Bailey Phillip Jakob Ecclestone. Photo: RNZ / Natalie Akoorie
A young autistic man was placed in a home with intellectually disabled residents without the specialist care he needed before going on to fatally stab a visitor.
Bailey Phillip Jakob Ecclestone killed Matthew Williams by stabbing him in the neck as the good Samaritan tried to intervene in a fight between Ecclestone and another resident, Joseph Pitcaithly.
The violent altercation on 7 February last year at a Community Living home in Hamilton prompted a recommendation by experts to hold all referrals of residents with Autism Spectrum Disorder (ASD) and other behavioural issues into community residential services "until safety is confirmed".
The recommendation, one of 19 made in a review of the serious event and incidents leading up to it, was the only one listed as critical.
A redacted version of the report was released to RNZ under the Official Information Act.
Ecclestone had been transferred to the residential home from another and before that he had been in the care of Oranga Tamariki until the age of 18.
At school he had been bullied and ostracised, had few friends and poor social understanding and in 2017 he was diagnosed with attention deficit hyperactivity disorder (ADHD) and the following year with ASD.
He was also a heavy drinker, smoked cannabis and took other substances but according to the report, there was no documented attempt to enact any form of intervention to help Ecclestone understand the impact of cannabis use.
The review team of a quality improvement consultant, community psychologist and social worker, referred to Ecclestone as Person A and said there was minimal focus on him as a person.
"Staff regularly used denigratory language when discussing Person A in the interviews."
Ecclestone liked cooking and was encouraged to do it but it didn't appear any steps were taken to develop the strength and after the killing, staff told the review team Ecclestone only liked "cooking" and "making a mess".
"There was a good deal of staff focus in these interviews and incident reports on Person A's mess-making, but not on what this behaviour may have been communicating."
Ecclestone's conditions meant he was funded for one-on-one care but on the night of the stabbing no staff members were at the house and the support appeared to have ceased, the report noted.
"Despite this clearly stated need, frequent gaps occurred where the home was not staffed, including the time of the sentinel event. It is unclear how long and how often these gaps occurred."
Counselling and other support sessions were arranged for Ecclestone but when he declined them no further support was offered.
"Staff seemed to the reviewers to be shrugging their shoulders and saying it was Person A's choice to not engage."
Now 22, Ecclestone was raised by his aunt but after a chance meeting with his mother at the age of 10, he became confused over why she had limited contact with him.
After that, his behaviour spiralled and he was eventually put into OT care and excluded from school at 15.
According to the report, the one person Ecclestone built a relationship with at the house resigned, and staff did not have the skills, time and in some instances the inclination to engage meaningfully with him.
There was also high numbers of non-core staff "filling in" at the house because of shortages.
Notes from an incident leading up to the stabbing demonstrated an authoritarian approach more aligned to institutionalisation.
Admissions things could have been done better
Community Living chief executive David Oldershaw acknowledged the report identified there were "some things we could have done better in the lead up" to the tragedy.
"Overall we have reflected as you do when an incident like this occurs. We've done a lot in terms of increasing training, bringing in expertise when it's needed for complex situations - a range of initiatives that respond to the requirements in the report."
Oldershaw said Ecclestone was getting all the funded hours of support he was entitled to.
"There certainly isn't an issue of under-delivery here. Fundings for residential disability services is very challenging and Community Living's been advocating for years for more funding resource for support, and also access to things like specialist expertise when it's needed.
"We've got a pretty extensive history of over-delivering support hours, not under-delivering them."
He said the hold on referrals to Community Living's residential homes in the Waikato and Bay of Plenty was across the board, not just for people with ASD and it was implemented immediately by the provider and not as a requirement of the review.
The Ministry of Disabled People - Whaikaha deputy chief executive Amanda Bleckmann, said there was no requirement from Whaikaha that specific referrals remain on hold.
However, she said autistic people with no other eligible disability diagnosis were generally not referred to residential services funded by Whaikaha. Since 2014 autistic people had been eligible for disability support services.
Bleckmann said many factors were taken into account when considering the compatibility of those living in a residential home, including choice, age, community, cultural and support needs.
"The largest group of people living in community residential services are people with an intellectual disability, followed by people with a physical disability. Disabled people may also have other disabilities, including autism."
Fifteen of the report's recommendations were implemented by Community Living by September last year and four more were partially implemented with work ongoing.
Bleckmann said the ministry was satisfied the provider was working as quickly as possible to implement changes.