It’s a tragedy that’s reverberated throughout the community: Justin Bautista, a 29-year-old nurse, was stabbed to death last Monday at a transitional group home on the Hawaii State Hospital grounds, leaving behind a fiance and 1-year-old daughter. Tommy Kekoa Carvalho, a patient at the home, was indicted for second-degree murder by a grand jury on Wednesday.

Given the danger that the 25-year-old Carvalho poses to others, Circuit Judge Ronald Johnson has ordered him held without bail. Yet administrators at the State Hospital, along with a unanimous panel of clinicians independent of the hospital and the judge who appointed them, had earlier deemed Carvalho ready to successfully leave the hospital’s confines, approving of his placement in the less-secure transitional home.

As those left behind struggle to understand this terrible loss, it’s essential that the Hawaii Department of Health (DOH) and State Hospital determine not only how this killing occurred, but how state mental health workers can be protected from violence in the future.

State Hospital administrator Kenneth Luke has confirmed that Carvalho left the hospital grounds on the day of the killing, and that the group home he lived in, known as a State Operated Specialized Residential Program, has staff present 24 hours a day. Transitional home residents are no longer considered State Hospital patients and are able to earn the right to leave for day outings — and Carvalho had done so.

Luke also confirmed that DOH Director Kenneth Fink has ordered a top-to-bottom review of security procedures at the transitional home, to identify potential gaps and risks.

Heightened security measures should remain in place until there is a full understanding of the gaps that allowed for Bautista’s death. An analysis of safety, campuswide, and tighter procedures to protect against bringing dangerous items back onto the property should be launched immediately.

At a news conference on the incident, Luke cautioned against rashly concluding that the State Hospital pull back on efforts to treat its patients in support of a transition back to community life. Agreed: The State Hospital’s policy of pursuing treatment and reentry for patients is worthy.

However, safeguards must be reevaluated as to whether reentry benchmarks need to be set higher, especially when the patient has a history of violence, as Carvalho did. DOH must scrutinize its procedures and critically reexamine its standards for judging a State Hospital patient fit for release.

And given Bautista’s loss of life, it is crucial that staffers’ safety and security be top priorities. Settings where public workers must interact with people who have committed criminal, and especially violent, acts demand extraordinary measures to ensure workers are safe. DOH must revamp security processes for all corners of the hospital grounds, including the transitional group homes.

Everything must be on the table, including more staffing, training and management, to reduce the risk of harm for all on campus.

The death of Justin Bautista is the only known instance of a staffer on the Hawaii State Hospital campus being killed by a patient, Luke said, describing Monday’s deadly incident as “unanticipated and unprovoked.” However, treating patients who sometimes relapse is not uncommon in the mental health system. The potential for violence should be acknowledged and prepared for, with higher protections for staff in the transitional program as well as the hospital itself.

Since the new main hospital opened in 2022, Luke said, the facility has become safer. However, the hospital is already overcrowded again, holding 325 patients while its standard capacity is 297 patients.

Overcrowding and understaffing are chronic problems at the State Hospital. But Bautista’s tragic death gives urgency to the need to reassess the hospital’s operating procedures, and for reforms that minimize risk of harm to both patients and staffers.