A coroner has recommended the Hawke's Bay District Health Board make changes after a depressed man took his own life in 2014.
David Joseph Liamanaia Bentin of Napier died on 11 September 2014.
After an inquest, the Coroner recommends emergency mental staff be required to record discussions with patients relating to identifying support people who can be contacted for further information. Another recommendation is that staff record if a patient declines consent for that contact or any reason for contact not being made.
The coroner also recommended the DHB ensure availability in waiting areas, and provide to Mental Health Service patients and their supporters, copies of the two publications produced by the Ministry of Health, "TIHEI MAURI ORA-supporting whanau through suicidal distress" and "Are you worried someone is thinking of suicide?".
Mr Bentin had just started to get help before he took his life in 2014.
Medical Director Mental Health and Addiction Service Simon Shaw said the district health board received the recommendations from the coroner last month and was working through those recommendations.
"The health board has already implemented a new policy called Mental Health Service Follow-up After Attempted Suicide, following one of the recommendations, and is currently auditing the results from that policy," he said.
"The board will provide a formal report back to the Ministry of Justice in July this year."
Last year Mr Bentin's partner, Hawke's Bay detective Stacey Bailey, told Hawke's Bay Today she had known Mr Bentin suffered from depression during their nine-year relationship, but never knew just how deep it went.
He always seemed to be smiling.
"I knew there was something ... but I never knew how bad it was because he always came out of it."
She said he would get "low", and she would remind him of all the good things in his life - his children, his great job, his good health.
In August 2014 it had taken her a lot of courage for her to reach out and ask workmates for help when she found Mr Bentin was missing and suspected he was going to take his life.
"I was worried but I was also embarrassed that I was over-reacting and it was just a cry for help. But he was serious," she said.
Mr Bentin then admitted he had been struggling with depression for the past 14 years. Ms Bailey said it was hard enough to get him to go to the doctor, let alone take medication.
He suffered in silence for many years, and Ms Bailey said she suspected it was because of the stigma that mental health struggles to shake off.
The couple had two young children and had shared custody of Mr Bentin's older daughter.
WHERE TO GET HELP
• Lifeline - 0800 543 354
• Depression Helpline (24/7) - 0800 111 757
• Healthline - 0800 611 116
• Suicide Crisis Helpline (aimed at those in distress, or those who are concerned about the wellbeing of someone else) - 0508 828 865 (0508 TAUTOKO)
• Youthline - 0800 376 633, free text 234 or email firstname.lastname@example.org
• Mental health crisis services (for emergencies only) 0800 112 334