This year the Herald’s award-winning newsroom produced a range of first-class journalism, including investigating the state of our mental health in the Great Minds series, how NZ can rebuild stronger post-Covid with The New New Zealand and how to minimise the impact of living in an Inflation Nation.
We also tackled our literacy crisis in our Reading Block series, while dogged investigative reporting by Kate McNamara resulted in an investigation into the awarding of contracts to businesses associated with family members of Cabinet minister Nanaia Mahuta.
The following article was one of the best-read Premium articles in 2022. The story originally ran in October.
Warning: This article discusses suspected suicide and mental health problems and could be distressing for some people. If you need help, contact Lifeline on 0800 543 354 or text 4357 (HELP)
She was a teenager who seemed to have everything going for her. But for two years she endured a devastating spiral into mental illness. Why couldn't she be saved?
Caroline Fausett was making dinner one night when she saw her daughter take off again.
It was just before 7pm on a Friday in May 2019. At their family's home on a quiet, semi-rural street in South Auckland, 17-year-old Cassandra had become agitated after a conversation with her father, Steve, and stormed out through a side door. Caroline called out to her daughter to come back, but she didn't stop.
Caroline felt a knot in her stomach. It was happening again.
"Please be safe," Caroline texted her daughter. "Love you. Ring me when you've had some space and I'll come get you."
Cassandra — 1.6 metres tall, thin, blonde hair pulled back in a ponytail, usually dressed in sporty clothes — might have struck anyone who didn't know her well as a teenager with everything going for her. Vivacious and smart, academically driven, a talented athlete. Her parents were adoring and attentive. Teachers and coaches talked about her with pride.
In the past two years, however, Cassandra had endured a catastrophic spiral into mental illness. A parade of psychiatrists had given her a long list of diagnoses that included anxiety, obsessive-compulsive disorder (OCD), depression, anorexia, and borderline personality disorder. She had been prescribed so many medications her parents could hardly recall them all; she had spent dozens of hours in therapy. And she kept getting worse.
Cassandra was one of a growing number of young people whose lives have been disrupted by mental health difficulties at a crucial stage in their development. Rates of mental health problems such as depression, anxiety, and self-harm among children and adolescents rose significantly in the decade before Covid-19, and the pandemic has amplified the trend, aggravating problems for those who were already vulnerable and triggering new episodes of mental illness and distress for many who have never experienced them before.
It is a phenomenon that is happening across high-income countries, for reasons that are complicated and not yet well understood, and experts say it will have profound social and economic consequences. It is overwhelming public services – schools, GPs, police, emergency departments, mental health providers – and causing immense suffering for thousands of Kiwi families.
Cassandra's illness had taken over her life. It had disrupted her schooling and robbed her of hope for the future. A lot of the time she felt despondent and worthless. Then, suddenly, she would be seized by overpowering urges to hurt herself. She had tried to kill herself several times.
The family's existence had become a series of chaotic, terrifying episodes involving 111 calls, police, mental health crisis teams, emergency departments, and psychiatric units, that always seemed to end in the same disheartening way — with Cassandra being sent home with her parents, even though they believed they couldn't protect her. Caroline, a school librarian, and Steve, a landscape architect, both in their 50s at the time, were constantly on edge, fearful that it was a matter of time before Cassandra took her own life. Their relationship was straining under the tension. Their relationship with the mental health services that cared for Cassandra had also become fraught.
How many times had they protested to Cassandra's clinicians that they couldn't keep her safe? Earlier on that Friday in May, Steve had called the service to say Cassandra wanted to be admitted to the psychiatric ward at Starship Children's Hospital because she was feeling a danger to herself. The clinician had done what they usually seemed to do —listened and "validated" Steve's concerns — but she told him inpatient care wasn't suitable for Cassandra. "This is ridiculous!" Steve vented, according to the clinician's note, and when he told Cassandra that hospital wasn't an option, Cassandra was so upset that she took off.
