Nicky Stevens' father has called for change after another Waikato DHB patient was found dead.
The man's body was found in the Waikato River on Sunday, in similar circumstances to 21-year-old Stevens in 2015.
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Ciriber Wallace Bain ruled in 2018 Stevens' death had been "avoidable" and the DHB should not have allowed him out of the Henry Rongomau Bennett Centre unescorted.
Dave Macpherson told Newshub he doesn't understand how such a death could have happened again.
"We're left wondering, just shaking our heads in disbelief, in horror. What the hell is going on that they haven't learnt from last time?"
Macpherson was previously a member of the DHB himself, but was removed when the board was replaced with a commissioner.
He said there needs to change at the top.
"What's happening now is not working, people in charge now are not working, Government has put a lot of extra money into mental health, they don't yet have a programme of how they want to spend it."
The DHB told Newshub in a statement on Tuesday the death was a "tragedy". It said the patient was out on approved unescorted leave and "at the stage of transitioning to live in the community".
"Once it was clear that he had not returned as arranged, and was not in the immediate environs of the Henry Rongomau Bennett Centre, the police were notified and staff worked closely with the police and family in attempting to locate him," said Vicki Aitken and Dr Rees Tapsell, respectively the executive director and director of clinical services of Waikato DHB's Mental Health & Addictions Service, in a joint statement.
It wouldn't say more about the death due to privacy concerns. The death has been referred to the coroner.
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