Mental health staff did not report that the primary caregiver of a man who later attacked his ex-wife with a sword had gone overseas, an inquiry has found.
Manjit Singh was on leave from Auckland's Mason Clinic last year when he attacked Leonie Singh in her home in Hamilton.
He pleaded guilty to wounding with intent to injure, and was sentenced to seven years in prison, some of which would be spent in a mental health facility.
An external inquiry ruled staff were not to blame for the attack, but had failed to report when Singh's community carer left suddenly for two months.
It said an assessment of Singh's leave conditions should have been made as soon as it was clear the carer was gone.
Director of Mental Health John Crawshaw said the ministry must support staff to recall patients for short periods if necessary, and to ensure they were stable and taking their medication.