Coroner slates system in teen suicide case

Nelson coroner Ian Smith says he is appalled at the state of the mental health system.

He was commenting yesterday after a hearing in Nelson into the death of a 14-year-old boy.

Mr Smith found that Luke Alexander Soutar's death on March 13 was self-inflicted.

Mr Smith told the hearing that if someone was dying of cancer, people would be queuing up on his or her doorstep to help "but with mental health, we seem to have this big, ginormous gap."

In a bleak afternoon at the Nelson courthouse yesterday, he ruled on three deaths involving teenage boys.

Details of self-inflicted deaths are usually suppressed, but Mr Smith, who has regularly voiced concern about New Zealand's high rate of youth suicide, agreed to allow details of Luke's case to be published.

Luke's mother, Susan Soutar, said in a written statement to the hearing that her son had been diagnosed as depressed last year and had been prescribed medication. However, it did not seem to help.

In July last year, he was referred to a child psychiatrist and admitted to the children's ward at Nelson Hospital. He ran away several times.

After Luke was discharged from the hospital, his psychiatrist returned to the United States. This left no fulltime child psychiatrist in the region.

Luke was instead referred to psychiatric nurse Mike Carter of the Child Adolescent Mental Health Service, Mrs Soutar said.

Mr Carter said he was the only mental health service worker dealing with youths under 18 in the Nelson-Marlborough region.

In August last year, Luke tried to injure himself and was taken to intensive care.

Mrs Soutar said Mr Carter tried to have Luke admitted to Christchurch Hospital, which had a secure psychiatric hospital for young people. However, it could accommodate only nine patients and the family were told Luke's condition was not bad enough.

After being discharged from hospital, he was referred to the Children, Young Persons and their Families Service (CYFS), which recommended he have a tracker for his own safety.

"My husband took a week off work to look after him. They had nowhere for Luke to go," Mrs Soutar said.

Luke then began to settle down and CYFS withdrew, she said.

After Luke tried to commit suicide in March this year, Mrs Soutar called the hospital to speak to Mr Carter, but he was unable to be contacted. She was told to call Mr Carter in the morning, and when she did he told her Luke's case had been closed and she would have to go through her GP to get it reopened.

But the family's GP was unavailable that day and by the time an appointment could be made Luke had taken his own life.

Mr Carter said he was not aware that the GP was unable to see Luke immediately and said he would have dealt with the situation directly if he had known.

He said it was "highly unusual" that the hospital had not been able to contact him earlier, as he had a pager, cellphone and answer phone.

Since Luke's death, new systems had been put in place in the hospital's emergency department to ensure patients could be kept there until the appropriate staff were available.

Mr Smith said he would make a recommendation that cases could be reopened automatically without going through a GP. He was horrified by the number of suicides and attempted suicides in the region.

Tasman police district commander Superintendent Grant O'Fee said that since January there had been three road deaths in the Nelson Bays region - and 11 suicides.

- NZPA