Teen let down by carers
Boy’s death could have been prevented.
The coroner has criticised the Ministry of Social Development in a damning finding that said a teen’s death might have been prevented if an overworked, inexperienced social worker hadn’t failed to appropriately act on his suicide threats.
The 15-year-old died in 2014. The boy’s social worker, the worker’s supervisor, his school principal and school counsellor and his family therapist knew of his suicide plan but didn’t tell the teenager’s parents.
An inquest was held in two parts, in 2015 and 2016, and this week coroner Marcus Elliott released his findings, criticising the ministry for failing to dedicate proper resources to the “complex” case, or give social workers enough training.
Legal restrictions prevent the teen and those involved in his care being identified.
He was in the ministry’s custody after intervention by Child Youth and Family (CYF) but was living with his parents in Auckland when he died.
Since his death CYF has been disestablished and its role taken over by the new Ministry for Vulnerable Children, Oranga Tamariki.
The morning of his death, the teenager detailed to the family therapist a plan to commit suicide.
The therapist warned the boy’s CYF social worker he was at “high risk” of suicide before phoning the boy’s mother, telling her to monitor her son but not specifying he was suicidal, because of fears of how the teen’s father would react.
The social worker informed the boy’s school of his comments. However, the counsellor and school principal opted to leave the matter with CYF after speaking to the teenager.
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The social worker consulted her superior and contacted a mental health assessment team but according to the findings didn’t follow the correct process in urgent situations and faxed a referral form after 5pm.
The fax wasn’t seen by the assessment team until after the teen had died. There was dispute over whether the social worker informed the team’s receptionist of the urgency.
A review of the case by the Chief Social Worker identified the social worker was “overwhelmed” by her work with the teenager’s family — a particularly complex case. The social worker and her supervisor agreed they were inexperienced in dealing with suicide concerns in young people and coroner Elliott said their failure to grasp the immediacy of the risk affected their response.
Elliott didn’t blame the social workers, but criticised the ministry. “[It] placed its employees in a position where they didn’t have the capacity to give this situation the attention it deserved . . . This was not fair on the family, nor was it fair on [the workers],” the findings say.
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“It is not clear that [the CYF workers] had been sufficiently trained in understanding the potential triggers for suicidal risk — and the importance of addressing these — or the urgency of expressions of suicidal ideation.
“To a large extent, the shortcomings of the afternoon . . . were a consequence of the ministry’s failure to provide the necessary resources to deal with the difficulties that day. This meant that all possible preventive steps were not taken that day . . . [the] suicide might have been prevented had they been taken.”
After the Chief Social Worker’s investigation improvements were made to how it supported families, including giving social workers more direct contact with young people and their families, more training to deal with suicide concerns and employing more staff. These were in line with the coroner’s recommendations.
Oranga Tamariki regional manager Jaimee Barwood offered condolences to the teen’s family.
“The death of a young person is always a tragedy for all those who knew him. It is also something our staff feel deeply. The ministry acknowledges the coroner’s findings in this case, and is now considering his recommendations in detail.
“We share the coroner’s view that it is important to consider if this case contains lessons that will help prevent the loss of young people in similar circumstances in the future.
“We note the coroner’s comment that no one is to blame for this young man’s death. We also note that a number of agencies had responsibilities relating to this young man.
“In this case we agree with the coroner and chief social worker that more information should have been shared with this young man’s parents. However, we must always place the interests of the child first.”
Mental Health Foundation chief executive Shaun Robinson said the lack of intervention in the teenager’s case was “very concerning”.
“We would hope that social workers, therapists, and school staff would have adequate training and support to appropriately respond to young people in distress.”