Photo: RNZ
Warning: This story discusses substance abuse and suicide.
A teenager who took his own life following a battle with substance abuse was failed by shamefully inadequate mental healthcare, his grandmother says.
Coroner Mary-Anne Borrowdale ruled the boy died by suicide in February 2023 while he was living with his grandmother, although many details of the case could not be reported because of strict non-publication orders.
The boy's grandmother told the coroner that while drug use had damaged his mental well-being, "it was the dreadful lack of access to adequate mental healthcare and support that put the final nail in his coffin".
She asked the coroner to highlight New Zealand's "shamefully inadequate" mental health facilities and resources, including a lack of safe places to house people who needed an assessment or supervision, a lack of suitably qualified mental health workers, delays in providing assessment, care, and support, and a lack of cohesion between the departments such as police, the justice system, Oranga Tamariki, doctors and mental health workers.
With no assurances help would come soon, he "gave up hope and gave up the fight", she said.
Coroner Borrowdale said she could not go so far as to say mental health system flaws had been instrumental in the teenager's death, but it represented the experiences of a young man and his family trying to navigate an overburdened and under-resourced system.
For that reason, the coroner asked for her findings to be distributed to the agencies and government officials with influence over youth justice and mental health services.
A teen's descent into substance abuse
The report detailed how a high-performing and well-adjusted child had developed into a teenager with a history of behavioural problems, criminal offending and possible psychosis.
The boy had a largely unremarkable early childhood, excelled at primary school, was academically gifted, involved in a range of sports and was regarded as having leadership potential.
"He was empathetic and insightful and had no problems with concentration, comprehension, or impulsivity. He had good relationships with his peers and teachers," the coroner said.
By the time the boy reached intermediate, his behaviour had changed.
He gravitated towards a toxic peer group and started swearing, bullying and fighting.
As a teenager, he was regularly using cannabis and alcohol by the time he was in Year 12, and he was often truant from school.
He went on to experiment with stronger drugs and had a "bad trip" on ecstasy (MDMA) that required medical intervention, after which family and friends noticed he was cognitively slower, had poor memory and comprehension, and strained interactions with others.
The teen committed 11 burglaries and shoplifting offences and was summonsed to appear at the Youth Court, which ordered a psychological report.
Substance-induced psychotic disorder
The psychologist's opinion was the teenager might have been suffering from an undiagnosed psychotic (delusional) disorder that was possibly substance-induced and said he required a psychiatric assessment.
He showed no signs of suicidal ideation, appeared to be future-focused, and did not express feelings of hopelessness or wanting to end his life.
The teenager was eventually bailed to live in a remote area with his grandmother where he had no access to drugs.
Three days before he died, the boy's grandmother said she told the psychologist that he needed urgent psychiatric assessment.
In a follow-up assessment done over the phone, the psychologist found the teenager had views approaching the delusional and testing confirmed he was suffering from auditory hallucinations.
She said his MDMA use might have reached the threshold for substance-induced psychosis and there was sufficient evidence to warrant referring the teenager for a psychiatric assessment, which could be obtained more quickly through a court order.
The teenager had a remote Youth Court appearance, although his grandmother said he had been "stressing about it" because he wanted to be let off his bail conditions and restart his life.
The judge told the teenager he needed to have a further psychiatric assessment and asked him to be patient with the process.
His grandmother said he was very disappointed and frustrated after the appearance, but they sat down, had a cuppa and talked it over.
In New Zealand, a psychiatric assessment examines potential mental illness through a medical lens, often determining whether treatment using medication is appropriate.
A psychological assessment focuses on understanding the thoughts, emotions, and behaviours of an individual.
Findings
Coroner Borrowdale found the teenager took his own life because he was upset by the delay in releasing him from bail, which meant he would need to continue living in the remote area for another six weeks.
She said there had been an impulsive element to his actions that day and while it was not possible to know for sure what prompted his suicide, he was likely in some despair about his extended confinement and isolation.
"We must assume that, in the moment, [his] frustrations tragically overpowered him," she said.
The coroner said psychological assessments had validated the need for further psychiatric assessment, which was accepted and advanced by the court and the judge had explained the need for patience.
"No one who was involved with [the teenager] at that time apprehended that he was at risk of ending his own life," she said.
"Nevertheless, there has been recent official recognition of 'significant unmet need' in the primary mental health and addiction services available to young people.
"[The teenager's] death represents the experiences of one young man and his family in trying to navigate an overburdened and under-resourced system.
"For that reason, I am distributing this finding to agencies and government officials who have influence over the delivery of these services, and for whom I expect that this finding will be informative and provide an opportunity for reflection and action."
The coroner cited medical research that had established cannabis use by teenagers was associated with an increased risk of mental health problems and suicidal ideation.
There was recent evidence of a heightened risk for people who abused both cannabis and MDMA and evidence of substance-induced psychosis after consuming MDMA once, she said.
The coroner encouraged all caregivers and guardians of young people who used drugs, including cannabis, to be aware of their risks and avenues for help and support in reducing their children's recreational drug use.
Coroner Borrowdale offered her condolences to the teenager's family and to all people who felt his loss.
Where to get help:
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
- Lifeline: 0800 543 354 or text HELP to 4357.
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
- Depression Helpline: 0800 111 757 or text 4202.
- Samaritans: 0800 726 666.
- Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
- What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
- Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
- Rural Support Trust Helpline: 0800 787 254.
- Healthline: 0800 611 116.
- Rainbow Youth: (09) 376 4155.
- OUTLine: 0800 688 5463.
If it is an emergency and you feel like you or someone else is at risk, call 111.
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