The LynnMall terror attack review says officials did not call the family of the man responsible for the attack to see if they could help deradicalise him.
Ahamed Samsudeen attacked shoppers in the Auckland mall in September last year, seriously injuring four women and one man with a knife, a few weeks after his release from four-plus years on remand in prison. Another man suffered a minor wound, and another dislocated his shoulder while trying to stop the attack.
In a 128-page report released yesterday, a triple watchdog review expresses surprise several times - including over the fact no-one contacted the 32-year-old's sister overseas to see if their family could help.
"We are also surprised that there was no attempt to communicate with his family overseas, and in particular his sister with whom he was known to have been in frequent telephone contact," the report stated.
In the immediate aftermath of the attack, the government, police, Corrections and the Security Intelligence Service (SIS) stressed they had done everything they could.
But the review found four major deficiencies, notably chances lost by the agencies since 2016 to try to deradicalise Samsudeen.
Defusing him may not have worked, the review said, but added: "We will never know what might have happened, because it was not attempted."
Police appeared to reject that in a statement. It said "numerous" attempts were made by them and others to disengage him from extremism, while also telling RNZ they accepted that in hindsight "there were missed opportunities", lessons to learn, and they would "approach a case like this differently now".
Police Commissioner Andrew Coster said they had a new programme for extremists, though there were "only a very small number of cases ... single digits" and none at the Samsudeen level. "I'm not going to go into details."
The review does not say the attack could have been prevented, nor that the pressure of 24/7 surveillance in the weeks after Samsudeen got out of jail may have sparked the violence.
But it is clear there was nothing inevitable about it.
"It appears that Police and Corrections had mostly discounted any chance of disengagement and rehabilitation for Mr Samsudeen," the review said.
It suggests he probably had no fixed plan before 3 September, just alternating thoughts of "revenge and martyrdom".
He likely formed the intent when he set out for the mall.
In the morning, "he posted quotes on fighting for Allah's cause, Paradise, and martyrdom to a Facebook page he had created the day before".
"He then attended prayers at Masjid e Bilal, talked to his family over the phone, and told them he would call back after he had done his shopping."
He put a single glove on his right hand, with which he later would grasp the supermarket knife.
"He put on some headphones and listened to ISIL co-opted nasheeds."
These songs typically glorified fighting and martyrdom. Islamic State was ascendant in the Middle East at the time Samsudeen became radicalised after 2015.
This was an end-point various reports show Samsudeen was headed towards for years, through childhood struggles in his home country, Sri Lanka, then a struggle to get accepted into this country as a refugee, then a struggle to get out of the country - he strove to be deported, but was blocked, as an RNZ investigation reported yesterday.
The review states all the agencies "were doing what they thought best ... with limited experience", and the government has seized upon that, saying "the report recognises the system did its best".
That "best" though was not enough to fill the many gaps around the handling of the man.
"When Mr Samsudeen was showing warning signs of radicalisation, he needed proactive and positive wraparound support," the review said.
Psychologists told the review that addressing mental health or social difficulties was the "starting point" for disengaging extremism.
Police told the review they considered bringing a family member to New Zealand for Samsudeen's release from prison in July 2021 as a "protective factor", but Covid-19 prevented that possibility.
"Nonetheless, neither Police nor Corrections seem to have consulted his family at all about whether they could assist by encouraging Mr Samsudeen to engage with the support that was available," the review found.
A 'watch group' and working group that met 13 times over the years, looked at engaging with his family but "this was dismissed in 2018 and never discussed again".
Those who knew Samsudeen - and the review notes how the Muslim and Sri Lankan communities "told us they would have been willing to help if they had been asked" - and a report into the case by the Federation of Islamic Associations, described much more a lonely and troubled migrant unmoored from his family and with mental health issues, than in any way a religiously educated or practising believer.
He got his education online about Islam.
"We were also told that people searching terms related to Islam online are easily led to violent extremist material through search algorithms," reviewers said.
The prisons inspectorate also investigated, and said Samsudeen "was vulnerable, isolated, and had extremist beliefs".
Yet there was no long-term, co-ordinated plan in place for disengaging him from violent extremism.
"Had a plan been developed, these factors may have been addressed," the inspectorate said.
Instead, Corrections treated him like any other remand prisoner, even as police argued in court he was a "high-risk potential terrorist" - a risk categorisation that kept him behind bars "on remand for over five times as long as the average male prisoner", the main review said.
The review is at pains not to attribute fault, and instead urges agencies to adopt its lessons.
Coster told RNZ said the now fully-operational He Aranga Ake programme stressed community engagement and access to mental health and other services.
"That is an intervention that didn't exist five years ago," Coster said.
He Aranga Ake began being worked on four years ago, and was funded by the government in 2020.
In the Samsudeen case, police "staff were very diligent and doing everything that they could see to do in the circumstances".
"We were breaking new ground at the point this case presented," Coster said.
"Police explored many, many different avenues for managing the risk in this case.
"You know, the fact that we applied the kind of resources that we did to surveillance, and to the active management of him at all stages, was a reflection of the concern that we had."
He would not comment on police not contacting the family for help.
Corrections admitted it had missed opportunities to de-radicalise Samsudeen and said it was developing new psychological assessment and treatment guidelines for extremism, had added a principal adviser, and was investigating options for general training in psychological assessment.
The department's chief executive, Jeremy Lightfoot, told Morning Report although there had been investment in the persons of extreme risk unit at the prison where Samsudeen was on remand, it had not - at that time - had "the specialist psychological capability - and particularly the transition back into community capabilities - that it now has".
"I think that's what we've focused our investment on, because I acknowledge there were things for us to learn and this particular case was unique to New Zealand context at that time."
In a similar situation today, someone coming into custody would have "very immediate, specialist case management support, with people with the expertise to understand the impact of the radicalised environment extremists use", Lightfoot said.
Nonetheless, the review describes a national security system that, several years on from the mosque attacks, and as recently as last year, had fundamental things missing.
"No disengagement programmes were available for Mr Samsudeen while he was in prison. His violent extremist beliefs did not change, and he became increasingly aggrieved and alienated," the review said.
The country still does not have in place a strategic framework for preventing and countering violent extremism, seven years after spy agencies and police began surveilling Samsudeen, and 15 months since his attack.
The framework recommended by the mosque Royal Commission is due for release next year, the Department of Prime Minister and Cabinet said, stressing there had been a lot of consultation.
For more than four of those seven years, Samsudeen was locked up, on remand, while confusion swirled about what to charge him with in regards to Islamic State material he imbibed online and disseminated.
His behaviour gradually became more erratic, his anger more pronounced.
Support services were needed, the review said.
"Instead, the warning signs only triggered increased surveillance by Police and the NZSIS."
Police "seem to have believed that he had passed the point of intervention without some enforcement response" though they had little reason to believe that he would refuse to engage.
An inquest will be held at some stage though its timing is uncertain.