In the months before Clayborne Conley fatally shot his ex-girlfriend, her 13-year-old daughter and then himself, his friends say his behavior became more bizarre and disturbing.

Conley, an Iraq veteran with a history of violence, mental instability and substance abuse, struggled with depression, they said. He talked about killing himself over his estranged relationship with Kristine Cass, showed up at her home uninvited and, during the week of the shootings, twice went to her workplace and caused a scene, the friends said.

As someone who was conditionally released nine months earlier from the Hawaii State Hospital for the mentally ill, Conley was supposed to be regularly treated by professionals.

But if the troubled war veteran was getting help, the treatment did no good in the early-morning hours of Aug. 20. Not long after Cass told a friend she was considering filing a restraining order against her ex-boyfriend, Conley broke into Cass’ rented Makiki cottage and shot her; her daughter, Saundra; and a neighbor’s dog before killing himself.

"This was a complete failure of the system," said Linda Tsai, a friend of Cass and Conley. "Clay was adrift, and he wasn’t getting the help he needed. If he was refusing to accept help, someone from the system needed to intervene."

The Conley case is the latest example of what critics say is the failure of the state to adequately monitor and treat former criminal defendants who are on conditional release from the Kaneohe hospital.

Roughly 450 of the former patients are living in Hawaii under supervision of probation officers and mental health professionals, and must abide by specific conditions, such as getting regular mental health treatment, staying sober and taking prescribed medications. If they violate the conditions, they can lose their freedom and be re-admitted to the hospital.

All the patients were originally charged with crimes ranging from petty theft to murder, acquitted by reason of mental defect, treated at the hospital and eventually released. Some have been on conditional release for decades.

A judge approved each release based on the experts’ assessments of whether the patient could be safely discharged and under what conditions. Most leave the hospital without significant problems. One man acquitted of murder more than 30 years ago, for instance, has been on conditional release since then and continues to do well, state officials say.

"The vast majority (of cases) are success stories," said Dr. William Sheehan, acting chief and medical director for the Department of Health’s Adult Mental Health Division, which provides mandated treatment to the conditional-release population.

But in the wake of steep cuts in adult mental health services the past two years and intense governmentwide budget pressures, patient advocates, prosecutors and others increasingly are questioning whether the state is able to provide sufficient oversight for the conditional-release population. Some say the public is at greater risk because of monitoring gaps and inconsistencies or because patients are being released prematurely from a hospital that is perennially overcrowded.

The facility recently had 191 patients, well over the 168 the staff is budgeted to handle but less than the licensed maximum capacity of 202, according to DOH officials.

"The system has crashed," said Poka Laenui, who heads Hale Naau Pono, a nonprofit provider of mental health services in West Oahu. "It is in fact dysfunctional."

In a September interview before he was appointed the city’s managing director , acting Prosecutor Douglas Chin said, "You have a mental health system that is under enormous pressure, and those pressures end up favoring the release of people and overruling public safety concerns."

State officials defend the system, saying public safety is not being compromised and that the process is working effectively despite fiscal challenges.

"There are no gaps caused by any budget issues," said Janice Okubo, a DOH spokeswoman.

A court spokeswoman also disputed the notion that budget and overcrowding pressures play a factor in the release of hospital patients.

Judiciary representative Marsha Kitagawa said in a written statement that a judge considers reports from three mental health professionals before deciding whether to conditionally release someone and will do so only if the court is satisfied the patient will not be a danger to his- or herself, others or property. Budget and overcrowding concerns are not considered, she said.

Despite efforts to keep the released patients on track, some invariably falter, health officials say. They cite the complexities of mental illness, the difficulty of predicting human behavior and other factors, such as substance abuse. Some patients have been involved in violent incidents.

"Our goal is there not to be any incidents of this tragic nature that you see in the community," the DOH’s Sheehan said. "We want zero suicides, we want zero episodes of violence in the community. Having said that, we have not been able to get our risks down to zero."

While a high-profile case like a double murder will grab headlines, those tend to be rare.

It is the lesser incidents happening more frequently and potentially affecting more people that underscore shortcomings in the system, critics say.

Laenui of Hale Naau said his organization has encountered numerous incidents at the group homes it operates in which the staff sought immediate treatment for conditional-release clients appearing to relapse. But the case managers overseeing the clients’ care for the state declined to intervene, saying they already had reached the state-imposed 3 1/2 -hour cap allotted monthly for each client, according to Laenui.

As a cost-saving measure, the Health Department switched to the lower case-management cap in January 2009, sparking protests that the restrictions would hurt the mentally ill. Previously, case managers could spend up to 3 1/2 hours a week on each case without getting special authorization.

