Chris Barton was in court to hear the inquest for schoolboy Toran Henry who committed suicide in 2008, aged 17
Deb Williams settles into her back row seat of the Auckland Coroners Court and gets out the photos. She arranges them around her, a protective semi-circle on the ledge by the window, some stuck to the glass.
The photos speak of a beautiful daughter, Cloudy, full of life. She died on January 29, 2008, at just 20 years old.
There are photos of Toran Tiavare Henry full of life too. He died, aged 17, on March 20 the same year. As children Toran and Cloudy once played together.
Cloudy's inquest has yet to happen. This is Toran's. During the 18-day hearing, the photos on the wall are a stark reminder of tragic loss, of mothers' grief, of young lives ended.
Coroner Murray Jamieson begins with statistics. Over the seven years from 2002 to 2008, an average of 150 citizens of greater Auckland - from Mangawhai to the Waikato River - have taken their lives each year.
The substantial increase in the Auckland adult population over the same period provides a small comfort - the rate of suicide in Auckland is declining. Teen suicides in Auckland average 14 a year.
Toran's inquest is different from most, not just because it takes a marathon 18 days, but because what happens can be made public.
Normally inquests into suicide, while open to the public, are suppressed because the family requests that the information is kept private.
But in some suicides - such as Shane Fisher's in Auckland and Brenda Moore's in Waikato - the family overrides privacy in favour of accountability, the public's right to know, and in the hope lessons may be learned.
Toran's mother, Maria Bradshaw, has been speaking out more than most - making herself unpopular with Toran's school, Takapuna Grammar, the Marinoto North Child and Adolescent Mental Health Service of the Waitemata District Health Board, and even the police.
"I believe that it takes a village to raise a child and I accept my very strong and real responsibility as a parent, but I feel very, very, let down by my community," she tells the court.
The Coroners Court follows an inquisitorial process quite different from the adversarial system that pits the prosecution against the defence with a judge or jury deciding the outcome.
Evidence is given to the coroner then cross-examined by the other parties - in this case by barristers for the school, Marinoto, two psychiatrists and the police.
Five against one seems an unfair fight. At times it appears quite adversarial too, in the way barristers frequently leap up to object to lines of questioning.
What soon becomes apparent is the massive amount of evidence gathered, plus the fact that our court system is still using paper rather than computer files.
The legal teams trundle in each day with suitcases from which they extract fat ring-binders of documents - Police Bundle One and Two, Takapuna Bundle, Waitemata Bundle Volume One and Two, etc.
The weighing of evidence is meticulous, laborious and terribly time-consuming as witnesses flip pages to be taken to various sections of the documents to confirm or dispute facts.
Expert witnesses called by the coroner bring more documents in the form of scientific research papers, largely to deal with the question of whether Toran's medication played a part in his death - as covered in the NZ Herald on Wednesday.
Bradshaw's criticism of the police is relatively minor, but highlights the difference between suicide and crime. When it's fairly obvious, as in Toran's case, that death is self-inflicted, meticulous scene examination does not always occur.
"It is very important that when a child does commit suicide we gather every shred of information we can that may help us to prevent future deaths," says Bradshaw.
Toran's autopsy report makes no mention of his black eye from a fight the day before and initially shows no evidence of the anti-depressant fluoxetine, better known as Prozac, in his blood. Only on Bradshaw's insistence was another test carried out to show fluoxetine present at therapeutic levels.
Takapuna Grammar staff give evidence they acted professionally and did what they could to support Toran when he was at the school, but his lack of attendance made it difficult. Some teachers were aware Toran had self-harmed, that he was taking fluoxetine for depression and that he was under the care of Marinoto, but others were not.
The recurring question is how mental health information about students should be shared. The school is highly discreet about communicating mental health matters, signifying it only by the initials of a staff member attached to the student's name in the minutes of meetings.
Moira Macnab, representing Bradshaw, asks a Takapuna Grammar staff member why.
Ms Macnab: At this stage, you are aware that Toran, according to you, has health issues and has attempted to kill himself, yet it would appear the notes would suggest that he is discussed as wagging and working with you. It is inconsistent, is it not?
TGS Staff: I would never put detail about a student wanting to kill himself in a dean's meeting, discussed in that way. It is an indication that there are guidance issues, and that is a signal to other deans and senior management who read the minutes.
Ms Macnab: So are you saying anybody who wags has heath issues?
TGS Staff: No, I am not saying that.
Ms Macnab: There is no mention of health issues here at all, is there?
TGS Staff: No, there is no mention of health issues. I think that the staff in the school for whom these minutes are taken, which are the deans and the senior management, know that if students are connected with me, even my knowledge of them, that it means that there are mental health issues.
The same issue is taken up with a teacher who was asked to reintegrate Toran back into his class in 2007 after he had been away, attending Northern Health School.
Ms Macnab: Do you consider that it was a bit unfair that you were not told of Toran's health situation?
Teacher: In terms of being a school teacher in my situation, I would have thought, in hindsight, it would have been a good idea to know. Yes.
Ms Macnab: So you were not told that he was under Marinoto care?
Teacher: No.
Police barrister Chris Morris attempts to move the discussion forward with a senior teacher, asking whether it was sometimes necessary for teachers to monitor some students during the day, such as when a student was a diabetic.
Mr Morris: How would that student's condition and possible needs be communicated to those at the coalface?
Senior teacher: There is a document produced annually which lists the physical and medical conditions of students, which indicates students, for example, who have insulin dependency or who have reactions to various items that is distributed to staff on a confidential basis.
