Mistakes and mismanagement by the Ministry of Social Development meant it failed to prevent the self-inflicted death of a Porirua teenager in 2005, Wellington coroner Garry Evans says.
Denbora Oum, 14, died even though the Child, Youth and Family Service was aware he posed a high suicide risk, the inquest
into his death found.
CYFS knew he had shown signs of depression from a young age and that he had said he felt sad and worthless some of the time and hopeless most of the time.
It was aware he was being bullied by his mother and a brother; his parents had separated; his father had died when he was young; there had been multiple CYFS placements and exposure to drugs.
Denbora died at a Porirua home CYFS had placed him in. His caregiver found his body.
The boy had been intending to enrol at Mana College the day he died.
The inquest was told gaps in Denbora's file were likely to have hindered understanding of his situation.
Poor staffing at the Porirua CYFS office also meant poor supervision leading up to his death. The ministry was unable to find an up-to-date management plan relating to the case for the coroner to examine.
It and CYFS apologised to the court for mistakes that had been made.
CYFS said it had strengthened the way it responded to reports of concern about a young person or child.
Mr Evans said he was staggered to learn the ministry received 110,000 notifications in 2008-2009, and complimented its senior management in admitting that mistakes had been made in Denbora's care.
The coroner said the ministry had taken significant steps to improve its systems and practices.
That was important given the high levels of child abuse and neglect and the state increasingly being called on to act "in loco parentis".
"These findings show that out of this sad case of Denbora Oum much good has come," Mr Evans said.
Denbora was born in New Zealand, one of five children in a Cambodian family.
- NZPA
