The Waitematā District Health Board has been criticised for how it cared for a man who was discharged from its community mental health service and later died.
Mental Health Commissioner Kevin Allan said the man in his 50s had a history of a major depressive episode with psychotic symptoms, post-traumatic stress disorder, and chronic obstructive pulmonary disease.
He was receiving support from two organisations to help him live in the community.
When the man was discharged, the DHB failed to appoint a lead organisation to oversee his ongoing care and the man's family wasn't involved in the decision, Mr Allan said.
Incorrect assumptions were made at a multidisciplinary review meeting about the level of support available to the man from his GP and family, and concerns about the man's reluctance to get support were not acted on, Mr Allan said.
Sometime later, the man's sister took him to see his doctor. He was very short of breath and had lost a significant amount of weight.
He was treated in hospital, but died from pneumonia.
He was also malnourished and suffering from depression.
The DHB said it has apologised for shortcomings in communications about post-discharge arrangements in this case.
It said it should have involved the family in the planning of the patient's care.
The DHB said it has reviewed and improved its discharge processes.