Staff at Christchurch's Hillmorton Hospital failed an 18-year-old in the lead-up to his death, a report says.
The findings by Coroner Sue Johnson have been released after they were suppressed for four years.
Harry McLean was diagnosed as suffering from depression and a Narcissistic Personality Disorder and was found to have died from self-inflicted injuries while he was a patient at Hillmorton Hospital, which is run by the Canterbury District Health Board (CDHB).
McLean was rushed to Christchurch Hospital after an incident at Hillmorton on November 21, 2013. He died three days later.
READ MORE: Grieving mum muzzled by ruling
Coroner Johnson was satisfied his death was self inflicted, but not suicide.
The Coroner said she could not be satisfied Harry McLean had sufficient judgment to form an intent to end his life, after he consumed a combination of Lorazepam and alcohol.
McLean's mother, Maria Dillon, is angry she was denied the chance to talk publicly until Friday about what happened to her son because of stringent suppression orders around the case.
"I feel an overwhelming sense of relief, that the Coroner's report into my son's death has finally been released. It has been incredibly challenging, navigating the legal system and suppression, in the aftermath of Harry's death by suicide."
She added: "The Coroner's report contains no surprises for me. My initial gut instinct that something had gone horribly wrong with Harry's care and treatment has been echoed in the CDHB's serious incident report and the Coroner's report into his death.
"I strongly believe that public accountability is vital, in the area of Mental Health Care in New Zealand. My son's death is not isolated to one DHB and the two doctor's overseeing his care: his death has been repeated up and down New Zealand. We simply must do better."
The former Papanui High School student, who was a promising competitive dancer, tried to take his own life twice before being admitted to Hillmorton on November 2, 2013.
He was placed on what the CDHB described as level 3 observations – where the patient must be checked at least every 15 minutes.
By November 8, McLean was moved up to level 1 observations after another suicide attempt inside Hillmorton.
Ten days later he was reported to be feeling better and moved back into an open ward. However, by November 21, Harry had taken a turn for the worse. Records show the 18-year old was thinking of suicide and had formulated a plan the previous night to end his life.
A serious incident review by the CDHB found that a meeting between McLean and his consultant on November 21 was not documented in a detailed way. The note was not written by his consultant, but by a trainee intern.
McLean's consultant said he presented with a chronic risk of suicide, but that in the days leading up to his death his mood noticeably improved and he did not consider his patient's plan to [suicide] was current.
"Has some trouble late at night ... mood is good till this time ... still thinking of suicide at night."
The consultant stated the focus had to be "immediate intent" and that, based on his assessments at that time, McLean did not appear to be an immediate risk.
Johnson observed there was "nothing in the notes which showed any attempt to reduce risk of Harry becoming suicidal again that evening".
"There is no evidence Harry's consultant discussed with Harry himself and, with the nurse present at the consultation, ways for Harry to be kept safe if his mood dipped again that evening and he felt suicidal."
McLean was found to have consumed alcohol that day. He had a blood reading of 69 milligrams per 100 millilitres - more than twice the legal driving limit.
He was administered 1mg of Lorazepam at 9pm.
When the 18-year old was found, "standard ward observations" were carried out by a nurse aide.
"Had Harry's observation levels been increased, then an enrolled nurse or his registered nurse would have been carrying out observations," the Coroner said.
Observation policies at CDHB have since changed.
CDHB chief medical officer Dr Sue Nightingale said: "We accept and acknowledge the Coroner's findings and, again, would like to apologise to Mr McLean's family for their loss. We would also like to reassure that we are always working hard to improve the care we provide to reduce the chances of a tragedy like this occurring again."
Coroner Johnson concluded "the fact remains that there is no evidence of a plan in case Harry felt suicidal again that evening".
WHERE TO GET HELP:
Lifeline (open 24/7) - 0800 543 354
Depression Helpline (open 24/7) - 0800 111 757
Healthline (open 24/7) - 0800 611 116
Samaritans (open 24/7) - 0800 726 666
Suicide Crisis Helpline (open 24/7) - 0508 828 865 (0508 TAUTOKO). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
0800 WHATSUP children's helpline - phone 0800 9428 787 between 1pm and 10pm on weekdays and from 3pm to 10pm on weekends. Online chat is available from 7pm to 10pm every day.
Kidsline (open 24/7) - 0800 543 754. This service is for children aged 5 to 18. Those who ring between 4pm and 9pm on weekdays will speak to a Kidsline buddy. These are specially trained teenage telephone counsellors.
Your local Rural Support Trust - 0800 787 254 (0800 RURAL HELP)
Alcohol Drug Help (open 24/7) - 0800 787 797. You can also text 8691 for free.
For further information, contact the Mental Health Foundation's free Resource and Information Service (09 623 4812).
- The Press