Our View: Tragedy confirms need for changes

The death of Tauranga teenager Kayla Wright is a tragedy that will, hopefully, prompt changes to the mental health system.
Kayla took her life after mental health professionals released her from care - despite the fact she was highly likely to commit suicide. Her family thought she was in safe hands.
The 18-year-old suffered from anorexia nervosa for more than a year when she died in November 2008.
Coroner Wallace Bain is calling for changes after investigating her death. Dr Bain notes "heartbreaking similarities" between Kayla's death and those of two other people and said these were unnecessary. Dr Bain says Kayla's release "simply defies common sense" given "her history, her health conditions and her state of intentions were clear".
He has written to the director of mental health asking for the definition of a mental disorder to be widened in regards to treatment. Kayla's family support the coroner's findings.
This case, and indeed its similarities with the other two, should be ringing alarm bells at the Ministry of Health.
Any hint of a systemic problem with how doctors treat mental health patients should be immediately reviewed.
What can be learned from these deaths? What changes should be made? How can the system prevent similar deaths from happening in the future?
It is a fact of life that people will suffer from mental illness and it is critical they are treated with sensitivity and all due care is taken with those who are most vulnerable. A young person indicating they want to take their own life is most certainly vulnerable. They and their families need to have confidence their safety will be paramount.
No system is ever perfect. Doctors will always make mistakes and sometimes people slip through the cracks. In this case, the director of mental health needs to closely examine the coroner's findings and make any necessary changes.