Now it had been an hour and Cassandra hadn't returned to the house.
Caroline texted her again. And then again.
Finally, her phone pinged with a reply.
"Your (sic) gonna be waiting forever," Cassandra wrote. "I'm killing myself once and for all. I ask for help I get none."
"But we can do better and get past this," Caroline responded.
"I can't be bothered trying," Cassandra shot back. "It's not worth it anymore."
"That's why we're going to go somewhere different."
"I don't care. I hate my life. And I can't be bothered changing. Nothing works."
"These things take a while and we just need new people helping which we are getting this week."
"I don't care. I just want to die."
The parents searched their neighbourhood for Cassandra. Police traced Cassandra's mobile phone to a location near the Botanic Gardens, next to the Southern Motorway. When they found Cassandra, she refused to come with them, so a big male officer picked her up, forced her into a car, and they drove her to the paediatric ED at Middlemore Hospital.
The next morning, a psychiatrist came to assess Cassandra and recommended that she be admitted to the Child & Family Unit (CFU) at Starship Children's Hospital, a psychiatric facility for children with severe acute mental illness. It was Cassandra's fourth admission to the unit in seven months.
Cassandra was a "joyful, bubbly, happy girl" when she was younger, says Caroline. She was intelligent, particularly with numbers. Precocious. Sporty. Whatever Cassandra tried — swimming, tumbling, cheerleading, running, surf lifesaving — she seemed to be good at it. Some of her most memorable moments occurred on a football pitch: She could dribble, pass, and shoot, but was also, for a girl of slender physique, unafraid to get stuck into hard tackles. When she scored a goal, she celebrated by doing somersaults.
"She was cocky and moved with a swagger, and we all loved her for it," one of her coaches says.
Early on, however, Caroline had an inkling that her daughter would be complicated.
From the time she started kindergarten, Cassandra couldn't stand to be separated from Caroline. She refused to stay at other people's houses without her mother, even that of her grandparents. Cassandra clung so closely to Caroline that psychologists would later describe their relationship as "enmeshed", meaning that it blurred conventional parent-child boundaries.
Cassandra also displayed some compulsive traits, insisting when she played that her dolls and toys be perfectly ordered. There were times that Caroline wondered if Cassandra was on the autism spectrum. (Several of the clinicians who later assessed Cassandra also shared this suspicion, but Cassandra was never formally assessed.) As Cassandra grew older, Caroline discovered there was a darker side to Cassandra's obsessive quirks: Cassandra believed that if she didn't do certain things, her mother would die.
At 10, Cassandra had her first encounter with mental health services. She wrote in a book that her biggest worries included kidnappers, murders, and being in a car crash; Caroline showed it to a resource teacher at school and Cassandra was referred to Whirinaki, the child and adolescent mental health service in Counties Manukau. (The service later changed its name and is now part of Te Whatu Ora, the new national health authority.) Two years later, Cassandra was sent back to Whirinaki after an episode of self-harm.
Despite these problems, Cassandra seemed in many ways to be flourishing by the time she reached her teenage years.
At secondary school, she was near the top of her class in in several subjects and won numerous awards for academic performance and outstanding effort. She played several sports at a high level; she had multiple part-time jobs; she had a busy social life. Her collection of pets included a Bichon Maltese dog named Casey that she adored so much it had its own wardrobe and Instagram account.
Cassandra's journals — which her mother shared, along with a large volume of other documents relating to Cassandra's life and treatment — record the sort of things you'd expect of an adolescent girl who was deeply loved and loved life: She wrote about friendships, boys, teachers, homework assignments, getting her braces removed. "Woohoo!" she said one day after Caroline surprised her with tickets to an Ed Sheeran concert.
But there was also evidence of a mind that was becoming more and more troubled.
