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The woman harmed another woman in 2015 while being an outpatient of the DHB.
Her mother had repeated contacted the DHB with concerns about her daughter, including her newly acquired hunting knives.
In a report released today, commissioner Kevin Allan said the DHB and the woman's psychiatrist did not provide her with adequate care.
She had been reluctant to engage with clinical mental health staff but was happy to talk with the Māori Mental Health service, the report said
A specialist mental health nurse, Jacqueline Kidd, gave evidence that it may have been better to engage with the patient using te ao Māori.
"It can be complex to work as a nurse across the clinical and Māori worlds but in my view [the DHB] seemed in this case to abandon the Māori world in favour of the clinical one."
The woman's care lacked the most basic factors of Māori communication and care, she said.
The report outlines increasing concerns about the bipolar woman's behaviour in the lead up to the incident.
She had stopped taking her medication, had taken up some extreme diet and exercise and was at risk of neglecting her child who was eventually looked after by her grandmother.
The commissioner said the DHB needed to work more with Māori communities to integrate with cultural and clinical care better.
He was also critical of her psychiatrist.
The DHB had written letters of apology to the woman and her family since the incident.
In a statement today, the DHB said it had sincerely and unreservedly apologised for the distress they experienced.
It had already appointed a new Māori health leadership team which was working to better integrate its Māori health directorate with its mental health service.