Kaitaia coroner Robin Fountain was especially concerned about the circumstances of the death by suicide of a 32-year-old Kaitaia woman.
The woman's death was one of nine suicides he inquired into this week.
She had been discharged from Whangarei Hospital's mental health unit although her mother and sister questioned the
release and told Northland Health staff they believed the discharge was premature.
When the woman returned to Kaitaia, her sister feared she was suicidal and raised her concern with a mental health worker in the town.
She had urged that her sister be visited, saying: "I think tomorrow will be too late."
It was.
The woman was found the next day, not having been visited.
Mr Fountain is recommending Northland Health review the way the case was handled and look at what resources are available in the Kaitaia area for mental health.
He is also calling for the review to include a face-to-face meeting with the woman's family, and for a written report of the review results to be given to the family.
The Northland District Health Board had not seen the coroner's report yesterday on the case and would not comment.
But its general manager of mental health, Sue Wyeth, says the board is aware of a significant number of suicides in the Kaitaia Hospital district - that is, the area north of the Mangamuka Ranges.
Most at risk are 25 to 44-year-olds, with a particularly high number of male Maori.
Sue Wyeth says the board is involved in looking at ways of managing the issue.