Mr Morris: Allergies to bee stings, all those sorts of things?
Senior teacher: Absolutely, correct, yes.
Mr Morris: Is there anything similar in existence for students that may be on medication for mental illnesses?
The senior teacher confirms that school does not have a formalised system to convey such information.
Other communication problems emerge. Early in 2008 Toran wanted to turn his life around and go back to school to get the NCEA credits he needed to do an AUT course. He was advised it couldn't be done by staff who were unaware of his difficulties and care under Marinoto the year before. With his plans dashed, he became dejected.
Similarly, when Toran was brought to the school by the police in a distressed state, no one asked Toran, or tried to get to the bottom of, what had happened - that he had run out of a session at Marinoto because he thought the staff were trying to put him into foster care.
Toran also had unresolved feelings about his father, a Cook Islander, who had not seen him since he was 14 months old. His mother told of violence against her, having to leave Rarotonga and being granted a protection order.
At age 7 a meeting was arranged between Toran and his father, but his father failed to attend. Sometimes, rather than tell friends, he would say his father was dead. One of his friends was asked how he felt. "What he said he really wanted to do [was] tell his dad how he really felt about him. He never got to do it."
Against this background, much of it unknown to Marinoto, staff at Malaga, the cultural arm of the service, told Toran they knew his father, who was in a relationship with a niece of one of the staff, and that they would try to organise a meeting.
His father didn't want to meet Toran. "I agree with you that for Toran to anticipate meeting his father and then for him not to meet his father would have been incredibly distressing for him," a psychiatrist tells the court.
The coroner questions the clinical director of Mental Health and Addiction Services at Waitemata, Murray Patton, who was not with the service during Toran's period of care, about the incident.
Coroner: You would agree that an absent father in a young man, 16 and 17, who had been absent for some time and who had been - for whatever reason, unable to meet commitments to meet with him earlier in his life prior to the interaction, would be a matter of great sensitivity in dealing with an adolescent who had presented with Toran's particular set of problems to Marinoto?
Dr Patton: In general, yes.
Coroner: Yes, and you agree that the way in why that was handled by the Waitemata District Health Board in general was not good?
Dr Patton: Look, I am very concerned that there was such a marked disparity between what was understood to have been agreed, I am very concerned about that.
Coroner: There was an error made, yes? This is very important - are you not accepting that something went wrong?
Dr Patton: I am saying, I do not understand why there were such different views about whether or not an agreement had been made, a commitment to set up the meeting - that troubles me. I do not know what was behind that, so I do not know whether that was an error or not. I just do not know whether it is one of those failings in communication where people are just talking past each other despite best intentions or whether it was something of a different nature.
Coroner: So you are unwilling to accept that an organisation that was aware of the importance of this particular facet of Toran Henry's problems needed to be scrupulous about dealing with that particular facet of his problems, that is the absence of his father?
Dr Patton: No, I would accept that completely.
Patton concedes the service was not scrupulous in the way it dealt with the situation and didn't do enough to provide some redress.
Another disparity for the coroner to decide on is the interaction between Bradshaw and the psychiatrist who prescribed fluoxetine to Toran in 2008.
The psychiatrist had not met Toran before, had only about half an hour beforehand to read his medical file and had to conduct the consultation in a cafe.
Toran had asked to go back on fluoxetine, but did not want to meet at Marinoto because of an incident with Malaga staff who kept trying to talk to him when he didn't want to. At the cafe Bradshaw raised concerns with the psychiatrist about side effects from fluoxetine.
Ms Macnab: And in fact, I asked [Marinoto staff] about your conduct and asked this question, this is at page 1887, and was it at a level that would be quite intimidating to a family member hearing it. [Marinoto staff's] answer was yes. Do you accept that you are intimidating?
Psychiatrist: Absolutely not.
Ms Macnab: Do you think that it is acceptable to come across as intimidating?
Psychiatrist: I am practising as a doctor in New Zealand. Me being intimidating with my clients is absolutely ridiculous and I do not believe that Ms Bradshaw would tolerate that anyway, if it was the truth.
Ms Macnab: Well, so you are saying [Marinoto staff] and Ms Bradshaw are making up that you came across that way?
Psychiatrist: Well, you said it.
Expert witnesses give evidence that it was appropriate for the psychiatrist to prescribe fluoxetine. They also say Toran's diagnosis of depression was correct, countering his mother's concerns that Toran's real problem was substance abuse - mainly binge-drinking.
At times Toran drank a lot - in one instance 18 stubbies and half a bottle of Malibu - although his social workers say that was not particularly unusual for his age group. Several psychiatrists point out that depression and drinking go hand-in-hand. He was advised not to take his medication when he was drinking.
There's no doubt, too, that Toran was troubled, presenting to hospital emergency departments on three occasions, twice for self-harming and once for threatening suicide.
At various times he had had relationship difficulties with girlfriends, trouble with the police for driving outside the conditions of his licence and remorse over stealing money from his mother.
His schoolwork had suffered, he was wagging often, plus he felt fatigued and had lost weight.
In the last few days of his life, he was also picking fights, including with his close friends, which was out of character.
The tragedy was that no one, including his mother, could imagine Toran would decide to take his own life.
"That morning I had sat on the end of the bed and chatted to him, we talked about our plans for Easter, he was relaxed, happy, looking forward to things," his mother tells the court.
The coroner on Tuesday made a ruling of self-inflicted death and adjourned to make his written findings.
