A coroner is encouraging mental health services to take stronger steps to ensure patients are seen by professionals after a man killed himself after he turned up late for an appointment and was unable to see his doctor.
Wellington regional coroner Ian Smith says while mental health services at Capital and Coast District Health Board had not failed 20-year-old Scott Pollock, district health boards needed to do more when patients fail to keep appointments or turn up late.
"I believe it requires a far more robust process to either ask the patient to wait until he or she has been able to be seen, or in any event, if the patient fails to turn up then contact must be immediately arranged.
"It is all too often that it is these failures to keep the appointments of mental health patients that have tragic outcomes," he said in his findings last month.
Mr Pollock had turned up 20 minutes late for an appointment and was unable to be seen by the psychiatrist who had left for lunch and the nurse who was on leave. He declined the chance to make another appointment.
Mr Pollock, who had been discharged from the army after his personality disorder was diagnosed in 2008.
He had a history of self-harm and was found dead in Paraparaumu on August 30 in 2010.