A mother whose son died while he was staying at a Hamilton mental health facility has criticised the care he received there.
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Nicky Stevens was admitted to the Henry Bennett centre in 2015 with acute psychosis after a serious suicide attempt.
His family had made clear he shouldn't be left unsupervised, but three weeks after he was admitted, the 21-year-old went out on a smoke break on his own and never came back.
His mother, Jane, told an inquiry she knew it was serious when she got the call saying he was missing.
"I [was] very, very, very clear that he [was] at huge risk of suicide and they [needed] to act immediately."
She said she told the centre where he was likely to be.
"I urged them to do an urgent search of the gully, and down to the river in front of the hospital as that is where I [knew he would] go."
The nurse who made the call, who has name suppression, told the inquiry he did everything he could. He said at the time he didn't think Nicky was at high risk of committing suicide, but did tell the call-taker his mother said he could be by the river.
But she says her tone was far more critical than this.
"I fail to understand how my desperate pleas could be translated into one line that sounded like Nicky had gone off for a picnic at the river."
The nurse sent a fax of the missing persons report to the police before phoning them, but they never got it.
It wasn't until a different nurse on the night shift got an error report saying the fax was never sent that they realised the police didn't have all the information they needed.
The police didn't start their search until two days after Nicky went missing.
The next morning, his body was found in the Waikato River by a member of the public.
Coroner Wallace Bain will hear more evidence from health professionals on Thursday.
Where to find help and support:
Need to Talk? - Call or text 1737
Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
Samaritans - 0800 726 666
Depression Helpline - 0800 111 757
Suicide Crisis Helpline - 0508 828 865 (0508 TAUTOKO)