KEY POINTS:
The double-suicide of a young West Coast couple was "an entirely preventable tragedy", say grieving family - but mental health services say they "did everything right" in their handling of the case.
Leanne Foster, 26, took her own life, six months after giving birth through IVF treatment to a baby daughter - and a day after mental health services declared she was not a suicide risk.
Left to bring up baby Nicole on his own, Foster's partner, 32-year-old Brendon Alexander, went into a downward spiral and six weeks later was found dead in his car on an isolated track overlooking the cemetery where Foster was buried.
Last week Westport coroner Peter Roseli ruled suicide as the official cause of Alexander's death.
The double-suicide has rocked the small South Island town of Reefton and left the couple's now 21-month-old daughter Nicole an orphan. Since Alexander's death, she has been jointly cared for by both sets of grandparents.
Although the coroner's decision has brought some closure for both families, there is still anger over the way mental health services handled Foster's case.
In an exclusive interview with the Herald on Sunday, Foster's parents said had warning signs been heeded, their daughter and her partner would be alive today.
Leanne Foster's father, Jimmy, alerted Christchurch Hospital to his daughter's mental state on March 5 last year and was referred to the hospital's emergency psychiatric team.
After speaking to Foster on the telephone they recommended she make an appointment to see the mental health team at Greymouth Hospital.
Christchurch Hospital is standing by its handling of the case, saying that, from the evidence it had, Foster did not warrant emergency mental health service intervention.
At the time Foster was suffering depression, which the family believe was brought on by the arrival of her daughter Nicole, anxiety attacks and paranoia.
She was seen in Greymouth the following day and after a 90-minute assessment it was decided Foster was not a suicide risk. She was sent home with sleeping pills and told to make an appointment for a full medical assessment at the Reefton Medical Centre. The next day Foster committed suicide.
"I told mental health services I had grave concerns for her wellbeing. Those were my exact words. This was an entirely preventable tragedy," Jimmy Foster told the Herald on Sunday.
"If we had marched her (Leanne) inside Christchurch Hospital and demanded action, she and Brendon would be here today. That's a certainty.
"We were in Christchurch. I should have insisted we be seen in Christchurch, not Greymouth, simply because it's closer to where we live. ... Jimmy Foster said that when his daughter was seen in Greymouth he was told "she's fine, she's not as bad as you told us".
Helen Foster puts the blame at the door of Christchurch Hospital. Had they admitted Leanne at the time and assessed her properly, both Nicole's parents would be alive today, she said.
However, in his ruling Roseli said mental health services could not have foreseen that Foster would commit suicide a day after being assessed as not at risk of harming herself.
A review of the case by independent consultant Dr Graham Mellsop also found mental health services had made rational decisions about Foster, given the information they had to work with. He concluded that a face-to-face assessment of Foster in Christchurch was unlikely to have resulted in a different management plan for her.
West Coast District Health board chief executive Kevin Hague told the Herald on Sunday that while the deaths were a tragedy, Foster had received timely access to mental health services.
"In this situation the family and mental health services did everything right - but unfortunately they were unable to prevent this tragedy from occurring."
