The parents of a teenage girl who died after overdosing on anxiety medication have criticised the lack of communication by agencies which were looking after her mental health.
Child Youth and Family (CYF) was singled out by Coroner Garry Evans for closing the case on the 17-year-old without ensuring any adequate support services for her.
Upper Hutt's Rachel Mackley died in hospital a week after overdosing on anti-depressant medication in September 2010. Her death followed years of bullying and emotional problems, including an eating disorder and self-harm.
Coroner Evans allowed the details surrounding her death to be made public at an inquest in the Wellington District Court today.
The inquest was told how the Heretaunga College student was twice admitted to hospital after overdosing on her anxiety medicine in the week before her fatal overdose.
However, staff assessed her as low risk, and no management plan was put in place.
Her mother Joanna Mackley told the inquest she was in "disbelief'' when Hutt Valley District Health Board's crisis assessment and treatment team (CATT) discharged her daughter from hospital after the second overdose.
"I thought she needed secure hospitalisation.''
In March 2009 Rachel's school guidance counsellor Nick Dye contacted CYF because he was concerned her mental health was deteriorating.
CYF investigated, but Rachel would not co-operate with them. The case worker closed the investigation in May because she felt there was enough support for the teenager.
CYF supervisor Jan Fisher said as well as being in a school play and having a part-time job, she was also supported by her school counsellors, her teacher, her parents and her homeopath.
"They all seemed very concerned for her wellbeing.''
Coroner Evans said none of those people were appropriate to offer specialised mental health support to Rachel.
"It seems to me that the backing off by CYFs was premature.''
Rachel's parents were divorced and her father Ken Mackley said he had never been contacted by CYF about his daughter - something Ms Fisher agreed was not good enough, and policies had changed around contacting both parents of children they were investigating.
Mrs Mackley said she had received only one phone call from the agency and a meeting was never arranged with them.
Mr Mackley was also concerned that after the first overdose, his daughter was prescribed two months worth of anti-depressant medication by a doctor at a youth service, Vibe.
He thought weekly doses of medication would have been more appropriate than supplying her with hundreds of pills.
Mr Mackley also felt he was not being updated on Rachel's health by any of the specialists who were looking after her in the months before she died.
"I did not get a chance to help my daughter with this.''
The day before Rachel's final overdose Mr Dye found out she was threatening to take another overdose.
Earlier on the day of her fatal overdose he tried to warn health authorities, including the DHB and the eating disorder service which regularly dealt with Rachel, but no urgent action was taken.
Coroner Evans said Mr Dye's calls to the DHB should have been of some concern.
"It might be thought that CATT could have done something further than acting passively,'' he said.
DHB staff were due to give evidence tomorrow.
Where to get help
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (4pm to 6pm weekdays)
• Whatsup: 0800 942 8787 (noon to midnight)
• The Word
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.