An acute youth mental health facility in Wellington lost track of young people in their care 35 times.
Figures provided to Newshub under the Official Information Act show in the year to April, patients went missing 35 times from Wellington's Adolescent Inpatient Service - 26 of those incidents resulted in missing people reports to police.
The data shows the 35 missing people of concern incidents related to 21 people, meaning some of those people were missing more than once.
During the same time period, there were five suicide attempts and 27 self-harm incidents.
In a statement, the District Health Board said the increase in incidents was down to a temporary move after a fire damaged their unit - the service has now moved back.
"A 'missing person of concern' relates to a situation where a person leaves the unit without informing staff of where they are going," Nigel Fairley, Mental Health, Addictions and Intellectual Disability Service general manager told Newshub.
"This includes youth who are informal clients, who can leave anytime, but do so without telling staff where they are going. The terminology is used broadly for reporting purposes.
"An increase is attributed to the temporary relocation of the service to an open ward in Wellington.
"The service was relocated after a fire damaged our adult acute inpatient ward, which meant that RRAIS clients were located in a new environment and were less settled. The service returned to its original location in September."
The Prime Minister has admitted some acute care facilities might actually be causing more harm to mental health patients - and she's hoping a new suicide prevention office will hold them to account.
A shoulder injury in 2017 was the beginning of a tough time for former All Black Nehe Milner Skudder - the on-going struggle meant he missed out on this year's World Cup.
'Over the years I've built up a tool kit of strategies and resources - I still found myself going back to some dark places," he said.
He found his way out of those dark places and on Wednesday helped the Government launch its National Suicide Prevention office
This particular milestone is somewhat bittersweet. It is bitter because New Zealand's high rate of suicide is shameful," said Jacinda Ardern.
The Government acknowledges there's no easy fix - and even acute services - which deal with our most at-risk patients aren't coping.
"Over a number of years, there have been reports that a number of our acute services are actually contributing to harm," said Ardern.
Earlier this year Newshub spoke to a teenager who lives with bipolar - she spoke of seeing others self-harming while at Wellington's Adolescent Inpatient Service
"Every day you would walk in there would be blood in the sink," she told NewsHub at the time.
Where to find help and support:
- Need to Talk? - Call or text 1737
- Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
- Youthline - 0800 376 633, text 234, email firstname.lastname@example.org or online chat
- Samaritans - 0800 726 666
- Depression Helpline - 0800 111 757
- Suicide Crisis Helpline - 0508 828 865 (0508 TAUTOKO)