A coroner says mental health services failed to warn the Civil Aviation Authority that a man who went on to kill himself by flying his plane into the sea was unfit to fly.
Daroish Kraidy, 53, took off from Ardmore Airport in Auckland in his bi-plane in March this year.
There was an extensive search, but the aircraft was not found until it was accidentally snared by a trawler net in August.
Chief Coroner Neil McLean today released his findings, saying there was overwhelming evidence that Mr Kraidy never intended to return - and with a background of previous threats and attempts to suicide, he either deliberately crashed his plane or ran out of fuel.
Judge McLean said the Auckland District Health Board's mental health services overlooked their legal obligation to notify the CAA of pilots unfit to fly, and has reminded all boards about the law.