The Wellington coroner has taken aim at the region's mental health services after one of its patients committed suicide.
In a decision released today, Coroner Ian Smith found former Victoria University lecturer Fujio Kano, 66, took his own life on November 30, 2011.
Kano's body was found on the Wellington Motorway near the Tinakori off-ramp. Nearby were some of his possessions, including a ripped up medical appointment sheet.
At the time of his death, Kano was living at the Te Whare Ahuru psychiatric unit in Lower Hutt, but was on leave with his family for the weekend.
Leading up to his death he had been transferred multiple times between different mental facilities. His family said he had become distressed by the moves and concerned he would never get out.
His family also criticised the Hutt Valley and Capital and Coast DHBs over transfers, poor communication and shabby conditions in mental health wards.
Coroner Smith also questioned the decision to transfer Kano to Lower Hutt, when he clearly had not wanted to move.
The myriad of mental health units in the region were "difficult to understand" and he questioned whether there was unnecessary duplication.
The CCDHB responded that any decision to transfer a patient considered their wishes and their family's, along with the availability of treatment and care.
The Hutt Valley DHB said it had upgraded the Te Whare Ahuru unit since Kano was a resident there.
- The Dominion Post
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