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A district health board already scrutinised for mental health service failings has been criticised by a coroner in his findings on the death of a 17-year-old woman.
Her death followed a number of other incidents at the Hutt Valley DHB, which has already been subject to a central government review.
Rachel Mackley died following a massive anti-depressant overdose in September 2010. The teenager's death followed years of bullying and emotional problems, including an eating disorder and self-harm.
Coroner Gary Evans allowed the details surrounding her death to be made public after an inquest in July in the hope of avoiding a repeat incident.
The troubled Heretaunga College student had twice been admitted to hospital after over-dosing on her anxiety medicine in September 2010. However, staff assessed her as low risk, and no management plan was put in place.
The following week, on September 23, she took a much bigger overdose and was admitted to Hutt Hospital where she later died.
In his recommendations, Coroner Evans said the health board needed to review its outpatient care management and implement a system whereby case managers were implemented to ensure patients' care was coordinated and clinical responsibility was easily identifiable.
Coroner Evans also recommended patients who had been assessed as having a remaining risk of self-harm upon discharge had their risks, early warning signs and intervention plans documented in a risk management plan.
Her mother Joanna Mackley told an inquest into her daughter's death last year that she was in "disbelief" when the health board's crisis assessment and treatment team discharged her daughter from hospital after the second overdose.
"I thought she needed secure hospitalisation," Mrs Mackley said.
The teenager's death came near the end of a Section 95 inquiry of the DHB's mental health services, commissioned by Ministry of Health's Director of Mental Health.
The DHB's chief executive Graham Dyer said the inquiry looked at five patients who were admitted to the health board's mental health inpatient unit, including one who committed suicide and a patient who set herself on fire.
The recommendations from the inquiry contributed to significant changes to mental health services in the Hutt Valley, Mr Dyer said.
He said the two recommendations made by Coroner Evans had been implemented and would be reviewed regularly.
"Other areas commented on by the coroner have also been or are currently being acted on, including bed management and the criteria for admission to intensive care, high dependency care and coronary care units."
Risk assessments were now completed for all clients at their first appointment, shift handovers had been improved and case managers were now designated for all clients, which was clearly identified in notes, Mr Dyer said.
Coroner Evan's recommendations:
* The DHB review its outpatient care management and create a system whereby case managers ensured patients' care was coordinated and clinical responsibility was easily identifiable.
* On discharge, patients who have been assessed as having a remaining risk of self-harm had their risks, early warning signs and intervention plans documented in a risk management plan and the plan be made available to the patient's family members/whanau/caregivers and their GP.
* 2012: Coroner Evans criticised the DHB following the death of Kirk Whittington in 2008, after he killed himself while on home leave from a mental health unit.
* 2011: Coroner Ian Smith called for improvement in temporary care facilities in the Hutt following the Jerome Perez's suicide in 2008.
* 2011: Coroner Smith again criticised the DHB for misdiagnosing Jerry Korewha. He died in 2009 after being hit by a car.
* 2010: Coroner Evans called on the DHB to review its mental health crisis systems after a student was left to assess James David Barnden in 2007. He killed himself 11 days later.
Where to get help:
* Lifeline: 0800 543 354 (available 24/7)
* Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
* Youth services: (06) 3555 906
* Youthline: 0800 376 633 free text 234 or email firstname.lastname@example.org
* Kidsline: 0800 543 754 (4pm to 6pm weekdays)
* Whatsup: 0800 942 8787 (1pm to 11pm)
* The Word [http://www.theword.org.nz/]
* Depression helpline: 0800 111 757 (available 24/7)
* Rainbow Youth: (09) 376 4155
* CASPER Suicide Prevention [http://www.casper.org.nz/]
* Healthline: 0800 611 116
* www.thelowdown.co.nz or free text 5626
- Brendan Manning of APNZ