Whānau of a man who lay dead in his Kāinga Ora unit for a week were unable to bury him in the Cook Islands because of how long it took to find his body.
Tairo Puangi, 42, died between 24 April and 2 May 2019, at his unit in Auckland's Onehunga.
Due to the length of time before he was found, his cause of death could not be ascertained, Coroner Tania Tetitaha ruled.
Puangi lived alone in the apartment building, which has now been torn down, and dealt with long-term mental health issues, including schizoaffective disorder and addiction.
His sister, Terani Puangi, said her brother was "a big unit" and his mental health issues could make him intimidating or aggressive to those he did not know.
She said he was "never the same" after their dad died when they were teenagers. She said the more recent deaths of their brother and mum made things worse.
Puangi had been arrested in 2018 for assaulting his tenancy manager and witnesses described him as "lonely" and missing his mum, who had lived nearby.
Terani Puangi said he remained close to her and their other sisters, one of which would catch up with him weekly for lunch.
"We talked regularly and he'd always be asking us for money to buy food. He loved his food - he'd been a chef in Rarotonga when he was younger and was a great cook.
"He was a funny guy and I'll always remember him cooking for us every Christmas."
In the days before his death, Puangi visited his doctor for his monthly anti-psychotic injection and no concerns were reported.
In the early hours of 24 April, neighbours heard banging for five to 10 minutes coming from his unit and noticed his bedroom window was broken and there was a bad smell.
A tenant reported the broken window to the tenancy manager as he was worried the windowpane could fall and hurt someone. He was told to contact customer support.
Five days later, customer support emailed the tenancy manager to follow up the tenant's concerns about the window and not seeing Puangi for days.
The tenancy manager tried calling Puangi but there was no answer. He visited the unit and took photos of the glass but did not knock due to Puangi's "risk rating".
The next day emergency powers of entry were granted to the unit so the window could be fixed.
On 2 May, Kāinga Ora staff and a locksmith went into the unit to find it in disarray and Puangi dead.
Terani Puangi said her sister had been calling him and had visited the apartments to see if he was there.
"We ended up getting a call from an officer we knew that we needed to head there and that's when we found out he was dead."
Due to decomposition, Terani Puangi said the family were not able to fly his body to Rarotonga to be buried on family land.
Her brother loved Rarotonga and his heritage, she said, so the decision was upsetting.
"Seven days lying there is too long. It's sad knowing he had to wait to be found."
Kāinga Ora told the Coroner welfare checks on tenants were not conducted until 2021, and they believed the response to concerns about Puangi and his death were "adequate".
Coroner Tetitaha said Puangi was a "vulnerable tenant" due to his mental health background and his absence should have generated more investigation.
"Kāinga Ora classified his mental unwellness as a risk instead of vulnerability - if a welfare check was done on April 24, his death may have been prevented.
"He shouldn't have been excluded from support measures due to his mental unwellness."
Coroner Tetitaha recommended Kāinga Ora reviewed its policies and its definition of vulnerable tenants to include mental health conditions.
"Urgent checks should be done on vulnerable tenants when concerns are raised."
Terani Puangi said she had come to terms with the situation and there was nothing to be done.
"It is what it is, I just hope Kāinga Ora have learnt from this and it doesn't happen again."
Kāinga Ora said it supported the Coroner's recommendations.
John Tubberty, Kāinga Ora's regional director for Auckland Central and East, said changes to the way they worked had been made.
"Further improvements to enhance the way we support at risk or vulnerable customers are being explored."
Tubberty noted as a landlord, there were limitations to the welfare role Kāinga could play as tenants had the right to peaceful enjoyment.
"If they provide us with medical information we record that and any associated vulnerabilities and use that to inform how we respond when concerns are raised."
This story was originally published by Stuff.