Source: Radio New Zealand
Leslie Raymond Parr killed his mother in 2024, more than two decades after killing his partner Fiona Maulolo in 1997. Supplied
Nurses caring for a killer at a forensic inpatient unit mistakenly believed he was there for “respite” as his notes were not accessible to them, a review into his care has revealed.
This meant the man, Leslie Parr – who killed his ex-partner in 1997 – did not receive a “comprehensive” mental state assessment required to identify any underlying symptoms of psychosis.
Five days after he was released back into the community he killed again, this time his mother.
The review also revealed that Parr, who had a diagnosis of schizophrenia and substance use disorder, tested positive for cannabis when he was admitted to the facility.
RNZ earlier revealed Leslie Raymond Parr killed his mother in 2024, more than two decades after killing his partner Fiona Maulolo in 1997.
Do you know more? Email sam.sherwood@rnz.co.nz
The revelations of a second killing prompted the Chief Victims Advisor to call for a Royal Commission of Inquiry into forensic mental health facilities.
Fiona Maulolo Supplied
A “high-level” summary report into the case was released by Health New Zealand after the Supreme Court dismissed Parr’s application for leave to appeal a decision declining name suppression.
The report said Parr, referred to as “Person A”, had a diagnosis of schizophrenia and substance use disorder (mainly cannabis and alcohol).
Parr was released back into the community in 2012 as a special patient to independent living under the care of the Forensic Community Mental Health Team (FCMHT). Then, in 2021, his legal status was changed from special patient to being managed under the Mental Health Act under a Community Treatment Order.
The order required a patient to attend for treatment and accept treatment as prescribed. However, he was also no longer subject to the same restrictions as a special patient and had declined to continue with urinary drug screening (UDS) tests, did not want FCMHT to engage with whānau; had declined consent to whānau being provided with a copy of his wellness plan and had declined home visits by the FCMHT.
On 23 May 2024, Parr was arrested following an assault of a relative. The report said the co-response team contacted the Mental Health After Hours Team and after a crisis mental health assessment Parr was admitted to an inpatient stay at Stanford House, an extended secure forensic inpatient unit, for a period of assessment.
He remained as an inpatient for a week before being discharged to resume community care under the FCMHT on 30 May.
A follow-up appointment was arranged for 4 June. He arrived about midday and was administered his usual medication.
Later that afternoon a relative called Parr’s case manager to raise concerns about Parr’s mental health.
The case manager provided the relative with the responsible clinician’s phone number and updated them of the relative’s concerns. An appointment with Parr’s clinician was organised for 48 hours later.
In the early hours of 5 June Parr was arrested for killing his mother a day prior.
The report included the findings and recommendations of an external review of services provided by Central Forensic Mental Health Services team(CFMHS), an internal review of the services provided by Stanford House by Whanganui Mental Health Services, and a services review by the FCMHT, CFMHS and Whanganui Mental Health Services more broadly.
The findings of the internal review of services provided by Stanford House said the admission process was “safe” with the appropriate outcome of a directed period of admission.
“Some aspects of the procedure were identified as ‘grey areas’ needing clarification for future admissions”.
However, there was a “lack of clarity of the location and purpose of admission”.
The responsible clinician who was employed by CFMHS entered notes into the Mental Health, Addiction and Intellectual Disability Service (MHAIDS) patient system.
“The notes were not accessible to the Stanford House nursing staff and they did not see the Responsible Clinician’s assessment of Person A or the plan for the admission.
“This led to a misinterpretation by the staff that Person A was at Stanford House for respite/reset and did not receive the comprehensive mental state assessment that was required to identify any underlying symptomatology of psychosis.”
The review recommended establishing a process to ensure intentions of the psychiatrist, the Director of Area Mental Health Services and responsible clinician around admission location to Stanford House and the purpose are clearly communicated to all staff.
It also recommended working with the Mental Health Medical Directors with oversight of MHAIDS and Whanganui clinicians to develop a standardised section of the admission documentation to include a comprehensive plan to cover the first 48 hours of assessment, care and treatment on admission.
The review also found that Stanford House staff were not recently trained or experienced in providing the more acute forensic care required for patients who, like Parr, were admitted urgently unplanned.
“Documentation of mental state assessments was inconsistent across shifts. Evaluating underlying aspects of mental state for any clinician viewing consecutive shifts documentation of mental state was not achievable because there was insufficient detail recorded.
“The inpatient care plans are not fit for purpose and lacked sufficient details in goals, interventions, and evaluations significantly limiting the effectiveness of assessment and observation and the overall depth of the understanding of ‘what was going on for Person A’.”