Because the relapsing patients weren’t treated immediately, some continued to deteriorate and committed crimes, including burglary, assaults and property damage, Laenui said.

One resident sliced another resident’s ear with a knife, while another held a hostage in his room, requiring police to break down the door, Laenui recalled. The hostage-taker was taken to a hospital emergency room, released and arrested later that day for allegedly assaulting a member of the public.

Asked whether crimes are happening because conditional-release clients are not getting services they need, Laenui replied: "Over and over again. There’s no doubt about it."

Added Louis Erteschik, attorney for the Hawaii Disability Rights Center: "With all the cuts in mental health services, they’re releasing these guys without providing appropriate monitoring. It’s a recipe for disaster."

Sheehan acknowledged that some private case managers have declined to respond to treatment calls because of the cap. That shouldn’t be happening, he said, and the agency will increase efforts to notify private providers that the vast majority of requests to exceed the cap have been granted, as long as the service is warranted.

The problem will be resolved definitely when the DOH completes the transfer of all conditional-release cases to its eight community-based mental health centers, where the caps don’t apply, Sheehan added.

About 375 of the roughly 450 conditional-release clients already are under the care of the eight centers. The remaining cases should be transferred by the end of June, he said.

To counter the notion that public safety is being compromised by budget cuts, Sheehan noted that the rates of rehospitalization and "sentinel events" (unexpected occurrences involving death or serious injury) among the conditional-release population have remained fairly steady since 2007. Roughly 13 percent to 15 percent of that group has been readmitted annually, and about 12 percent on average of the sentinel events committed by mental patients under DOH care involved conditional-release clients, according to DOH data.

After each serious incident, the DOH analyzes what happened and whether the system needs adjusting to make it more effective, officials said. "We take community safety seriously," Sheehan said.

People acquitted of felony charges and placed on conditional release receive more supervision by the courts, and any violations (such as failure to follow treatment requirements) or indications of increased levels of instability can trigger closer monitoring, according to the Judiciary.

Conditional-release clients must be seen at least once a month by a probation officer and a minimum of once a month by a mental health specialist. Some will get more intensive supervision depending on their risk assessment or other conditions.

Judiciary budget cuts and furlough days, however, have reduced the hours available to monitor conditional-release clients, spokeswoman Kitagawa wrote. Also, executive branch cuts and furloughs have reduced resources available for clients, "thereby increasing the work that must be performed by probation officers who can no longer rely on those agencies and community resources to treat, help monitor and provide other assistance to those on conditional release," she wrote.

The conditional-release program does not cover criminal defendants whose charges are dismissed because they are found unlikely to ever be fit to stand trial, are involuntarily committed civilly to the hospital and are eventually released.

That type of case also is triggering concerns.

Once criminal charges are dismissed, the civil commitment becomes a confidential family court matter, meaning the public is not privy to details about a patient’s release. What’s more, the discharged patient is under no obligation to get treatment — and, unlike with conditional-release clients, the state has no authority to maintain oversight. These patients are among those with the most pervasive mental illnesses, and they are getting the least amount of oversight — if they get any at all, experts say.

"It’s a glaring omission," said Reneau Kennedy, a psychologist who until several years ago served as the forensic chief for the state’s Adult Mental Health Division.

Joseph Navas, a schizophrenic with a history of substance abuse, was a civil commit case.

After his arrest in October 2006 for allegedly burglarizing a Wahiawa apartment, Navas was found unfit to stand trial and was not expected to ever become fit, and the burglary charge was dismissed. At the time of his arrest, Navas had eight prior admissions to the state hospital. He also had six prior felonies, 25 misdemeanors and five petty misdemeanors, according to court records. The convictions included a drug offense, assault, terroristic threatening and criminal property damage.

Despite such a volatile, unstable history, Navas was not required to continue mental health treatment or be monitored by a probation officer when he was released from the hospital in early 2009.

Fourteen months later, a homeless Navas was arrested for allegedly beating and raping a Mililani restaurant owner. A state judge recently put Navas’ trial on hold after experts found him unfit to proceed on charges related to the rape.

As with aspects of Clayborne Conley’s case, state officials could not comment on Navas’ release from the hospital, citing confidentiality regulations.

For critics of the state’s system, the Conley case has become the latest symbol of what’s wrong. Had the process been working as it should, the many warning signs would have been picked up, Conley would have been readmitted to the hospital, and Cass and her daughter still would be alive, according to their friends.

"This is a tragedy that never should have happened," Linda Tsai said.