Waitematā DHB says there are gaps in patient records in its mental health unit He Puna Wāiora that contravene its own protocols.
Watch Lisa Owen's full Checkpoint report here:
This follows two patients dying of suspected suicide within a week of each other in May.
Checkpoint last week revealed that both patients were on the lowest levels of observation - meaning they were only being checked and engaged with every hour.
That is despite the parents of the second patient who died warning He Puna Wāiora that he was at risk of killing himself and was actively seeking ways to harm himself.
Information obtained using an Official Information Request shows not all scheduled patient observations were being recorded at He Puna Wāiora - contrary to the DHB's own protocol.
Waitematā DHB said it was "not aware of any instances where inpatient observations have not been carried out to an acceptable level".
However, it said there were "occasional exceptions" when observations have not been reordered as "completed". This usually happened when staff were calming and protecting patients and "de-escalating a situation with an aggressive service-user".
In these situations, staff continued to observe patients but this might not be be formally recorded as the priority was maintaining safety and managing the situation, it said.
Waitematā DHB's protocols say records must be maintained without any omissions, and entries should never be recorded retrospectively.
The DHB and Health Minister David Clark declined to be interviewed.
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