In late 2017, Cassandra was referred to Whirinaki again. By this time, her compulsive traits had developed into OCD that was severely disrupting her life. She couldn't go to bed without speaking on the phone to her grandmother and worried that if she didn't say "Love you, bye," twice before she hung up, something terrible would happen to her grandmother. Cassandra was agitated by odd numbers and by power sockets that had been left on. She found it distressing hearing other people's bodily noises — coughs, sneezes, eating sounds. It got to the point that the family stopped having dinner together because Cassandra found the noises unbearable.
Cassandra was also brutally hard on herself. She berated herself for perceived mistakes and dwelt on them for days. She stayed up late at night working on school assignments, doing far more work than was expected. She formed intense attachments to people and felt crushed when they disappointed her.
As Cassandra's Year 11 exams approached, she was suffering panic attacks, having trouble sleeping, and crying most days. She also began thinking often about suicide.
"Got really sad and depressed and had another meltdown," she wrote in her journal one day.
"Cried myself to sleep," she recorded on another.
"Cried in the car on the way home. Didn't want to go to school."
"Hate my life, would rather die."
"I am getting sicker and sicker."
In November 2017, the family went on a short break to Melbourne to celebrate Cassandra finishing her NCEA level one exams. They rented an apartment downtown and planned four days of shopping and sightseeing.
But Cassandra seemed more anxious than usual. At the apartment complex one night, she stayed in the gym working out until after 11pm. Cassandra was always sporty and fit, but this was on another level. She had started obsessing about her body weight, counting how many calories she was burning.
"Something switched," Caroline says.
When they returned to New Zealand, the family spent part of the summer at their holiday home in Pauanui, where Cassandra swam, sunbathed, played tennis, hung out with friends, and walked her dog on the beach. But Cassandra was skipping meals and exercising for hours every day.
In a meeting at Whirinaki in January 2018, Cassandra's psychiatrist diagnosed her with anorexia. Blood tests revealed that Cassandra's sudden weight loss was having a dangerous impact on her body, so she was admitted that day to a ward at Starship for adolescents with eating disorders. Cassandra spent two weeks on the ward, being fed through a nasogastric tube until she started eating meals regularly again.
"I've never been so miserable in my life," Cassandra texted her psychologist from Starship one day.
Anorexia complicated Cassandra's treatment. Until then, Caroline says, the family was satisfied with Cassandra's care at Whirinaki; Cassandra liked her psychiatrist and formed an extremely close bond with the psychologist she saw for talk therapy every week. But after Cassandra was diagnosed with anorexia, her clinicians wanted to prioritise treating the eating disorder, so they suspended the sessions she'd been having with her psychologist and started a new form of therapy with a new clinician taking the lead. Cassandra didn't like the new therapist and was devastated at the prospect of losing her psychologist; she took it as a betrayal. Caroline made a formal complaint to the service, which she didn't believe was taken seriously, and they asked to be transferred to another provider.
Te Whatu Ora, approached by the Herald for comment, declined to talk about specific details of Cassandra's care, citing complex privacy protections, but said an external review has recently been completed that made several recommendations, some of which have already been implemented. It plans to meet the parents soon to discuss the review's findings.
In August 2018, Cassandra was sent back to Whirinaki. By this time, her weight and eating had returned to normal, but her other mental health problems remained serious. Her previous psychiatrist and psychologist had left, so a new team of clinicians was assigned to treat her. Cassandra bristled at being asked to open herself to yet another group of professionals. "I don't know you," Cassandra said dismissively to one of new clinicians when she was introduced. She insisted she didn't want Whirinaki's help and asked to be discharged.
Then the suicide attempts started.
Over the next year, the family's daily existence became a terrifying cycle in which Cassandra would be triggered by something and be suddenly overwhelmed by distress. She would react by hurting herself or fleeing. Caroline and Steve could never be sure when Cassandra's self-destructive impulses would explode again.
"Our life was like a war zone," Steve recalls.
