The Kinohaku home where Ross Bremner fatally attacked Maurice O'Donnell and Mona Tuwhangai in 2016. Photo: RNZ / Cole Eastham-Farrelly
- Ross Bremner's mental illness to blame for murders
- Coroner finds mental health care appropriate
- Details of tragedy released for first time
Warning: This story includes details of a graphic nature and may be upsetting.
The unpredictable nature of Ross Bremner's schizophrenia - and not his mental health care - led to a frenzied attack on his parents and a couple he didn't know that killed three of them, and ended when he took his own life.
Coroner Michael Robb's findings into the cause of Clare Bremner, Maurice O'Donnell, Mona Tuwhangai and Bremner's deaths on 4 October, 2016 have been released, and show the 35-year-old was extremely mentally unwell when he inflicted the fatal attacks, which left his father in critical condition.
Keith Bremner survived his injuries but couldn't remember the attacks. He died in June, almost eight years after the murders.
For the first time, details of the attacks can be reported.
What happened on 4 October 2016
Ross Bremner. Photo: NZ Police
On the day of the attacks, Keith, 64, and Clare, 60, arrived at their Ōtorohanga home separately before 4pm.
Earlier Clare texted Bremner, who lived with his parents, to ask if he was okay and tell him she was on the way home. At 3.11pm he replied saying: "Good see you then."
At 4.19pm, Clare spoke to one of her sisters on the phone for seven minutes and they made plans to catch up.
About 8pm, a neighbour heard gurgling noises from the front of the Bremner house and went with her adult son to investigate.
"They went to Keith and Clare's property at about 8.20pm and were met with a traumatic scene."
Keith was lying on the front porch in a pool of blood, with significant knife wounds.
Emergency services were called and he was rushed to hospital in critical condition.
Police found Clare deceased, lying in a pool of blood with similar wounds to her head and throat.
Coroner Robb said evidence showed a "very violent" and "frenzied attack on Clare and Keith".
Police said the attack happened about 6.15pm.
They were unable to locate the weapon, and Bremner and his silver Holden Vectra were gone.
His mobile phone was in his bedroom, with his last communication the text to his mother.
At 3.30pm that day, O'Donnell, 72 and Tuwhangai, 82, arrived home at Kinohaku from shopping in Te Awamutu.
The property on Kāwhia Harbour is an hour's drive from Ōtorohanga.
Coroner Robb found that after the attack on his parents, Bremner drove to the property, selecting it at random, and parked the car behind a shed so it could not be seen from the road or house.
The car became stuck in a boggy patch and Bremner approached the house on foot.
He hopped into the couple's car - his fingerprint was later lifted from the gearstick - but the car keys were inside.
Coroner Robb said the couple were in the middle of a meal when Bremner attacked them violently, using items from a shed.
"The actions are not carried out as some kind of robbery, but are essentially frenzied and purposeless."
Bremner took off his Guns N' Roses t-shirt after the attack and made a half-hearted attempt to wash it.
It was found in the kitchen, damp and with splatters of O'Donnell's blood.
Bremner tried to find something to wear before tipping Tuwhangai's handbag upside down, rummaging through the contents and pocketing her bank card.
He also tried to clean blood off a knife outside.
Coroner Robb said Bremner took his own life shortly after the killings. The method by which he died cannot be reported.
It was three days before their bodies were discovered by a neighbour.
Flowers outside the property in Taharoa. Photo: RNZ / Cole Eastham-Farrelly
Was Bremner's mental health care adequate?
Bremner was the oldest of three siblings and a "loving" brother to his sisters, but his mental health took a turn in 2003.
He began smoking weed as a teenager and after one session aged about 24, he claimed someone laced the marijuana with "magic mushrooms".
Bremner was admitted to hospital for paranoid delusions between 2003 and 2013.
He assaulted his grandparents and once assaulted a man while experiencing hallucinations, and a psychologist.
Forensic psychiatrist Dr David Chaplow said 1500 pages of clinical notes pointed to challenges stabilising Bremner's illness.
Both Chaplow and a Te Whatu Ora Waikato serious event review found Bremner became paranoid with the urge to fight people whenever he reduced his anti-psychotic medication.
In April 2016, with the support of his parents, Bremner asked his GP to decrease his clozapine medication because of side-effects including anxiety, panic, poor short-term memory, being overweight, constipation, lethargy and lack of motivation.
He was referred to a psychiatrist who reviewed Bremner's file and declined the request.
In August, Bremner went to his GP with Keith and asked to go off his medication.
The GP suggested a very small, slow reduction in one of his four medications.
Five weeks later on 19 September, the pair revisited Bremner's GP and he reported mild anxiety.
Bremner was advised to return to the original dose and there's no indication he refused.
A week later - on 26 September - Bremner picked a fight with a stranger in Te Awamutu, prompting his father to call community mental health services.
After a telephone triage, he was referred to a psychiatrist two days later.
That psychiatrist noted a single psychotic event and discussed admission to the Henry Rongomau Bennett Centre or a respite facility, but both were declined by Bremner and his parents.
No change to his medication was made and blood tests were ordered.
Bremner was to return to the psychiatrist on 5 October.
Coroner's conclusions
Coroner Robb found Bremner should have been assessed by a psychiatrist on the day of the Te Awamutu attack, but there was no evidence to show the delay impacted on the tragedy.
He said for Bremner to be admitted under compulsory care he needed to be mentally disordered on 28 September, but he was not.
The coroner found Bremner, who always expressed remorse for his actions, was taking his medication.
He said there was no obvious error or omission in Bremner's care between his last appointment and the murders.
"If Ross was showing symptoms supportive of an ongoing decline, I consider it highly likely that his attentive parents would have voiced their concerns about this as their previous communications had demonstrated.
"The result leaves me to conclude that Ross was simply not presenting with symptoms of acute decline until his tragic actions on 4 October, 2016."
He did not find an obligation for Bremner to meet WINZ to find work triggered the events.
Instead he said the unpredictable illness - impacted by slight medication changes - caused Bremner's sudden and dramatic deterioration.
The coroner made no formal recommendations.
A lawyer acting for the Bremner family said he had been instructed not to speak to journalists.
The Tuwhangai and O'Donnell whānau did not wish to participate in an inquest.
Daughter Jo Kukutai previously told Checkpoint she forgave Bremner.
Te Whatu Ora Waikato operations director Michelle Sutherland acknowledged the tragic event and the findings, noting no recommendations were made to Health NZ.
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