Counties Manukau DHB is investigating whether it failed in its care of mental health patient Jamie Way, who went missing for three weeks after he was discharged.
Jamie Way, 53, was found by police on May 18 in the Auckland Botanic Gardens in Manurewa, where it was believed he stayed since he went missing on April 26.
Jamie had been experiencing significant mental distress, including having suicidal thoughts, when he asked his sister - Tracey - to admit him to a mental health facility on April 15.
On April 18, Tracey - her brother's only relative in Tāmaki Makaurau - took Jamie to a facility in South Auckland.
She spoke to Jamie a couple of times while he was under supervision and he continued to exhibit signs of mental distress.
She called the facility again on April 28 and discovered he had reportedly been discharged and released on the side of the road in Totara Heights near Manukau two days earlier.
After speaking with the mental health facility staff member who dropped him off, Tracey said Jamie reportedly told the staffer he didn't want to be driven home or to a friend's house to prevent them from learning the addresses.
From then, it was believed Jamie went to the gardens, which were only a short walk from Eugenia Rise where he was left.
His disappearance prompted a call from Counties Manukau police for information on his whereabouts.
After being found, Jamie was taken to Middlemore Hospital and required surgery thanks to an injury he had sustained to his foot during his disappearance.
Tracey earlier told the NZ Herald she would be filing a complaint regarding her brother's care.
The Herald learned last week an "internal review" into Jamie's care had begun, through a statement from Counties Manukau Health mental health and addictions general manager Charles Tutagalevao.
"We are keen to understand this situation better, and we plan to share any learnings and recommendations that come from the review with all the teams involved," he said.
When the Herald asked for more specifics on the investigation, the DHB provided the following statement - this time from a Counties Manukau Health spokesperson.
"We will conduct a team level review, with the charge nurse manager reviewing the systems, processes and care decisions.
"This will involve a review of the clinical notes and interviews with the staff involved.
"Recommendations will then be drafted for consideration by the senior leadership group."
It was understood Jamie was moved across more than one mental health facility between April 18 and 26.
The spokesperson wouldn't confirm what facilities were involved in the review, citing Jamie's privacy.
"We are not allowed to provide this level of specific information about a person's care journey without their consent."
Tracey had been very critical of the facility's decision to release her brother on the street without contacting his family, particularly given his mental state at the time.
"To me, I just think that's appalling," she said.
In a previous statement supplied after Jamie was found, Tutagalevao was "very pleased" to hear Jamie had been found and recognised the stressful situation he and his whānau were in.
"We welcome any feedback from Jamie or his whānau and hope to work in partnership in supporting his wellbeing."
Where to get help: • Lifeline: 0800 543 354 (available 24/7) • Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7) • Youthline: 0800 376 633 or text 234 (available 24/7) • Kidsline: 0800 543 754 (available 24/7) • Whatsup: 0800 942 8787 (12pm to 11pm) • Depression helpline: 0800 111 757 or text 4202 (available 24/7) • Anxiety helpline: 0800 269 4389 (0800 ANXIETY) (available 24/7) • Rainbow Youth: (09) 376 4155 If it is an emergency and you feel like you or someone else is at risk, call 111.