They called crisis lines and 111 numerous times. They spent many nights in emergency departments. They chased Cassandra across hospital grounds when she took off in a frenzy; wrestled with her when she tried to jump out of the car in traffic. At night, they slept on the floor of Cassandra's bedroom or in the hallway outside, checking on her regularly, afraid to fall asleep in case she did something to hurt herself.
"Every second of every day, I was worried about her," Steve says.
They appealed on numerous occasions to Cassandra's clinicians that the treatments weren't working, that they couldn't protect Cassandra at home. Surely, they argued, there must be a long-term facility where Cassandra would be safe until she recovered? They spent hours searching the internet for private therapists and treatment facilities that might be able to help their daughter. They looked overseas for alternatives. But there didn't seem to be any good options.
"I was at a loss to know where to go," Steve says.
Several times Cassandra was admitted to the psychiatric ward at Starship, but only for brief stays, and her doctors seemed reluctant to send her back there when the parents brought it up.
"They kept saying, 'This isn't the place for her,'" Caroline says, "and we were asking, 'Well, where is the place for Cassandra?' And they couldn't say. They just didn't know."
"Because there was no plan B," Steve says. "There was no other place to put her."
In March 2019, Whirinaki put Cassandra into a group programme of dialectical behaviour therapy (DBT), a form of intensive talk therapy designed to treat people who have difficulty regulating emotions and controlling self-destructive urges. Caroline and Steve say they were told it was the most effective treatment Whirinaki could offer, and so they went into it with high hopes. Cassandra, too, was determined to make it work.
But she was too unwell, her parents say. Cassandra's obsessive-compulsive traits and sensory processing problems were now so severe at that time that she found the group sessions intolerable. Caroline and Steve felt that the clinicians who ran the programme didn't give Cassandra enough leeway and stuck too rigidly to their rules.
After a few months of DBT, they asked if Cassandra could take a break. They worried that it was making her worse and she would soon be kicked out anyway. They were told if Cassandra stopped, she would have to go back on a waiting list that was months long. Caroline and Steve felt they had no choice but to pull her out. In Cassandra's clinical notes, the discharge was recorded as being a result of "poor engagement". Cassandra was devastated, her parents say. To her, it seemed as if another door had closed.
Over the next several months, Cassandra's contact with Whirinaki reduced, according to her medical records. An occupational therapist was brought in to assess Cassandra's sensory processing difficulties and ended up taking over her case. "I was only meant to do a sensory assessment on this girl and I have ended up case managing her which means managing her risk," the therapist wrote in an email to colleagues one day.
Cassandra met that therapist in early September 2019. She was a "4 out of 10" in mood that day, according to the therapist's notes. She had been feeling constantly sad, frustrated, and angry, but denied having any suicidal thoughts at that moment. Cassandra told the therapist she was making plans to attend the University of Auckland the next year, where she wanted to study accountancy and economics.
A week later: Cassandra phoned a mental health helpline.
On the morning of September 13, 2019, Caroline took Cassandra to a sportswear sale at the ASB Showgrounds. It was crowded and noisy, which made Cassandra anxious. Cassandra spent $388 on clothing, including Adidas track pants, a Hurley sweatshirt, and Nike leggings. That afternoon, Cassandra went to see some friends, but her mood got darker as the day went on.
"I feel like running away and dying," she texted Caroline.
At around 9pm, Cassandra rang a helpline and told a counsellor she was worried she was going to hurt herself; the counsellor called the police. Two police arrived at the family's home at around 10pm. One officer went to Cassandra's bedroom and sat down on her bed. He was calm and empathetic, Caroline recalls, and Cassandra seemed to trust him.
"I will probably do something tomorrow and die," Cassandra told the officer, according to a police summary of the exchange. "Nothing is going to change."
But Cassandra also told the officer she was willing to get help and believed she needed it. According to officers' account, the police called the after-hours mental health team at Counties Manukau DHB and were told the mental health team "wouldn't be able to visit the home address due to lack of resources but would make contact tomorrow".
