An Auckland woman whose son died suddenly after being bullied at school has written a 161-page report she says outlines "gross negligence" leading to his death.
Toran Henry, 17, was found dead in his Takapuna home shortly after he was bullied at Takapuna Grammar School. He was being treated for depression when he died.
His mother Maria Bradshaw has spent four months researching, writing and producing a report she told NZPA summarises "all available evidence".
Her report - laid out and annotated as if it were a university thesis - would ensure the coroner had all available information to determine the cause of her son's death, she said.
It would allow the coroner to "identify the circumstances leading up to it, and make recommendations to prevent future deaths".
While her son was dead, he could still leave a legacy in the form of improved mental health services, Ms Bradshaw said.
"I'm here to do that for him."
Ms Bradshaw, who graduated with an MBA last year, is now on an invalid's benefit of $170 a week.
She did her report in Takapuna library, as she did not have a home phone or internet connection.
While it had been "very emotive" researching her son's death, she considered her report was more objective than others already carried out.
"I've employed my (MBA) research skills to be as objective as possible," she said.
"It's very emotive to me, it's very difficult, but everything I've said is an objective assessment of the research I found.
"My primary objective was to help me understand what happened to my son."
Ms Bradshaw said she had provided "documentary evidence of gross negligence by agencies and individuals with a statutory duty of care to my son".
Takapuna Grammar School, the Education Review Office, the Waitemata District Health Board and police have all examined their roles in the death.
"None of these investigations has operated from a complete information base, and all have been under resourced," she said.
She wanted to correct inaccuracies and fill in gaps for the coroner, assess whether the standard of care provided was up to standard, identify care deficiencies and areas where performance could be improved.
Ms Bradshaw has talked of launching private prosecutions, which would include manslaughter, and would be seeking exemplary damages.
She told NZPA she could not afford such action, so her hope was a lawyer would read her report and take up the case for her.
She alleged:
* errors in prescribing her son anti-depressants;
* police destroyed evidence at the death scene;
* failures by medical professionals to make correct diagnoses, by the school to protect Toran, and by the DHB to obtain informed consent before prescribing anti-depressants;
* perceived errors by psychiatrists;
* shortcomings in the autopsy report.
Ms Bradshaw even examined her own role as a parent, though in general her "critical errors" related to her failure to question the treatment provided by others.
She had tried to address her son's substance abuse, trying a range of strategies, and sought support from Toughlove.
She regretted not pushing the DHB to address the substance abuse.
"Had I done so, Toran may have been properly assessed and diagnosed and received support to abstain from or reduce his consumption of alcohol," she said.
"Given that he took prozac in order to reduce his tolerance for alcohol and achieve intoxication more quickly, this may have been the most important action I could have taken."
- NZPA
Mum of bullied boy releases report into his death
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