Lakes District Health Board is reviewing the mental health care previously received by a Rotorua woman who plunged to her death in a mud pool at the city's Kuirau Park.
Charmaine Erina Butler, 28, climbed two fences around the pool and jumped in about 9.20am on Friday.
She had previously been treatedas an inpatient and in the community by mental health nurses.
Her body was recovered 1 1/2 hours after she went into the pool by Rotorua Fire Service officers who used ropes attached to the hydraulic arm of a truck to lift her out.
Police were alerted after a local businessman saw the woman jump into the pool as he was driving to work.
The man, who did not want to be named, said he was extremely shaken by the incident.
After he saw the woman jump, the businessman called emergency services on his cellphone and tried to lower a blanket to her but it wouldn't reach.
"She went pretty quickly," he said.
Lakes District Health Board communications officer Sue Wilkie confirmed the woman had been cared for by mental health nurses in the community and as an inpatient at Rotorua Hospital's Whare Whakaue unit.
Mrs Wilkie said the woman had been free to leave whenever she pleased, as restrictions only applied to inpatients who required "seclusion".
Staff were distressed by the woman's death and the board had launched a review into her care.
The death comes three months after emergency services stopped a Rotorua man jumping into another boiling hot pool at Kuirau Park.
The 34-year-old was rescued after teetering on the edge of the pool for 1 1/2 hours.
Rotorua District Council says it is doing all it can to stop people throwing themselves into the boiling mud pools.
But despite fences, warning signs, platforms and staff patrols, people still went where they were not supposed to, the council's parks and recreation manager, Garry Page, said.
"We're extremely vigilant about safety in the area but if someone is determined to do things like this, then we can't really stop them."
The 30ha public reserve has more than 12 mud and thermal pools, some of which reach temperatures of more than 100C.
Raising the height of the 1.4m fences had been suggested, but sightseers would then not have a proper view, Mr Page said.