It was recommended the Stanford House nursing staff were upskilled in thorough, more acute mental state assessment and consistent documentation of the acute forensic patient.
The review also revealed that when Parr was admitted to Stanford House on 23 May he was directed to provide a UDS sample. This was the first time he’d been directed to do so since December 2022 as testing was no longer required or made a condition once he ceased being a special patient. He had also “consistently refused” to consent when being asked to previously.
“The sample taken at Stanford house tested positive for cannabis.”
The review recommended ensuring community forensic pathway patients were “well supported” by Alcohol and Other Drug (AOD) clinicians if they have or develop substance use problems.
It was also recommended they engage all community clinicians in discussion regarding a successful way of negotiating with patients, at the time of reclassification, that would “motivate and move them” to provide urine drug screens when there was a high suspicion of alcohol and other drug use.
There was also “limited face to face whānau involvement” in Parr’s wellbeing plan.
“Family were not present at discharge hui despite having valuable insight into Person A’s substance use and daily challenges.
“Standards emphasise the expectation of active involvement of patient’s whānau in their care where possible.”
The findings of the external review, which the report said was still being finalised, included that FCMHT did not uphold MHAIDS Whānau Framework and Whānau Participation Policy and that there was an absence of senior medical staff and diffuse clinical leadership.
“Throughout and prior to the period of investigation there was a lack of a specialist psychiatrist within the FCMHT.”
Concerns were also raised in the review regarding the model of forensic community care.
“There was discrepancy between senior leadership views of the role and purpose of the forensic community team and those of clinicians. There were also differences in understanding and expectations regarding urine drug screens (UDS).”
There was also no agreed Service Level Agreement in place that described the relevant roles and responsibilities of Whanganui District and CFMHS in the care of forensic community clients in Whanganui.
“Due to well-established and collegial relationships, all parties worked in a coordinated manner through the review period. However, the complexity of the interservice relationships created gaps in service delivery.”
The review also found that not all FCMHT team members who interacted with Parr documented the interactions in the notes on a regular basis.
The external review had four “positive findings” including that FCMHT staff made “good efforts” to integrate key information across the separated clinical records of CFMHS and Whanganui District.
The review also said after Parr killed his mother there was “excellent collaboration” by all parties including police and crisis mental health services to ensure Parr was “safely transferred to an appropriate acute forensic inpatient setting as quickly as possible”.
Several recommendations had been identified as a result of the reviews. They were grouped into six themes including whānau engagement, clinical leadership and senior medical staff and model of forensic community care.
In response to questions from RNZ on Monday about the report HNZ national director of mental health and addictions Phil Grady said the reviews identified the practical and legal challenges of enforcing urine drug screening for people receiving care in the community under a Community Treatment Order.
“As a result, the reviews recommended that services clearly set out expectations and processes for urine drug screening for all relevant clients. Work to implement this recommendation is underway.”
In relation to nursing staff believing Parr was at Stanford House for “respite”, Grady said the reviews characterised this is a “system and process issue, rather than an individual failure”.
He said the reviews also highlighted several “improvement areas to reduce the risk of similar misunderstandings in the future”.
“The reviews found that a gap in information‑sharing contributed to misinterpretation of the purpose of the admission and affected how assessment processes were carried out during the admission period.
“These findings form part of the overall learning from the reviews and underpin several of the recommendations focused on assessment processes, documentation, and communication between services. Health NZ is actively progressing implementation of review recommendations.”
Chief Victims Advisor Ruth Money told RNZ on Monday she remained “very concerned about the length of time these reviews and then subsequent implementation of actions take”.
“Each review identifies similar issues to the last, which is why an independent inquiry across all regions that establishes nationwide best practice and improvement actions that are mandatory is my continuing advice to the Government.
“While this environment is complex, the multiple incident reports highlight that tragic events like this are preventable. Improvements should be made proactively, not reactively after someone has been tragically killed.”
Grady earlier said HNZ recognised that questions had been raised about aspects of Parr’s care and the decisions made at the time.
“These were complex clinical decisions based on the information available, and the external review has carefully examined those concerns.
“Where the review has identified areas that could be clearer or stronger, such as expectations around drug screening, information sharing, and clinical oversight, we are acting on those findings to improve consistency and strengthen practice across the service.”
An external review of the care Parr received was being finalised.
“We are committed to implementing any recommended changes so that we continue to strengthen the quality and safety of the care we provide.”
Director of Mental Health Dr John Crawshaw earlier said once the external review is available, he would consider whether any further actions were required.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
