A coroner has criticised the way a mental health patient at risk of self-harm was discharged from Hutt Valley District Health Board services.
Coroner Garry Evans says Megan Jane Oxenham died at home of self-inflicted wounds in May 2010.
Mr Evans says Ms Oxenham had bipolar depression and was admitted to Te Whare Ahuru, the psychiatric unit at Hutt Hospital, where she was subject to a compulsory treatment order.
He says it was open to staff to discharge her - which family wanted - but it was done poorly with inadequate follow-up.
Mr Evans says Ms Oxenham was at risk of further serious self-harming behaviour and should not have been left alone at any time.
He says there should have been a discharge plan, a copy should have been given to the family, and mental health services should have visited daily, not after three days.
The coroner has recommended that this process is followed in future.