The coroner has criticised the Ministry of Social Development in a damning finding which said a teenager's death might have been prevented if an overworked, inexperienced social worker hadn't failed to appropriately act on the teen's suicide threats.
The 15-year-old died in 2014. The teen's social worker and the worker's supervisor, his school principal and school counsellor and his family therapist knew of his suicide plan but didn't tell the teenager's parents.
An inquest was held in two parts, in 2015 and 2016, and this week coroner Marcus Elliott released findings into the death to the Herald on Sunday, criticising the ministry for failing to dedicate proper resources to the "complex" case, or give social workers enough training in dealing with suicidal ideation.
Legal restrictions prevent the teenager and those involved in his care from being identified.
The teen was in the ministry's custody after intervention by Child Youth and Family (CYF) but was living with his parents in Auckland when he died.
Since the teenager's death CYF has been disestablished and its role taken over by the new Ministry for Vulnerable Children, Oranga Tamariki.
The morning of his death, the teenager detailed to the family therapist a plan to commit suicide. The therapist warned the boy's CYF social worker the teen was at "high risk" of suicide before phoning the boy's mother, telling her to monitor her son but not specifying he was suicidal, because of fears of how the teen's father would react.
The social worker informed the boy's school of his comments. However the counsellor and the school principal opted to leave the matter with CYF after speaking to the teenager.
The social worker consulted her superior and contacted a mental health assessment team but according to the findings didn't follow the correct process in urgent situations and faxed a referral form after 5pm.
The fax wasn't seen by the assessment team until after the teenager had died. There was dispute over whether the social worker informed the team's receptionist of the urgency.
A review of the case by the Office of the Chief Social Worker identified the social worker was "overwhelmed" by her work with the teenager's family- a particularly complex case.
The social worker and her supervisor agreed they were inexperienced in dealing with suicide concerns in young people and coroner Elliott said their failure to grasp the immediacy of the risk affected their response.
Coroner Elliott didn't blame the social workers, but criticised the ministry.
"[The Ministry] placed its employees in a position where they didn't have the capacity to give this situation the attention it deserved... This was not fair on the family, nor was it fair on [the workers]," the findings say.
"It is not clear that [the CYF workers] had been sufficiently trained in understanding the potential triggers for suicidal risk- and the importance of addressing these - or the urgency of expressions of suicidal ideation.
"To a large extent, the shortcomings of the afternoon ... were a consequence of the Ministry's failure to provide the necessary resources to deal with the difficulties that day.
"This meant that all possible preventive steps were not taken that day. It is unfortunate that they were not because [the] suicide might have been prevented had they been taken."
"A referral [to the mental health team] did not discharge the ongoing responsibility which the chief executive of the Ministry owed to [the teenager]. Given that the [social workers] had chosen not to inform the family of the full extent of the issue themselves that day, it was incumbent upon them to ensure that [the crises team] actually carried out an assessment."
After the Chief Social Worker's investigation improvements were made to how it supported families including giving social workers more direct contact with young people and their families, more training to deal with suicide concerns and employing more staff.
The improvements were in line with the coroner's recommendations.
In response to questions from the Herald on Sunday Oranga Tamariki regional manager Jaimee Barwood offered condolences to the teen's family.
"The death of a young person is always a tragedy for all those who knew him. It is also something our staff feel deeply," Barwood said.
"The ministry acknowledges the coroner's findings in this case, and is now considering his recommendations in detail.
"We share the coroner's view that it is important to consider if this case contains lessons that will help prevent the loss of young people in similar circumstances in the future.
"The Ministry's new approach to the care and protection of children, along with changes introduced by Child, Youth and Family since 2014 have already gone a long way towards implementing the coroner's recommendations.
"We note the coroner's comment that no one is to blame for this young man's death. We also note that a number of agencies had responsibilities relating to this young man.
"In this case we agree with the coroner and chief social worker that more information should have been shared with this young man's parents. However, we must always place the interests of the child first."
Mental Health Foundation chief executive Shaun Robinson said the lack of intervention in the teenager's case was "very concerning".
"We would hope that social workers, therapists, and school staff would have adequate training and support to appropriately respond to young people in distress," Robinson said.
Children's Commissioner Andrew Becroft said it was a "terribly sad" case and was "all too familiar territory".
In 2014 the commissioner's office identified the risk of high workloads, lack of supervision, less than adequate partnerships between agencies and failures to engage with whanau, he said.
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider.
However, if you or someone else is in danger or endangering others, call police immediately on 111.
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Samaritans 0800 726 666
• If it is an emergency and you feel like you or someone else is at risk, call 111.