The family of a depressed young father who took his own life are still angry that he was failed by the mental health system.
But Colin Milne, whose son Brad told him days before he died, 'You and mum are not responsible for the way that I am', has welcomed the findings of a frustrated coroner who's called for an urgent overhaul of support systems for people with depression.
Coroner Wallace Bain hit out after looking into the deaths of 30-year-old Brad Milne and 18-year-old Brendan Russell.
The coroner referred his findings to the Law Commission to be examined as part of its review on the media's reporting of suicide.
"Too many cases before coroners courts are demonstrating how suicide victims and their families feel no one is listening and in the end a life is lost when with appropriate help it may have been saved," he said.
Both inquests, held in Tauranga in May, raised harrowing issues of people suffering from depression and suicidal thoughts and having difficulty getting appropriate help.
Coroner Bain, who previously presided over the inquests of five Kawerau youth suicides, heard from distraught families and friends struggling with how to get appropriate help for their troubled loved ones, even if it was available.
After the July 2011 death of married father-of-two Brad Milne, his family lodged a formal complaint with the Health & Disability Commissioner over the lack of care he had received.
They felt he wasn't properly monitored after changing medication and had "no one to turn to", because if help was available, he would have responded positively to it.
"Brad was left to his own devices," Colin Milne said today.
Mr Milne welcomed the findings and hoped an urgent review of the mental health system would save future lives.
"We'll always [be] angry about the lack of support, especially when someone's so obviously in a bad way," he said.
"The Commissioner dismissed most of our complaints. He was mildly critical that counselling wasn't offered at an earlier stage, but that was about all the satisfaction we got out of that."
Since his son's death, Mr Milne has become aware of places which could have helped.
"That's the sad thing. There's a place called the Turning Point Trust in Tauranga, and I'm pretty sure if Brad had been steered there, he would probably still be here now. If families just knew about these places ..."
Hugh Norriss of the Mental Health Foundation supported the recommendations, and while there was a range of "very good" mental health services and information available, he accepted the challenge was in spreading the word.
"It needs to be bigger than a mental health issue - it's what we need to do in the community as well."
The Health & Disability Commissioner was unable to comment today.
Law Commission president, Justice Sir Grant Hammond confirmed receipt of Coroner Bain's findings.
He said they will be taken into account when completing the Commission's final report, due early next year.
Where to get help
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (4pm to 6pm weekdays)
• Whatsup: 0800 942 8787 (1pm to 11pm 7 days, for people aged 5 - 18)
• The Word
• Depression helpline: 0800 111 757 (24-hour service)
• Rainbow Youth: (09) 376 4155
• If it is an emergency and you feel like you or someone else is at risk, call 111.