The parents of a man believed to have killed himself in a mental health unit say policies putting disabled people in such places - where they do not belong - are violating their human rights.
Tamaki Heke, 24, was one of two patients at the unit who died by suspected suicide within a week of each other last month.
Mr Heke, who had foetal alcohol spectrum disorder - a neurodisability caused by drinking during pregnancy - had been at Waitematā DHB's He Puna Waiora Unit for about three years.
Despite that he was a talented pianist, and his foster parents - Peter and Rita Willcox, a registered nurse - told Checkpoint a mental health unit was the wrong place for their son, whose condition meant he functioned at about the level of a 10-year-old.
They said they struggled to get the right help for him.
"His IQ was low, but not low enough to get help from the disability services. You've got this person who can only reason like a nine- to 10-year-old and he's in an adult environment and he just can't cope.
Mr Willcox said in his early teenage years Mr Heke had been eligible for financial support for his condition, but after his 17th birthday he qualified for nothing.
"There was expectations of the system that you could just chuck him out into the world with no support," he said.
"In reality if you are a nine- to 10-year-old, let's face it, it's illegal for a parent to leave their child at home under the age of 14, without supervision, and yet here was the government expecting a nine- or 10-year-old to go out there and be completely independent."
The couple had a meeting with an official in community mental health over Mr Heke's need for support, but were told there was nothing that could be done.
"I said to him 'so, do I give him a sleeping bag and let him go under the bridge?' He said 'well, if that's what you have to do, that's what you have to do'," Mrs Willcox said.
Mrs Willcox said they had become suspicious that Mr Heke was suicidal because of a prior conversation about a song he said he wanted to be remembered by.
Days before, they had also become aware of a social media post he made after a friend at the unit had taken his own life. Mr Heke had a history of copycat actions and they feared he would do the same.
They said they had warned He Puna Waiora that their son was in danger of taking his own life, but Mrs Willcox said it took several attempts to be put through to the unit. When told of her concerns, she said she was assured Mr Heke would be talked to and then observed.
She said if he had been under proper clinical supervision, authorities would have been alert to the danger too.
"You'll see, when the [coroner's] investigation comes out, he committed suicide in an identical manner, word-for-word identical."
They said Mr Heke should have been put in a secure unit after they raised concerns.
Mr Willcox said they didn't blame He Puna Waiora because its "hands were tied by Wellington politics" and the organisation took him in as a last resort because there was nowhere else for him to go.
Mental Health Services clinical director Susanna Galea-Singer said that because there was not a national pathway for Foetal Alcohol Spectrum Disorder, people with the condition often found themselves in units not specifically designed for their needs.
Dr Galea-Singer said the Willcox family did contact the unit on the night Tamaki died and expressed concerns about him being at risk of suicide and at the time, the unit was fully staffed.
She said staff at He Puna Waiora attended to Tamaki Heke's needs for an extended period, and in the most challenging of situations.
Waitematā DHB had worked with his family and arranged for him to be transferred to a community facility run by an NGO. It paid for this, even though it didn't receive specific funding for it, Dr Galea-Singer.
She said this option ultimately proved unsuccessful and he returned to He Puna Waiora.
Waitematā DHB has announced an independent external review that will look at how Mr Heke's parents' concerns were responded to.