A coroner has questioned Waikato DHB over a break down in its follow up care of a mental health patient who ended up being shot dead by police after a confrontation in Thames in 2015.
The inquest for 33-year-old Vaughan Te Moananui ended in Hamilton this afternoon.
It heard that poorly-documented patient notes by his community health worker were lacking detail and did not signal concerns over him possibly starting to drink alcohol while on a extensive regime of medication.
Coroner Michael Robb asked the DHB for evidence that it could not happen again.
Mental Health and Addictions executive director Vicki Aitken said mental health workers and clinicians needed to be clear about the expectations placed on them.
"The assurance is that as a service we are reviewing, auditing and monitoring what is occurring, both in terms of the team meetings but also in terms of the written record."
Coroner Robb told Ms Aitken that he could accept her assurance, but as a Coroner he was looking for something concrete.
"To show me that this is being implemented, that this is happening."
Ms Aitken told the coroner that you would expect to see evidence in files and clinical notes that multi-disciplinary team discussions have occurred.
The inquest was told that in April 2016 a serious event review was carried out following Me Te Moananui's death in May 2015.
Ms Aitken said that five recommendations were made. These include using a circle of care approach, providing advice and support for family/whanau on medication and side-effects, feed back from family included in any recovery planning and getting feed back from family/whanau.
The inquest heard that Mr Te Moananui did not want to be readmitted to the Henry Rongomau Bennett Centre at Waikato Hospital, but his whanau were against him being released home from care.
The Coroner has reserved his decision.