Coroner Ian Smith has urged mental health services in Wairarapa to use the experiences of a Masterton woman who lost her son to suicide last year.
The coroner's inquest in Masterton yesterday heard details of events leading to the death of Samuel Patrick Ryan, 16, in June 2011. "Please take up this lady's help - I don't want to find out later it didn't happen. Some of the questions you're asking I deal with all the time," said Mr Smith.
Sam's mum, Toni Ryan, asked why agencies involved with Sam - including police, Child Youth and Family, the Wairarapa District Health Board and Ministry of Justice - were not talking to one another and did not step in to protect Sam. "Everybody knew because I kept saying, 'Please help my baby. I'm terrified he's going to kill himself'."
Mrs Ryan said she was often upset in meetings with agencies leading up to the death because she knew how close he was to suicide. "The privacy and word of a 16-year-old, mentally ill child is more important than his life."
Mrs Ryan said Sam had not reached developmental milestones due to dyspraxia and mild autism, and later had started using drugs and alcohol, leaving school in 2010. "It was hard to keep Sam on the right track."
She said he had made a suicide attempt in November 2010, calling an ambulance himself and refusing to see his family at the hospital. He was discharged from the hospital the next day, without an assessment by Child and Adolescent Mental Health Services (CAMHS), and picked up by a friend, she said.
CAMHS clinical psychologist Wendy Fauft picked up Sam's case in November 2010 and worked with him and his family until January 2011 when his file was closed.
Ms Fauft told the inquest of many conversations with Sam and his family, which included attempts to connect him with Wairarapa Addiction Services and multisystemic therapy, and said Sam had resisted help.
Detective Sergeant Rick Joblin said on the day of Sam's death police had been called to the family's house after a report that he had taken his father's car without permission. When police arrived, Sam had returned and officers said they did not witness any suicidal behaviour.
Sam had previously been charged with theft and was to appear in the Youth Court. Youth aid officer David Drummond said Sam showed no respect for his parents or authority.
Former youth justice co-ordinator for Wairarapa and Tararua Janice Hemi-Williams said that on the day of Sam's death, Mrs Ryan had called her and asked if the social worker could go to the house, and Ms Hemi-Williams advised that she should call the crisis assessment and treatment team.
The coroner reserved his decision.