A coroner has criticised mental health services in Nelson following the death of a 28-year-old mentally ill man in late 2008.

Coroner Ian Smith said Scott Miles Chapman was found dead by mental health staff who went to the Nelson flat he was renting to give him medication on December 3, 2008. It was clear he had been dead for several days.

Death was found to be due to pneumonia complicated by Mr Chapman's diabetes and there were no suspicious circumstances.

Dr Mary McPherson told last year's inquest Mr Chapman had a nine-year history of mental health problems for undifferentiated schizophrenia and schizoid personality. He historically abused substances and had intermittent periods of aggression.

In his findings released today, Mr Smith said it was his view that Nelson Marlborough District Heath Board mental health services "failed to properly address the effect of Mr Chapman's diabetes condition, given his mental health diagnosis, and should have taken a more robust approach to ensure he received adequate care".

He thought that mental health services had failed in their duty of ensuring Mr Chapman was living in an environment where he was suitably provided for.

"He was put into accommodation that was effectively a bare shell, with the mental health services knowing this as they regularly visited to administer medication. They also knew of his poor diabetic control and that he had no family to assist," Mr Smith said.

The mental health services had to some extent "washed their hands of Mr Chapman", he added.

Mr Smith recommended that the Nelson Marlborough District Health Services should review their protocol for providing adequate medical treatment for patients under the Mental Health Act.

They should also review their protocol to ensure that a patient who was discharged should be placed in the community with adequate health care facilities.

He also recommended the Minister of Health should review the criteria under which mental health patients should receive adequate medical care for any life-threatening health situations where their ability to choose medical help may be limited by a mental health disorder.

"The pendulum needs to swing back to a degree of paternalistic guidance," he said.