A man who stomped a pensioner to death was just three days earlier given a "hasty discharge" from a mental health unit because it was too full, a report has found.
Gabriel Yad-Elohim was admitted into the Auckland District Health Board's Te Whetu Tawera - the mental health ward - on 17 September last year. He reported hearing voices telling him to kill people.
Doctors prescribed him anti-psychotic medication. A urine sample taken at the time showed Yad-Elohim had been using methamphetamine. There were also traces of cannabis.
The report said by 23 September - six days after his admission - Yad-Elohim was improving. He reported no longer hearing voices.
However, the report also found Yad-Elohim was "guarded in his presentation".
"Occupancy pressures required consideration of the patient being discharged that day," the report said.
The on-call psychiatrist thought it was a good idea to give him some unescorted leave from the ward before he was discharged. That happened without incident.
During his time Te Whetu, Yad-Elohim spent time in three wards and had been given 20 different nurses as his duty nurse.
He was discharged to a community facility but left after spending only one night there.
Yad-Elohim also left his medication behind. It was found by a mental health worker carrying out a check-up two days later.
When they visited the following day - on 27 September - Yad-Elohim was not there.
Evidence at his trial showed Yad-Elohim was on Auckland's Karangahape Rd at the time, trying to procure methamphetamine.
That was the day he was ripped off in a drug deal that ended in him stomping 69-year-old Michael Mulholland to death.
The report found Te Whetu was under "considerable occupancy pressure" at the time.
At Yad-Elohim's trial there was evidence that showed the ward was completely full - all 58 beds were in use.
Clinical director Peter McColl told the court he stood by his decision to discharge Yad-Elohim.
The report found that although the discharge had been planned - it was caused by the ward being full.
Overall, the report did not identify what it called "substantive care delivery problems" that contributed to the killing.
It also concluded Yad-Elohim had not hidden anything from mental health professionals. However, if that did happen - that may have been caused by the large number of staff that he saw and the difficulty in forming a close relationship with them.
"It seems very clear, however, that the considerable occupancy pressure within TWT [Te Whetu Tawera] compromised the implementation of the primary nursing model and contributed greatly to a hasty discharge."
The report made incidental findings.
One of its conclusions was that the ward should only operate at 85 to 90 percent capacity. The evidence from trial was that Te Whetu was at 100 percent at the time.
The report said when the unit was full, there was a heightened risk to care, and planning processes had to be abbreviated.
DHB blocked the release of the report
The district health board did not want RNZ News to have this report.
RNZ applied to the board under the Official Information Act. The board declined sighting privacy reasons, despite the report being part of the evidence at trial and Yad-Elohim's medical history being extensively canvassed.
RNZ has filed a complaint with the Ombudsman.
In the meantime, RNZ filed an application to the High Court for the document because it was on the court file.
The board again opposed its release sighting privacy.
But Justice van Bohemen found the report was in the public interest.
"Whether or not the care Mr Yad-Elohim received at Te Whetu Tawera bore directly on Mr Yad-Elohim's offending, that care and the review of that care in the report were part of the relevant factual background and were of public interest."
At Yad-Elohim's sentencing Justice van Bohemen called for an independent review into his care at Te Whetu.
A Ministry of Health spokesperson said it would look into the matter and decided whether further action would be taken.
The Coroner's file on Michael Mulholland's death also remains open but a decision on whether to hold an inquest has not yet been made.