Police and the Capital & Coast District Health Board have been strongly criticised in a coroner's report about the death of a mental health patient.
Andrew Perkins disappeared from Kenepuru hospital in Porirua and his body was found on hospital grounds 19 days later.
The report says that when Mr Perkins went missing, a nurse faxed a missing persons report to the police, who failed to follow up on it for several days.
The coroner has recommended the DHB and police set out clear protocols for dealing with missing patients, deemed at risk.
The Mental Health Foundation says similar scenarios have happened in the past and it hopes an important lesson has been learned.