This article deals with mental health problems, including attempted suicide.
A District Health Board (DHB) has been slammed for its failure to care for a teenager with suicidal thoughts.
The Mental Health Commissioner released a report on Monday, criticising the unnamed DHB for not following up the young man's care, which potentially led to his suicide in 2017.
In 2016, police found the young man in a situation where he appeared to be at risk of self-harming. He was admitted to hospital where he was assessed by a child and adolescent psychiatrist.
The man told the psychiatrist he was not willing to take medication but willing to receive help from the youth mental health service at the hospital.
The next day, he was discharged from hospital without medication, and with the plan he would have a follow-up appointment with the service nurse.
Over the next two months, the man met with a service nurse several times to discuss his mental health, then decided he no longer wanted support from the service, so the meetings discontinued.
The teenager had a history of mental health issues and died by suspected suicide in 2017.
Mental Health Commissioner Kevin Allan condemned the DHB for not discussing the man's case further.
Allan was critical the man did not receive a further psychiatric review after his discharge from hospital and that there was no multidisciplinary team involved in his care.
He was also critical of the DHB for not involving the man's mother more closely in his care.
"There was a lack of comprehensive formulation of risk over a period of time, and a lack of guidelines for risk management to be used once [the man] was discharged," he said.
"[The man's] mother was not involved in his psychiatric assessment while he was an inpatient, and so [the clinician] was unable to gather background information about his circumstances in order to expand the risk assessment.
"The failings by the DHB clinicians resulted in [the man's] risk not being appreciated, and he and his family feeling unsupported."
Allan recommended the DHB arrange training for all its service staff on communication with patients and their families and to review all patients seen and discharged by the service.
He called for the DHB to apologise to the man's family.
Where to find help and support:
Shine (domestic violence) - 0508 744 633
Women's Refuge - 0800 733 843 (0800 REFUGE)
Need to Talk? - Call or text 1737
What's Up - 0800 WHATS UP (0800 942 8787)
Lifeline - 0800 543 354 or (09) 5222 999 within Auckland
Samaritans - 0800 726 666
Depression Helpline - 0800 111 757
Suicide Crisis Helpline - 0508 828 865 (0508 TAUTOKO)
Shakti Community Council - 0800 742 584