The Auckland Coroner has criticised leave procedures at the Auckland District Health Board's acute inpatient mental health unit, Te Whetu Tawera, in his report on the death of a former patient.
Shane Fisher, 26, died in May 2006 while on day leave from the unit.
The coroner says procedures for Mr Fisher's leave were unsatisfactory and unsafe.
He says the leave provision form in Mr Fisher's clinical notes was confusing and provided only scant details about his condition on the day he died.
The coroner says important sections of the form including Mr Fisher's risk and safety plan and early warning signs were left blank.
The report recommends the district health board review its leave policy and the leave provision form used by Te Whetu Tawera, and ensure staff implement the new policies.
A board spokesperson says the issues raised have been dealt with.