The mother of a 16-year-old whose suspected suicide was the "catalyst" for several teenage deaths says better communication between agencies could have saved her son.
Masterton resident Toni Ryan found the body of her son Sam in their home last June.
Sam had dyspraxia and mild autism, suffered from depression, and had become increasingly involved with drugs and alcohol in the lead up to his death.
On the day he died he had stolen his father's truck before locking himself in his sleepout bedroom.
His death was followed by several others in Wairarapa, sparking a crisis meeting amid fears of copycat suspected suicides among the region's youth.
At an inquest yesterday Mrs Ryan made a tearful plea for all agencies involved in suicide prevention to communicate better.
"You knew [he was at risk] because I told you I was terrified my baby would kill himself - you knew that," she said.
"But you don't talk to each other . . . and nobody was stepping in to protect him from his own behaviour."
Mrs Ryan said a lack of support for her family had since led her to start a group, Friends and Family of Suicides.
"When I lost Sam he was the first of those young fellas in a long spate . . . then I watched as we started losing more of our babies, so I made the decision to start a support group.
"This community needs to realise what an incredibly valuable resource they have in those of us who have lost loved ones."
Coroner Ian Smith endorsed her actions, and urged those present to accept Mrs Ryan's offers of help.
"You listen to her, you take this lady onboard, you take her to the meetings . . . and you listen to the grassroots of people who have been there."
He did "not want to hear" that she had not been included in the region's suicide prevention programmes.
A family friend, Warren Adam, echoed Mrs Ryan's sentiments.
"I firmly believe that Sam's death was preventable, and the lack of action by some of the agencies involved was unacceptable. A lot of people are still pretty angry about the whole thing - I am, certainly."
A psychologist and a youth justice co-ordinator who gave evidence both said Sam repeatedly refused to engage in counselling and often turned up to meetings under the influence of drugs.
As he was 16, he was "entitled to refuse help".
Mr Smith reserved his decision.
- © Fairfax NZ News
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