On the afternoon of March 1, a 42-year-old woman receiving mental health services from a treatment facility called its hot line to say she had taken an overdose of medication.

A case manager called 911, and a team of emergency medical technicians was sent out. But the team didn't reach the woman, either because it could not find the woman's apartment or was told she did not live there. A second EMT team went out, but it was not clear what that team did.

That night, a case manager at the mental health treatment center, which is under contract with the state, discovered the woman never checked into The Queen's Medical Center emergency room.

But the manager assumed the EMT team had seen the woman and had decided she didn't need further care.

The woman was found dead in her apartment the next day, an apparent suicide.

Her death is one of three cases cited by U.S. Magistrate Kevin Chang in his scathing 50-page report on efforts by the Department of Health to implement a plan for providing services and care to Hawai'i's estimated 9,000 seriously mentally ill residents. None of the people cited in the report is identified.

In another case, a Hawai'i State Hospital patient was placed on temporary release under various conditions, including that he was not to meet any family member without permission from his probation officer.

However, the patient's mental health case manager responsible for making sure the patient fulfilled the conditions of his release apparently never received the information and did not know about past violence between the man and his family.

On April 13, the man went to his mother's home and stabbed her three times in the chest, leaving her in critical condition.

In the third case, a Hawai'i State Hospital patient with a history of drug use was released from the facility. Another person had been handling the patient's money, but the case manager — who did not know about the history — gave the man a large sum.

Less than a month later, he was found dead, apparently related to a methamphetamine overdose.

In his report, Chang said it's not clear whether the deaths and assault could have been prevented if the community plan had been in place, but he said the chances of avoiding those incidents would have increased.

Correction: Emergency Medical Services personnel are licensed and qualified to assess all types of patients. A previous version of this story contained incorrect information.