A coroner has ruled that a young man under the care of mental health facility the Henry Rongomau Bennett Centre was able to take his own life due to deficiencies in the care he was provided. Nicky Stevens took his own life after leaving the mental health unit at Waikato Hospital unsupervised in 2015, he was 21 years old. His family had expressly told the hospital that he was not be let out alone. Coroner Wallace Bain found the treatment Mr Stevens received from the DHB fell well short of what he and his parents would have expected and as a result he was able to take his own life. He also said Mr Stevens' death made clear the mental health system is in urgent need of being overhauled and significant changes need to be implemented. In a statement this morning the Waikato DHB said it will work through the report's findings and recommendations. It said the wake of Mr Stevens' death it has made changes to its processes around leave and the involvement of whānau in patients' care. Nicky's mother Jane Stevens and his father Dave Macpherson are in our Hamilton studio.