The Bay of Plenty District Health Board has apologised to the family of a young man who died of a suspected suicide four years ago.

A report released by Deputy Health and Disability Commissioner Kevin Allan this week found the DHB breached the Code of Health and Disability Services Consumers' Rights for failing to care for the man.

The man, known in the report as Mr A, first had contact with mental health services while in his late teens.

Two years later, in 2016, he was admitted voluntarily to the mental health ward for two nights after instances of self-harming.

Mr A died of a suspected suicide the following year.

Bay of Plenty District Health Board CEO Pete Chandler says the death of Mr A is a tragic case and the thoughts of the DHB were with his family.

'No family should lose a loved one in this way,” he says.

'I have formally apologised to the family on behalf of the DHB and would like to take this opportunity once more to extend our sincere apologies and deep regret for our failings in this case and the distress it has caused.

'The recommendations made by the commissioner in the report into this case are being implemented. We will continue this work to improve mental health and addiction services for the Bay of Plenty community and to ensure that local services meet national best practice standards,” says Chandler.

Between his admission to the ward and his death the next year Mr A was never seen in person by a DHB psychiatrist.

The report stated the DHB failed by not ensuring Mr A was seen by a consultant psychiatrist, either during his stay in hospital or after when he continued to be unwell.

It also failed in formulating and communicating a written plan with Mr A for his discharge from the community mental health service and to communicate this to his family, GP, and private psychologist.

'This was particularly important because at the time of the transition of care, the man was at risk and vulnerable, and required ongoing support,” the report says.

The report recommended that the DHB and the consultant psychiatrist provide a written apology to the family and that the DHB consider requiring community mental health service clients to be seen by a psychiatrist every three months.

It also suggested that it should no longer allow staff involved in a client's care to be part of the serious incident review team, as happened in this case, and that it review its processes for discharging clients from Community Mental Health Services to ensure a clear plan is established.

A Health and Disability Commission spokesperson said the DHB has been referred to the Director of Proceedings who is considering the referral and will decide whether to file a claim in the Human Rights Review Tribunal.

No decisions have been made yet.