A New Zealand district health board (DHB) has not adopted a coroner's recommendation to improve its mental health services after a psychiatric patient died in Samoa.
The recommendation was part of findings into the death of Hans Dalton - who was found in a Tafa'igata prison cell on Boxing Day 2012.
Exactly how he got there remains a mystery after a New Zealand inquest was hampered by Samoan authorities - who refused to hand over official information.
Coroner Peter Ryan did, however, recommend the Auckland District Health Board develop a protocol to better inform client's families about the risks involved in overseas travel - advice the DHB has not taken up.
Anneke Smith reports.