In a report released today, Dunedin coroner David Robinson also found there were no suspicious circumstances surrounding Stephen Uriah Maddren's death nor any ''want of care''.
Mr Maddren was found dead aged 28 in a toilet cubicle on the ninth floor of Dunedin Hospital on May 21 last year.
His death came four days after his release from prison, where he had served a sentence of three years on charges of burglary, receiving, theft and escaping lawful custody.
In 2014, he became the first prisoner to escape the Otago Corrections Facility at Milburn, when he climbed down a drain-pipe and leapt from a three-story building.
He spent eight days on the run, subject to a massive police manhunt, before being discovered in a hot water cupboard at a Milton shearers' quarters.
In 2008 he stood on the roof of the former Dunedin Chief Post Office threatening to shoot himself with a flare gun.
The coroner found Mr Maddren had a history of psychotic episodes, while his father had also committed suicide.
There were also indications he had suffered childhood sexual abuse, as well as sexual abuse at the hands of a fellow prisoner.
After his release from prison, he was taken to his mother's house, but because of her deteriorating mental state Mr Maddren felt he could not stay with her, the coroner's inquiry found.
Two associates of his, Jennifer and Mike Dunn, invited him to stay with them.
In a subsequent meeting with Probation, Mr Maddren acknowledged previous psychiatric issues but said he was ''good,'' denying thoughts of self-harm or suicide.
On the morning of the day of his death, he went to church with Mr and Mrs Dunn.
The coroner found he left church on his own, and the couple said later they thought ''maybe he just needed some space''.
Little was known of what he did between leaving church that morning and his death, aside from the fact he wrote a ''farewell and explanation'' letter and posted it to Mr and Mrs Dunn.
The report said they received the letter a few days after his death, which spoke of him "crushing under a weight of my regrets and failures and now is too heavy with the fear of failing again being added.”
It went on to say he had not previously felt strong enough to take his own life.
The couple later told police they regretted not realising the extent of his distress, and lamented having not been able to do more to help him.
His body was found shortly before midnight.
The Otago Daily Times is prohibited from publishing the manner of his death.
A brief note was scrawled on the on the wall of the toilet cubicle, along with another handwritten note in his possessions, while a bottle of brandy was found nearby.
Mr Robinson found he had a blood alcohol level indicating ''mild to moderate'' intoxication.
He found multiple clinicians had assessed Mr Maddren at a low risk of self-harm in the year leading up to his death.
"In such circumstances, particularly in the absence of recent expressed suicidal ideation or suicide attempts, there was no indication to those around him, or with responsibility for his wellbeing, to indicate that there was a risk of self-harm,'' he wrote.
As a result, Mr Robinson did not find any want of care nor that an opportunity to intervene had been missed.
His report concluded the manner of death was suicide and made no recommendations.
Need help?
Healthline: 0800 611 116
Lifeline Aotearoa: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO)
Samaritans: 0800 726 666
Alcohol Drug Helpline: 0800 787 797
General mental health inquiries: 0800 443 366
The Depression Helpline: 0800 111 757
Homecare Medical: 24-hour 1737 free text/phone
Youthline: 0800 376 633, txt 234 or talk@youthline.co.nz
What's Up (for 5-18 year olds; 1pm-11pm): 0800 942 8787
Kidsline (aimed at children up to age 14; 4pm-6pm weekdays): 0800 54 37 54 (0800 kidsline)
