The recommendation was part of a Coroner's findings into the death of Hans Dalton, a psychiatric patient found dead in a Tafa'igata prison cell on Boxing Day in 2012.
Exactly how he got there is still a mystery after a coronial inquest was hampered by Samoan authorities who refused to hand over official information.
Coroner Peter Ryan did, however, make a recommendation that the DHB develop a protocol for its mental health services to follow when a client is travelling overseas.
