately to the available information, the Authority’s report said.

The key failure was that officers were not sent to Ms Y’s address after the second call from the Henry Bennett Centre alerting Police to the location of Ms Morris. “If that had occurred, it is likely that Mrs White’s death would have been prevented.”

The Police response was inadequate in a number of respects, including:
• the initial response to the notification of Ms Morris’ escape;
• the lack of thorough questioning of the Henry Bennett Centre nurse during the first call; particularly in relation to known risk factors such as Ms Morris’ profound deafness, her current mental state and the exact details of the threat to kill;
• the dispatcher’s failure to advise the attending officers of the name of the person being threatened;
• the failure to notify the sergeant on duty and all units in the area about the threat;
• inadequate area enquiries by the attending officers and their failure to seek more information about the person under threat;
• the poor handling of the second call; including a lack of questioning on particular risk factors; and the recording of inaccurate and misleading information, which then led to the key failure to dispatch officers to apprehend Ms Morris; and
• the failure to consult a Duly Authorised Officer mental health professional.
Section 27 opinion and recommendations

Section 27(1) of the Independent Police Conduct Authority Act 1988 requires the Authority to form an opinion as to whether or not any act, omission, conduct, policy, practice or procedure the subject-matter of an investigation was contrary to law, unreasonable, unjustified, unfair or undesirable.

In this case, the Authority has formed the opinion that the failure of the attending officers to conduct more extensive enquiries at the time of the first house visit; and the communicator’s poor handling of the second call to Police were unreasonable and unjustified.

The Authority also formed the opinion that a number of matters were undesirable, including the inadequate handling of, and response to, the first call to Police and the later failure to clearly register as a priority that the location of Ms Morris was known and to dispatch officers at that point.

Police have advised that they have taken remedial action in connection with several staff involved.

Police have also taken action since this incident to improve relevant policy and training, as well as clarifying with the Ministry of Health each agency’s responsibilities when a mental health patient is reported missing.

The Authority supported the recommendations made in a Police review of their response to people with mental impairment and supports further training to all staff on relevant policy and legal powers.

The Authority also supports the continued roll-out of the Crime Reporting Line to all Police districts and recommended that this line be used for the notification of missing mental health patients.

Full Report

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