Christie Marceau was murdered in 2011, after a man who'd previously attacked her was bailed to an address a short walk from her home.

A coroner has recommended greater scrutiny of bail applications from serious offenders, after the killing of Auckland teen Christie Marceau.

Coroner Katharine Greig released her findings into Marceau's death on Tuesday, following an inquest last year.

﻿The 130-page report makes a host of recommendations to police, the Ministry of Justice, Corrections and Waitemata District Health Board (DHB).

GRAHAME COX/STUFF Akshay Anand, 18, was found not guilty of Marceau's murder by reason of insanity.

Akshay Chand stabbed 18-year-old Christie to death in 2011 at her North Shore home while on bail for a previous attack on her. His bail address was a short walk from Christie's home.

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Chand, also 18, was found not guilty of her murder by reason of insanity after being diagnosed with paranoid schizophrenia. He was placed in the care of Waitemata DHB's Mason Clinic as a special patient.

Kent Blechynden Christie Marceau's sister Heather Marceau and mother Tracey Marceau campaigned for tougher bail laws following her death.

In her findings, Greig said Christie's death had "shocked the nation".

"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."

She noted that because Marceau died while Chand was on bail, there was "some public expectation that the coronial inquiry would consider whether the judge exercised his judicial discretion to grant bail correctly".

The inquest had no power to do so, because the grant of bail was a judicial decision that could only be properly reviewed by way of appeal, which did not happen in this case, the coroner said.

However, she recommended in her findings that the chief executives of the Ministry of Justice and Corrections, and the Police Commissioner, consult with key stakeholders about bail applications involving serious offences and a 24-hour curfew.

This was to ensure evidence was provided to the court in a suitable format for all such applications, including details of the proposed address, and whether or not the proposed bail address was acceptable to the prosecuting authority.

Changes to legislation should be considered as part of the consultation, the Coroner said.

Following release of the coroner's report, Marceau's parents Tracey and Brian Marceau said New Zealand's bail system was "dysfunctional, non-communicative - a disaster".

"There were many hands on that knife that day," Tracey Marceau told RadioLIVE.

"I can't forgive them for that and I never will forgive them. They can do what they want and try and hush things up, but at the end of the day, they've got to live with what they did."

Among Coroner Greig's other recommendations were that the North Shore District Court undergo an in-depth review of document management, including the "adequacy of electronic document management systems".

She also recommended that the victim advisor service review its processes for advising victims of crime who wish to provide their views to the Court on a bail application.

Another issue examined in the findings was Chand's psychotic state around the time he killed Marceau, which eluded clinicians despite a dozen mental health checks.

The coroner was satisfied that on the 12 occasions he was seen by a health professional in the lead-up to Marceau's death, Chand was appropriately assessed for psychosis.

However, Chand never admitted to psychotic symptoms, and no evidence of the disorder was found by any of the mental health staff.

"Mr Chand is an intelligent, complicated, and difficult person who did not give any of the various health professionals who assessed him concern that he had a psychotic illness," the coroner said.

"It is clear only with hindsight that Mr Chand was so terribly dangerous to Christie because of his psychiatric condition."

Victim advocate Ruth Money said Marceau's parents had read the report and welcomed the recommendations.

After Marceau's death, her family had campaigned for bail law reforms.



"The coroner has been very thorough, which is all we could have asked for," Money said.

"The report itself is not telling us anything we don't already know. The family are very happy, as am I, that an independent investigation has happened for Christie. It highlights what we knew: that she was failed at every touch point.



"The only people who were there for Christie were the police investigating Chand's initial attack, and they tried so hard to oppose bail."



The findings came a month after Justice Minister Andrew Little said the current bail laws needed to be changed to stem the flow of people going to prison while on remand.



Tracey Marceau was keen to talk to Little about the proposed changes to air her concerns, Money said.



"I spoke to Tracey this morning who said Little was uneducated when it came to bail. She would welcome talking about the issue with him. She is someone who has experienced what can go wrong first hand.



"She thinks the changes will 100 per cent put public safety at risk. She is very sure he is wrong."

Meanwhile, Chief District Court Judge Jan-Marie Doogue said she was concerned about the "quality of information" available to judges in bail hearings.

"The findings of the coroner's inquest into the death of Christie Marceau highlight the risk created by information gaps in the criminal justice system and expose where some of those gaps are, especially around the quality of information that is placed before judges," Doogue said.

"To make sound, safe decisions that protect people from further harm, judges need as much information as possible.

"We rely on everyone across the system to capture that detail to the best of their ability and bring it to the court's attention."

She said District Court judges had led an initiative to provide judges considering bail applications with a pack that gathered together all information about a defendant held across police and court files, and including victims' views.

The Ministry of Justice had helped trial these "judge's packs" successfully in four regions and judges were eager to see them rolled out nationwide.

While these sorts of initiatives improved judges' knowledge, they could not eliminate risk completely, Doogue said.

Risk factors included those arising out of mental disorder where accurate clinical diagnosis may not always be possible.



"District Court judges are determined to play our part; we owe it to all parties involved in criminal proceedings, and the communities which the District Court serves, especially victims and their families – families like the Marceaus."



Last year, Stuff revealed Chand had been granted leave from his secure mental health ward without the Marceau family being advised.

At the time, Little said more needed to be done to protect and informs victim's families.