An Auckland teenager suffering from depression was let down by a mental health service that was frequently in crisis, a report says.
Seventeen-year-old Toran Henry, who had attended Takapuna Grammar on Auckland's North Shore, was found dead in the garage of his mother's home on March 20. Aninquest into his death will be held later this year.
A Waitemata District Health Board review into his care, released yesterday, is the second report on his death.
The first, carried out by Ian Barker, QC, found Takapuna Grammar acted in good faith and there was nothing it could have done to avert the tragedy.
The DHB review, which examined whether appropriate care was provided to Toran, raised concerns around the co-ordination of services, documentation of Toran's assessments and the prescribing of an anti-depressant drug.
It concluded that many mental health services in New Zealand were staffed by people who had only ever trained or worked in underfunded services and who had a "culture of coping rather than excellence".
It said that picture didn't entirely fit the Waitemata DHB staff who worked with Toran and were motivated to do their best for their clients, but the system was stressed and that had a direct impact on his the care he received.
The report's authors said their inquiry found a core theme was the loss of trust Toran and his mother had in the service.
The report said there was clear evidence the DHB was under-funded and offered a narrow range of responses which "significantly impacted on Toran's care". Toran was prescribed the anti-depressant fluoxetine and told he didn't need to take it on the days he drank alcohol.
The report said that advice made no "pharmacological sense" and could have reduced the effectiveness of the drug.
Waitemata DHB mental health services general manager Helen Wood said the recommendations within the report were reflective of Waitemata DHB's internal review process and significant steps had already been made.
