WARNING: This article, or links to it, contains information about suicide.
The parents of teen suicide victim Reiha McLelland want the failures in their daughter's case to be used as a blueprint for saving others at risk of self-harm.
The 2014 death of Reiha, 13, followed the end of an intense relationship with a former teacher, Sam Back, then 41.
"Reiha was far too important, too beautiful a girl with so much ahead of her that there has got to be some lessons learnt from this, as painful as it has been," said her mother, Hinemoa McClelland.
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"I don't want in the future another parent coming to us and saying, 'why didn't you do anything?'."
Reiha and Back embarked on an intense relationship in September 2013 which lasted until April 2014 when it was found they exchanged 4000 text messages in about three months, sparking a police investigation.
Back was not charged and no evidence has emerged showing a physical aspect to the relationship.
Inquiries by the Herald into the events which led to and followed her death have found failures which went beyond those stemming from her time at Gisborne Intermediate.
The inquiry into Reiha's death drew in the Tairawhiti District Health Board, police, Gisborne Intermediate and Back, along with his partner Angie Mepham, who had also formed a bond with the teenager.
The role of the police was of particular focus as the head of the child protection team, Theo Ackroyd, was also chairman of the Gisborne Intermediate board of trustees and had supported Back through the NZ Education Council hearing which saw the teacher banned from teaching.
Ackroyd's actions led to a police employment inquiry, which ended when he resigned from the police. He had been a detective sergeant.
A complaint to the Independent Police Conduct Agency by the McLellands is ongoing after evidence emerged of Ackroyd having a connection to the inquiry into Back, despite having declared a conflict of interest that should have kept him away from it.
There were also questions around Ackroyd's bid to keep Back's name suppression in place. He wrote to the Education Council to say it needed to remain because of possible criminal charges, even though a year earlier one of his subordinate officers concluded no charges should be laid.
An internal review by the health board - details of which have been obtained by the Herald - showed processes around treatment of adolescents in mental health care were changed as a result of the handling of Reiha's treatment.
The health board review led to the employment of a fulltime psychiatrist - a shift from the system which existed at the time of Reiha's treatment, when an out-of-town specialist was flown in for one day a week.
The previous mode of providing care had evolved from difficulty hiring someone with the right skills and experience to provide inpatient and community care.
But the review didn't lead to the creation of an adolescent mental health ward.
Instead, the DHB has the same system under which Reiha was treated - temporary care in the paediatric unit and a transfer when possible to the Wellington adolescent care facility almost seven hours' drive away.
Testimony to the coroner's hearing saw a health board manager concede it was "not what we would have in an ideal world" but was the reality of providing care in a comparatively small, rural community.
There was also extra training around risk assessment and a fresh philosophy to have a greater focus on being open with families after the decision by the psychologist and psychiatrist treating Reiha not to warn her parents of renewed threats of self-harm.
That decision was based on balancing her need for confidentiality against the perception of risk, with the inquest told both health professionals now believe Hinemoa and Bruce McLelland should have been told Reiha was again talking about suicide.
No documentation was produced at the inquest to show that a multi-agency approach was employed - an approach driven by health chiefs at a national level. The philosophy behind a range of agencies being involved in - and meeting regularly to discuss - cases was to avoid children falling between the cracks.
In Reiha's case, various agencies involved with her did not share information until after her death.
Police are at the centre of many multi-agency approaches. Eastern District criminal investigations manager Detective Inspector Rob Jones said police were bound from commenting on Reiha specifically.
Beyond that, he said: "The quality of service to children and their families should be no different regardless of where they reside in New Zealand."
Gisborne Intermediate, which was criticised for allowing Back to continue teaching and supporting his efforts to have his name suppressed, backed its conduct.
In a statement, its board said: "The Gisborne Intermediate School board is confident in its processes which were worked through with advice from a body specifically tasked with providing help and guidance to boards of trustees."
Experts working in mental health say there is underfunding across the system and that it is felt worst in child and adolescent services - and particularly in provincial New Zealand.
People's Mental Health Review spokesman Kyle MacDonald, a psychotherapist, said some provincial centres had little to offer adolescents in need of mental health care.
He said the review found that services were geared towards crisis intervention with ongoing treatment in some cases "nigh-on impossible" to obtain.
The review, which called for an inquiry into mental health services, produced evidence showing those in need had to develop a severe condition before help emerged.
Green Party health spokeswoman Julie-Anne Genter said access to adolescent and mental health care was "pretty bad" across the system. The problems became more obvious in provincial New Zealand, she said.
She also backed an inquiry. "We're at that state where things are falling apart."
The Herald asked Health Minister Jonathan Coleman if he believed adolescent mental health services were funded and staffed at a level to existing need. He answered: "Yes."
Asked if he was doing all he could for adolescents with mental health issues, he answered: "Yes."
IF YOU NEED HELP:
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.
Or if you need to talk to someone else:
• 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 (Mon-Fri 1pm to 10pm. Sat-Sun 3pm-10pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Samaritans 0800 726 666
The participant's death was unrelated to the pilot, according to Oranga Tamariki.