A Coroner has made a swathe of recommendations demanding urgent changes to court processes following the death of North Shore teenager Christie Marceau in a bid to "reduce the chances" of similar "devastating" deaths in future.
The recommendations were aimed at the Ministry of Justice, police, Department of Corrections and Waitemata District Health Board after a number of inadequacies - mainly around deficits in inter-agency information sharing - were identified in the handling of the youth who stabbed Christie to death in her Hillcrest home.
Christie, 18, died on November 7, 2011 in her mother Tracey's arms on the deck of their family home.
Minutes earlier Akshay Anand Chand had forced his way into the house, chased Christie to the deck and stabbed her repeatedly in the head.
Chand only stopped the frenzied attack when the knife bent to such an angle that he could no longer use it.
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The Herald revealed that Chand was on bail at the time and facing serious charges of kidnapping, threatening and assaulting Christie two months earlier.
When released on bail Chand was ordered not to associate with, attempt to contact, or go anywhere near Christie or her home.
Judge David McNaughton also imposed a 24-hour curfew in place and ordered Chand not to leave his mother's house unless he was going to medical or legal appointments.
But just 32 days later Chand - who later admitted he had been planning the attack for some time - walked to the Marceau house armed with a hammer and kitchen knife and took Christie's life.
Nikki Pender, the lawyer for the Marceau family, told Larry Williams that a case like this could happen again.
"The light that's been shone on this is a very dysfunctional system.
"From Christie's perspective, all she wanted was to be kept safe.
"Suddenly, no body's taking responsibility for it."
She says that it is not the first time that these recommendations have been made. She says that people need to work together and be allowed to implement changes.
In October 2012 Chand was found not guilty of murdering Christie by reason of insanity.
An inquest was held in June last year and looked at the administrative process at the North Shore District Court in the lead up to Chand being bailed; police bail-checking processes and protocols and whether they were adequate; what Chand's mental health was before Christie's death and what information Judge McNaughton had available to him when he made the bail decision.
In her final report today Coroner Katharine Greig said the overriding purpose of the inquest was to establish the cause and circumstances of Christie's death and to make any relevant recommendations that could prevent similar incidents in future.
Her final report was released today and contained 10 strong recommendations that did in fact, highlight the failings the Marceau's wanted addressed.
"Christie's death has been a devastating loss for her family, whose lives are forever changed," Coroner Greig said.
"Christie's death and the circumstances around it shocked the nation.
"Following Christie's death her family spearheaded high profile public efforts to reform aspects of bail laws," she said.
"During this campaign, and since, images of Christie's smiling face have been published in the media regularly and her face is a familiar image to New Zealanders.
"The tragedy and futility of Christie's death, together with questions as to how Mr Chand came to be in a position where he could kill Christie, have continued to resonate and are a matter of strong public interest."
Coroner Greig's findings span 127 pages and relay what evidence was given by each witness at the two-week inquest as well as detailed recommendations.
LISTEN TO NIKKI PENDER TALK WITH LARRY WILLIAMS ABOVE