The police didn't want to leave Cassandra at home; the officer thought she needed to go to hospital. Caroline told him it would be okay: Cassandra had taken medication and it would soon put her to sleep. If they took her to ED, they would probably wait for hours for a mental health assessment only to be sent home, and they were too tired to go through that again.
The officer gave Caroline his mobile number and told her to call him any time.
The next day, Saturday September 14, Cassandra was still despondent. She went to work and returned home at around 10.30pm. Soon after, she took off again in her car. Caroline phoned her and Cassandra said she was going to Burger King to get something to eat.
"What's going on?" Caroline texted. "Do I need to ring the police?"
Caroline rang the officer from the previous night and police began searching the area.
"I love you so much," Cassandra texted Caroline a while later.
"Love you too xXxX," Caroline replied. "Come home please."
Police found Cassandra at around 11.40pm in Papatoetoe, about 10km from her home. Cassandra was visibly upset and "highly uncooperative", according to a police case summary report. The officers escorted her to their car, but Cassandra slipped away. They handcuffed her and she wriggled free again.
Restrained in the back of a police car, Cassandra tried to knee herself in the face repeatedly. Officers decided she was too "dysregulated" for hospital, so they took her to the cells at Manukau police station.
Steve went to the station, where he was told a psychiatrist was on the way to assess Cassandra.
"Some senior Dr is coming in the next 40 mins," Steve texted Caroline, who was back at the family home.
There was confusion after the psychiatrist arrived. According to Whirinaki's clinical records, another mental health staff member at the station expected Cassandra to be detained under the Mental Health Act and admitted to hospital. But when the psychiatrist arrived and spoke to Cassandra, he apparently decided she didn't need inpatient care and could be released into the care of her father. It is unclear why the psychiatrist arrived at this conclusion; the doctor's notes are not included in Cassandra's file.
Cassandra was released from custody at around 4am.
The next day — Sunday September 15 — Cassandra went to work for a few hours, but in the afternoon became agitated again.
She told Caroline she wanted to be taken to hospital and sedated until she wasn't feeling suicidal.
Caroline gave her Lorazepam, an anti-anxiety medication, to calm her down.
Steve phoned the mental health crisis team and asked them if they could give Cassandra enough medication to "knock her out for a few days", until this crisis had passed.
"Father angry with [mental health service] and not happy with yesterday's assessment," a nurse recorded in Cassandra's medical notes.
That evening, at around 5pm, two nurses from the mental health service visited the family's home.
Steve cut them off at the door.
Cassandra seemed settled, he told them. She had friends over and they were playing with her dog. They had made chocolate waffles. He worried that talking to the nurses would only wind Cassandra up again.
That night, a psychiatrist on duty called Steve to follow up.
Steve "expressed ongoing concerns for Cassandra's safety", the psychiatrist noted.
Steve complained about all the medications Cassandra was taking; he didn't think they were working and might be making her worse. He complained that Cassandra's care hadn't been reviewed by a senior psychiatrist in three months. He complained that it always seemed to be a different person on the other end of these conversations.
The psychiatrist was sympathetic but said there wasn't much he could do without assessing Cassandra in person.
"He just went through the process," Steve recalls. "He listened to me. He allayed my fears slightly. But he didn't give me any solutions or options or anything, because there weren't any."
Twenty-four hours later, Cassandra was dead.
Every sudden death unleashes painful and difficult emotions, but the loss of a child to suspected suicide is particularly devastating. The blast radius is incalculable. It leaves a gaping hole that never closes.
Cassandra was one of 138 people aged between 15 and 24 who died by suspected suicide in 2019, and one of about 1230 in a decade, according to data from the Coroner's office. Those numbers might be shocking on their own, but they don't come close to capturing the extent of the wreckage a suspected suicide leaves behind. It shatters a wide circle of relatives, friends, schoolmates, teachers, teammates, coaches, workmates, and more.
