The 57-year-old man died on August 15, 2014, a short time after leaving the Kerferd Unit in Wangaratta.

He had had schizophrenia since 1986 or earlier and multiple psychiatric ward admissions since 1990, and was an involuntary patient at the clinic.

Police received a report he had tried to light a fire on April 6, 2014, which led to his admission.

He spoke of self harm twice in the months after his admission, and was found at a train station platform on May 5.

IN OTHER NEWS:

He walked out of Kerferd on July 28 and lit a small fire.

The 57-year-old again left the mental health service on the day of his death while under 15 minute observations.

Coroner Caitlin English recently handed down her findings into the incident, with a mandatory inquest required given the late man was in state care when he died.

The Coroners Prevention Unit found there were no opportunities to prevent his death.

A review by the North East Area Mental Health Service found issues with the patient observation system and poor clinical documentation, with plans made to address the issues.

But Ms English found the man's care at the clinic was adequate.

His mental health issues were becoming resistant to treatment, he was angry and frustrated about his detention, and he likely had a brain injury due to his condition.

He had failed to comply with multiple community treatment orders.

Albury Wodonga Health said they had addressed issues raised in the case.