Mental health unit 'failed teen'

The coroner has found that care was deficient on several occasions before 17-year-old Toran Henry committed suicide. Photo / Supplied

A coroner has strongly criticised the care provided by a specialist youth mental health unit leading up to the suicide of 17-year-old Toran Henry.

Auckland Coroner Murray Jamieson said Marinoto Child and Adolescent Mental Health Services' care of the teenager "was deficient on occasion and in particular on the day of his death".

His remarks were included in the findings of the inquest into Toran's death on March 20, 2008. The report was issued yesterday.

Dr Jamieson was critical that, in the face of escalating developments on the day of Toran's death, the Waitemata District Health Board's service left his care in the hands of a relatively inexperienced "key worker" who spoke to Toran by phone.

"Toran stated, that day, that he lost faith in one of his key workers, feeling that she had abused his trust," said the coroner.

He said the situation would have been better dealt with by immediate consultation with a specialist psychiatrist, who could have taken direct action "such as arranging an urgent home visit together with immediate admission to a secure facility if required".

There was criticism, too, of the way Toran had been prescribed the anti-depressant drug fluoxetine, better known as Prozac, which is not approved for treating major depressive disorders in children and adolescents in New Zealand. But it can be given to that age group by what is known as "off label" prescribing, which requires informed consent from the patient.

Dr Jamieson said the information given to Toran about the drug was not satisfactory. It was not a single comprehensive document, not up to date, not designed for a person of Toran's age and did not include clear advice about taking the drug in combination with alcohol or other drugs.

He recommended that Marinoto should review the information provided to adolescents, especially the importance of taking the medication as prescribed.

The coroner was also critical of the last occasion Toran was prescribed fluoxetine, at a cafe near Marinoto early in March 2008, by a registrar in psychiatry who had not met Toran or his mother, Maria Bradshaw, before.

The coroner said the consultation should have been carried out by a specialist psychiatrist "fully apprised of the history and clinical picture at a venue appropriate for such an important clinical encounter".

Dr Jamieson did not make any finding on whether taking the drug contributed to Toran's death.

Although the question came up during the inquest, the coroner has not addressed concerns that the drug packets in New Zealand do not carry a "Black Box" warning as required by the Food and Drug Administration in the United States. The warning explicitly states that "anti-depressants increased the risk compared to placebo of suicidal thinking and behaviour in children, adolescents, and young adults in short-term studies of major depressive disorder and other psychiatric disorders".

Malaga a le Pasifika, the cultural support service of Marinoto, was also criticised for the way it attempted, but failed, to organise a meeting between Toran and his father, Geoffrey Henry, a Cook Islander, whom Toran had not seen since he was 14 months old.

The coroner concluded that the circumstances relevant to Toran's death were:

* The career plan that Toran had set his heart on in early 2008 had proved impractical.

* Toran had been reminded of the absence and apparent rejection of him by his father.

* His relationship with his mother had been tense.

* His relationship with his girlfriend had recently been unhappy.

* The day before his death he had been humiliated in front of many peers when he was involved in a brief fight with a younger Takapuna Grammar School student.

* His abuse of alcohol clouded his judgment.

Clinical director of Mental Health and Addiction Services at Waitemata Murray Patton said a new fluoxetine information sheet had been developed for adolescents and children.

Marinoto clinical staff have also undertaken training to ensure all service users and families have knowledge of common and serious side-effects of psychiatric medicine and how to monitor for them.

Tragic toll
About 540 people a year take their own lives - many more than last year's road toll. More than 2500 New Zealanders are admitted to hospital each year through intentional self-harm.

Age range for 2009/2010:
* 10-14....7
* 15-19....53
* 20-24....189
* 25-29....136

Where to get help:
* Lifeline: 0800 543 354 (www.lifeline.co.nz)

* Youthline: 0800 376 633 (www.youthline.co.nz)

* Depression Helpline: 0800 111 757

* In an emergency (if you feel you or others are at risk of harm) phone 111

* Suicide Prevention Information New Zealand www.spinz.org.nz.