"Heartbreaking" and "absolutely avoidable". 

Those are the words an unmistakably frustrated Shaun Robinson, Mental Health Foundation chief executive, used to describe five unconnected but equally tragic homicides by five mentally-ill people. 

"What makes me most angry is that this is total system failure in terms of responding to people's mental health needs," Robinson told Open Justice. 

"Mental health has been ignored and under-resourced for decades in this country – in fact it's never been adequately accepted or the scale of the issue acknowledged or a proper, passionate, humane and effective response put in place and this is the worst end of the daily tragedies that result from that neglect." 

The killings all occurred in the Wellington area during 2015 and 2016 and have been the subject of extensive coronial inquiries and inquests. 

Coroner Michael Robb released his findings today and across all inquiries he has identified broadly common features. 

A number of flaws within the mental health system, with resourcing issues being the biggest cause, were exposed. 

Other common themes included situations where compulsory inpatient care, under the Mental Health Act, was not implemented, but should have been. 

Inadequate documentation of patients' history and care plans, and inadequate transfers of patients between health providers was also highlighted. 

Based on his findings, Coroner Robb – who made clear that violent acts such as the homicides are very rare with mentally-ill patients - has made a significant number of recommendations. 

Hutt Valley and Capital and Coast DHBs, which provide health services in the area the homicides occurred, have welcomed the findings. 

Chief executive for the Wellington DHBs' Mental Health, Addiction and Intellectual Disability Service Karla Bergquist said changes have taken place within the service since the homicides. 

"The service has implemented a number of significant system improvements since these events occurred, including the successful implementation of recommendations identified in an external review in July 2016. 

"The service is committed to meeting the recommendations of the Coroner and to monitoring and reviewing outcomes related to those recommendations." 

A Ministry of Health spokesperson praised the efforts taken place to improve care within the service, and acknowledged the findings of the Coroner's report. 

"To help address workforce shortages across the mental health and addiction sector, Budget 2019 is investing $77 million over four years in mental health and addiction workforce development." 

But while Robinson appreciates the Government's intent, he said it's not enough. 

The failures are not just that of the public health services, or the staff delivering the services. 

Robinson said they are just one piece of a very big puzzle. 

Other factors include meagre community support, mental health crises falling on police to deal with, inadequate emergency housing and inadequate income. 

"Every aspect of the system that should be there to support people when they are struggling and really vulnerable is just not there." 

Since the 2017 mental health and addictions inquiry, He Ara Oranga, Robinson said there is more acknowledgement of the scale of the issue – a scale that reveals 20 per cent of New Zealand adults every year will have a significant episode of mental distress, according to Ministry of Health figures. 

"Everything the Government has done has been good. It's just so far it's nowhere near enough and has not been systematic enough," he said. 

"We've still got a very big mountain to climb." 

WHERE TO GET HELP 
• Lifeline: 0800 543 354 (available 24/7) 
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7) 
• Youth services: (06) 3555 906 
• Youthline: 0800 376 633 
• Kidsline: 0800 543 754 (available 24/7) 
• Whatsup: 0800 942 8787 (1pm to 11pm) 
• Depression helpline: 0800 111 757 (available 24/7) 
• Rainbow Youth: (09) 376 4155 
• Helpline: 1737 
If it is an emergency and you feel like you or someone else is at risk, call 111