DHB needs to review outpatient care system - coroner

File photo / Ted Baghurst

A coroner has urged Hutt Valley District Health Board to review its outpatient care system following the death of a 17-year-old girl who overdosed on anti-depressants.

Rachel Mackley died after a massive overdose in September 2010.

The procedures of Hutt Hospital were criticised at an inquest into the teenager's death, which followed years of bullying and emotional problems, including an eating disorder and self-harm.

The troubled Heretaunga College student had twice been admitted to hospital after overdosing 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, Rachel took a much bigger overdose and was admitted to Hutt Hospital where she later died.

In his recommendations released today, Coroner Gary 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 that patients who has 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.

An external review of the care and treatment provided to Ms Mackley by the health board found no formulation of risk or patient of family psychopathology by the board's eating disorder service. The court described the absence as "unsatisfactory".

Coroner Evans also recommended the chief executive of the NZ Principals' Federation instigate the modification of pupil enrolment forms, so the names and contact details of both parents, caregivers or guardians be recognised equally, regardless of the student's living arrangements.

Evidence from Ms Mackley's school counsellor, Nicholas Dye, detailed how he called her mother about his concerns about her serious and imminent self-harming, but did not call Ms Mackley's father as he was down as an emergency contact.

Where to get help

• Youth services: (06) 3555 906

• Youthline: 0800 376 633

• Kidsline: 0800 543 754 (4pm to 6pm weekdays)

• Whatsup: 0800 942 8787 (noon to midnight)

• The Word

• Depression helpline: 0800 111 757 (24-hour service)

• Rainbow Youth: (09) 376 4155

• CASPER Suicide Prevention

If it is an emergency and you feel like you or someone else is at risk, call 111.