Cassandra's death rippled through several communities that had treasured her. Not everyone who knew her had been aware of her struggle with mental illness, or the extent of it. You could see the shock and confusion in the messages and emails that flooded into Caroline as the news spread, and in the faces of the mourners at Cassandra's funeral, at an Anglican church in Panmure, a week after she died.
Caroline and Steve tried to carry on as well as they knew how to after Cassandra's death, going to work, going through the motions of daily life, both dealing with the loss in their own ways. But the magnitude of the tragedy was inescapable.
"Life ended in that instant," Caroline says.
The loss of their only child pushed the parents further apart. Caroline wanted to split up, sell their house, leave behind the anguish of the past few years. Steve didn't, so they continued residing under the same roof but mostly led separate lives, connected only by shared memories of Cassandra and a grief they could never escape.
Caroline left Cassandra's bedroom almost exactly as it was the day Cassandra died. On a bookshelf there were dozens of colourful dolls, lined up meticulously. Cassandra's clothes remained in her wardrobe, hung, folded, and stacked just so. A string of medals from Cassandra's sporting achievements hung above her bed.
Caroline began sleeping in Cassandra's room at night with Cassandra's dog.
She surrounded herself with reminders of Cassandra's life.
In the weeks after Cassandra died, the coroner's office opened an inquest into her death, as it is required to do after a suspected suicide. Counties Manukau DHB also began an inquiry into what went wrong and whether any lessons could be learned from Cassandra's case. But those processes moved agonisingly slowly, and so Caroline began her own review.
She collected hundreds of pages of documents relating to Cassandra's journey through the mental health system, arranging them painstakingly in a stack of black folders. To the officials' notes she added her own commentary, pointing out things she thought the staff got wrong or left out. At night after work, she transcribed hand-written diaries in which she'd recorded Cassandra's experiences, and hundreds of text messages she'd exchanged with her daughter.
There were moments when the documents were too heart-wrenching to read, but mostly they gave Caroline an outlet for her grief. They helped her start to put things in order in her own mind. Eventually, she came to think of the work as having a higher purpose, as a validation of her daughter's suffering.
As she read through the records, Caroline says, she finally realised "what a f****** awful life she had those two years".
"What she had been through was horrendous," she says. "It was truly horrendous."
By Caroline's count, Cassandra had absconded 38 times in the last two years of her life. There were 17 major self-harm incidents. Twenty hospital admissions. Nine police callouts.
"When you're living it, day by day, you don't realise," she said. "But when you read it, it's like, 'Oh my God.' How did I ever let Cassandra go through that?"
As the months went by, Caroline grew angrier and angrier at the services that had cared for Cassandra in the two years before her death.
"Cassandra did not receive adequate treatment + support from CAMHS [child and adolescent mental health services]," she wrote in a notebook one day, and below that she began to list some of the major problems they'd encountered in the system:
Disconnected services that were confusing and exhausting to navigate.
The sheer number of staff they had to deal with over the years.
Bad and inconsistent communication from some of those clinicians.
Minimal education of parents about diagnoses and treatments and how they could support their child at home.
Lack of alternatives when their child was at high risk of suicide.
On September 16, 2020, a year to the day after Cassandra's death, Caroline turned up at the Coroner's office in Auckland with a bundle of documents she had pulled together about Cassandra. There was a summary of Caroline's views about Cassandra's care, extracts from her diaries, speeches from Cassandra's funeral. She hoped that whoever read it would "try to get to know her a little".
"I'm sorry this took so long," she wrote to whichever official would end up reviewing the documents, "I didn't know where to start, what to include and how to finish."
She gave another bundle to the panel leading the DHB's investigation.
And if anyone else wanted to know anything about her daughter, Caroline resolved, she would talk to them too.
So often Caroline sensed that people wanted to ask about what happened to Cassandra, about how Caroline was coping with her suspected suicide — to tell Caroline what Cassandra had meant to them.
But usually they found it too painful, too awkward. They didn't have the language. Or they worried that it would upset Caroline. And so mostly they didn't bring it up.
