The public health watchdog has faulted Bay of Plenty District Health Board and a psychiatrist over the care given to a mental health patient.
Health and Disability Commissioner Anthony Hill says better coordination and better documentation was needed in a sad case that ended in a suicide in 2010.
A 45-year-old patient had a severe personality disorder and was well known to the DHB's community mental health team.
He attempted suicide in 2010 but had been discharged to live at home with his partner, who became increasingly concerned for her safety and his wellbeing as his health deteriorated.
The woman tried repeatedly to get the DHB's acute psychiatric team to intervene but felt stonewalled. The family doctor also tried.
The commissioner investigated after receiving a complaint from the man's partner.
Mr Hill says inadequate handwritten documentation and a lack of communication by an unnamed psychiatrist breached patient rights and the Bay of Plenty DHB is responsible for failures in coordination between its services.
The DHB is making progress in reviewing policies and procedures, he says.