A review has found deficiencies by Waitemata District Health Board (DHB) in its care for an Auckland teenager who died suddenly having suffered depression.
Toran Henry, a 17-year-old Takapuna Grammar student, was found dead at his North Shore home in March.
His death came a day after he was badly beaten at the school while student looked on.
An external review of the DHB's care of Toran before his death was one of several carried out in relation to the issue, and its summary of findings were released today.
Services provided to Toran by two key specialist organisations -- assessment, consultation and treatment provider Marinoto North, and mental health liaison service Malaga a le Pasifika -- were put under the spotlight.
The report said in general, dealings with Toran were admirable, but let down by a lack of thoroughness.
A lack of thorough assessment information and little long-term planning was evident in notes taken by Marinoto North, and similar issues were evident from Malaga a le Pasifika.
It said the prescribing of depression treatment, fluoxetine, appeared to have been done hastily and before any psychological interventions had been tried.
The review also noted Toran was advised he need not take fluoxetine on the days he drank alcohol.
"This advice does not make pharmaceutical sense and could have further reduced the effectiveness of the antidepressant," the report said.
Systematic issues were also identified as something which may have denied Toran's mother adequate input into decision making over the use of the drug.
His mother had painted a picture of having at times been ignored and condescended to.
However, the review praised certain aspects of the care and acknowledge certain difficulties faced by the service providers.
"Marinoto North did an admirable job at keeping in touch with Toran and his mother. It was persistent and flexible with a young man who was reluctant to use the services." The review also outlined a need for increased funding from the DHB for child and adolescent health services, suggesting under-resourcing created pressure.
It made a raft of suggestions on ways services provided by Marinoto North and Malaga a le Pasifika could be improved.
They included training for all new child and adolescent mental health service workers who lacked experience in the area of drug and alcohol services.
Evaluations were also suggested on staff's capacity to provide effective psychological therapies at Marinoto North.
Both agencies were urged to improve note taking practices through training.
The Mental Health Commission welcomed the review's findings and said, if promptly adhered to, they could help reduce systems errors and improve the future quality of service delivery.
Commissioner Peter McGeorge said the findings had given the DHB plenty to reflect on.
He said the DHB accepted the need to make some systemic and process improvements, and that work had already begun.
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