Caroline wanted people to know that she wasn't afraid to talk about Cassandra. She was proud of her daughter. She wasn't embarrassed or ashamed by anything they went through. Nothing was off limits.
"I love talking about Cassandra," she would tell them. "I never stop talking about Cassandra."
"The only person you don't talk to about it is me," Steve says one afternoon.
It's now a cold, wet Thursday in August. Caroline and Steve have agreed to talk together about Cassandra, something they've mostly avoided doing in the past three years, and so they're sitting on a sofa in their living room, Cassandra's dog Casey stretched out between them. Both parents wear wristbands with the slogan I AM HOPE, from Mike King's mental health charity. A wood burner warms the room. The house is so quiet you can hear the rain beating on the deck outside.
Steve is guarded at first, but as soon as he starts talking his grief is palpable. His eyes fill with tears. His voice rises and cracks. If Caroline had somehow found a way to channel the emotions of the past few years into documenting Cassandra's experience, Steve has mostly turned them inward — but they are still close to the surface, raw.
Steve thinks about Cassandra all the time.
He adored his daughter. He recalls with obvious pride Cassandra learning to swim, playing football, doing somersaults and tricks on the trampoline in their back yard. Cassandra always insisted that Steve judge her routines and wouldn't let him leave until he'd given her a perfect score.
"She had the potential to be anything," Steve says. "Whatever she decided in her life she was going to do, she would've excelled at it. She operated on a different level to anyone I know."
But Cassandra had also confounded him. It crushed him to see his child so distressed and be powerless to help.
Like Caroline, he has grown angrier at the mental health system the more he has dwelt on the final months of Cassandra's life. He turns it over in his mind constantly. Decisions that were made. Interactions with clinicians. Things that might've been missed. Steve is convinced that all the medications made Cassandra's mental state worse. He is bewildered that there wasn't somewhere else to take her when she was at her most distressed.
"Important that the family 'takes ownership' of the process," the clinicians had said after reviewing Cassandra's case a few months before she died, but from the parents' viewpoint they'd done everything the experts recommended. They'd given Cassandra all the medications, tried all the different types of therapy. She just kept getting sicker, and then there seemed to be no other options. They were left on their own to deal with something they had no way of dealing with. They were drowning.
"They just carried on doing the same bloody things that they're taught in whatever school they went to," Steve says. "It wasn't fixing it, but there was no acknowledgment that they didn't have the skillset to deal with it."
"They didn't know what to do with her," Caroline says.
Steve blames himself, too. He had always regarded himself as a person who solved problems, yet he hadn't been able to figure out the one that mattered most. He saw himself as the family's provider, but he couldn't protect his child from herself.
"I'm still completely confused by what happened," Steve says. "I run this through my mind every single day. What could we have done differently? What would have changed the outcome?"
"I could get my head around just about anything else," he says.
Steve had tried talking to a counsellor after Cassandra died but gave up after a few sessions because the counsellor didn't seem to understand what he was going through. A support group for people bereaved by suspected suicide was more helpful. He found it comforting to meet so many others who'd lost relatives and who had similar stories about being let down by mental health services.
"I felt like I wasn't the only person in the world who had failed," he says, but when Auckland went into lockdown after the Covid-19 outbreak the group moved to video meetings and Steve lost contact.
There have been times since Cassandra died, Steve admits, that he has contemplated dying himself. But mostly he feels empty.
"My life is just so pointless," he says. "It's just absolutely pointless."
It added to Steve's loss that he felt he had not only lost his daughter but Caroline, too.
"We don't talk about it," he says. "I don't know why. Maybe, if you delved into it, Caroline blames me, and I live with that guilt all the time."
"Maybe it's that thing that just needs to be left unsaid because it's too raw between us."
He doesn't look at Caroline. She doesn't look at him.
