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A woman's desperate and repeated calls for help for her suicidal boyfriend were ignored for hours by police and psychiatric services because staff were stretched too thin.
No one came to take Finn Higgins into care because of a mix-up between police and Wellington mental health staff, allowing the 26-year-old to flee from his home in February.
His body was found a month later.
An independent review of his situation shows that the mental health crisis team failed Higgins at every turn, says his British-based sister, Zoe Gilbert, who says: "I'm appalled that mental health patients get such a poor deal in New Zealand."
An investigation by the Capital and Coast DHB began in February, followed by an independent report from Waikato-based psychiatric professor Graham Mellsop.
He identifies failings which led to Higgins' death, including:
A mental health nurse forced to "ask police to attend because of her other urgent commitments".
Police being unable to respond urgently because of having to deal with a gang fight.
Police and the DHB thinking the other was collecting Higgins.
Insufficient qualified mental health doctors available to commit people under the Mental Health Act.
Only one qualified doctor being on duty the day Higgins needed help. Mellsop says there should always be two and he recommends that training for mental health doctors should be reviewed.
Higgins was suffering from depression and increased anxiety over the breakdown of his relationship with his partner.
On the morning of February 11, a doctor told Higgins that he needed to be committed to mental health care, but the doctor was not qualified to do this. The doctor left Higgins, saying someone more qualified would return later.
Gilbert says her brother should never have been left alone, as his girlfriend was also mentally unwell.
Higgins ran off and tried to drown himself in Oriental Bay.
Later he returned home, sleepy from sedatives. He slept for three hours, during which time his girlfriend called the DHB crisis team twice to beg for help. No one came.
When Higgins woke, he fled again and was found dead a month later.
Gilbert said that if her brother had received prompt and adequate care he could have been helped.
She does not blame police but holds the DHB crisis team responsible for her brother's death, because mental health services were so stretched.
Mellsop says qualified hospital staff, rather than police officers, should have been sent to help Higgins.
Inspector Kevin Riordan declined to comment on the mix-up between police and the hospital before the coroner rules on the cause of death.
Dr Alison Masters, the DHB clinical director of mental health, says: "We again extend our sincere sympathies to the family of Finn Higgins over their tragic loss."
Gilbert says her brother first came under Community Assessment and Treatment Team care in February, four days before his disappearance on February 11.
She believes her brother was not properly advised of the full effects of the antidepressants he was taking, including citalopram, just days before he disappeared.
He had told his family that the citalopram made him feel worse.
Mellsop's report cites "vigorous debate" between academics as to whether some antidepressants "aggravate tendencies to anxiety or suicide in depressed people".
But a clear link has not been established.
Coroner Ian Smith from Cumbria in northwest England - where Gilbert lives - has spoken of his concerns about people killing themselves after taking antidepressants and he has dealt with many such cases.
Dr David Chaplow, New Zealand's director of mental health, says the Ministry of Health is aware of international concerns over citalopram and some other antidepressants but that a substantial body of evidence shows they can be effective.
He says: "The Ministry of Health would like to reassure those who are taking these drugs that they can be very helpful."
