Wellington Coroner Ian Smith says serious miscommunication between the police and mental health workers affected the death of a mentally-ill man who went missing in Wellington.
Finn Higgins, who was 26, was last seen alive on 11 February 2008, and his body was found in the suburb of Mt Victoria almost a month later.
His former partner called police the day he went missing, warning that he was threatening suicide.
Wellington's crisis assessment treatment team asked police to bring Mr Higgins in for assessment, but after more than three hours at home he ran away.
Police told the coroner it was not made clear that urgent assistance was required.
The coroner has recommended that police and the Ministry of Health review an existing agreement between them, focusing particularly on police assistance in transporting patients.