But now he tells her some of the things he's been wanting to say for three years but never seemed to be able to: That he's sorry. That he's consumed by sadness and guilt. That he's angry all the time. But that he's grateful, too. He wants Caroline to know that she was a terrific mother to Cassandra. That he loves them both so much. That Cassandra was the worst thing that ever happened to him but also the best.
"I want to tell Caroline that I loved Cassandra so much and say all the good things I experienced, because it was the best part of my life," he says.
"I'm just so sorry that we couldn't experience that grief together."
Several weeks later, in late September, Caroline and Steve each get a phone call from a representative at the former Counties Manukau DHB.
It's been months since they've heard anything from the health authority or the Coroner's office, and they'd started to wonder if Cassandra's case had been forgotten, if everyone in the system had moved on.
But now the process seems to be moving again after the Herald sent questions about Cassandra to Te Whatu Ora. The former DHB's review of Cassandra's case is finished, the representative tells them, and executives would like to meet the parents to discuss their findings.
In a written statement, Ian Soosay, clinical director for mental health services at Te Whatu Ora Counties Manukau, tells the Herald: "We would like to send our heartfelt condolences to Cassandra's family. They have lived through a terrible and traumatic experience. We would also like to sincerely apologise for not following up with the family on the external review of the case. Our processes were disrupted by Covid and we dropped the ball. The external review was completed and we have received a number of recommendations. The review team have now been in touch with Cassandra's family to meet and go over the findings, many of which have been implemented. "We also appreciate that there are specific aspects of her care that the family would like to highlight and have consented to share this with the media. However, the privacy protections in place for people who have died remain complex, and we have been advised that we are not in a position to speak freely about details of Cassandra's care. The coronial process remains active and we hope that the family will have the opportunity to ask further questions. The coroner will then decide which aspects of the case can be made public."
The Coroner won't comment except to confirm that Cassandra's file remains open.
Caroline says she's looking forward to meeting the executives from Te Whatu Ora in the coming weeks to find out what they have to say about Cassandra's care. "I don't really want an apology," she says. "It's not going to change my life. It's not going to make me feel any better. It's not what I hope to gain out of this." What Caroline does want, she says, is for people who run our public services to reflect on Cassandra's death and make changes so that other children and parents don't go through the "disaster" her family endured.
"There's just got to be somewhere safe for these kids to go," she says.
About this series
This article is the part of a series examining the rise in mental distress among young people and the state of services that support them. To understand these pressures, we have interviewed dozens of people all levels of the system in recent months, including teens and their parents, frontline staff, researchers, health officials, and others; obtained hundreds of documents which have not previously been made public; and reviewed data from numerous public bodies.
We will be publishing more stories in the coming week on the challenges faced by young people and their families in getting timely and effective care, the policies and initiatives that have been developed in response to the trend, and potential solutions to the crisis.
If you have information about this topic, particularly if your family has experience of using mental health services or you work in the sector, please contact Investigations Editor Alex Spence at alex.spence@nzme.co.nz. Because of the volume of correspondence, we cannot reply to all the responses we receive but we will read all of them. We will not publish your name or identify you as a source unless you want us to.
Where to get help
If it is an emergency and you or someone else is at risk, call 111.
For counselling and support
Lifeline: Call 0800 543 354 or text 4357 (HELP)
Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO)
Need to talk? Call or text 1737
Depression helpline: Call 0800 111 757 or text 4202
For children and young people
Youthline: Call 0800 376 633 or text 234
What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
For help with specific issues
Alcohol and Drug Helpline: Call 0800 787 797
Anxiety Helpline: Call 0800 269 4389 (0800 ANXIETY)
OutLine: Call 0800 688 5463 (0800 OUTLINE) (6pm-9pm)
Safe to talk (sexual harm): Call 0800 044 334 or text 4334
All services are free and available 24/7 unless otherwise specified.
For more information and support, talk to your local doctor, hauora, community mental health team, or counselling service. The Mental Health Foundation has more helplines and service contacts on its website.