Mistakes were made in the care of a woman who committed suicide after running away from Waikato Hospital's mental health centre, a clinician says.
Claire Watson left the psychiatric unit of the Henry Rongomau Bennett Centre in November 2011.
The doctor caring for the 30-year-old had downgraded her risk and she was being checked on at 10-minute intervals rather than being continuously observed.
A coroner's report has revealed the Health and Disability Commissioner had earlier found nurses wanted her to be observed more often but were too afraid to speak up.
Waikato District Health Board (DHB) director of clinical services Rees Tapsell told Checkpoint there were mix-ups within the team caring for her, over assessing the level of risk and the level of observation required.
"There were problems in terms of assigning her the appropriate level of observation - because, of course, observational and relational security for all patients is paramount."
The DHB was desperately sorry for Ms Watson's family and such a thing should not occur again, he said.
In July, the government announced a review of the Waikato DHB's mental health services following several high-profile escapes.