Coroner Tim Scott wants the suicide of a New Plymouth student who was in trouble with his parents to act as a warning to others.
The 16-year-old was found dead at his home last July and Mr Scott's findings were made public last week.
The boy's name and the names of those involved in the case were suppressed as they were entitled to privacy, he said.
There could be some benefit from making public the circumstances of the boy's death "in the hope that it may at least reduce the chances of similar deaths in the future", Mr Scott said.
"His death does serve as yet another example of the tragedy that can occur for apparently relatively insignificant reasons and with probably inadequate warning."
The boy's brother found him dead in the family garage.
"It was clear that his death was self-inflicted and a suicide," Mr Scott said.
The boy's mother told police her son's death was "totally out of the blue and totally unexpected".
Mr Scott said an "emotionally charged" note could only be seen as a suicide note. In it, he wrote "sometimes I think I would be better off dead".
The note referred to an incident that had upset him and recently another more lengthy note was discovered in a school exercise book.
During a telephone conversation on the day he died, the boy told his mother he wasn't going back to school and she now believed he meant it definitively because he intended to kill himself.
"She may be right. I cannot comment any further on that," Mr Scott said.
Sadly and tragically the note was a clear indication the teen intended to take his life but it referred positively to all family members.
The incident that upset the boy happened after his mother went to a rental house, where neighbours had seen young people coming and going, while the father was away.
The teenager had been staying there and had taken his father's car without permission and damaged it, he accepted responsibility but was grounded.
About two weeks before his death his mother discovered he had been leaving the house late at night, after everyone had gone to bed, to socialise with his friends.
Apart from some text messages, the boy did not give any indication of what he planned and those close to him believed he was thinking positively about life and his future, Mr Scott said.
"With the benefit of hindsight it now seems that the teenager became far more depressed than his mother realised over the incidents which led to his grounding.
"Even looking at the circumstances of [the teenager's] death with the benefit of hindsight, I cannot say with any certainty that anyone would or should have acted differently. Anyone determined to take their life will find a way and a means of doing so."
WHERE TO GET HELP IF YOU ARE DEPRESSED:
Lifeline: 0800 543 354
Depression helpline: 0800 111 757
Youthline: 0800 376 633
Samaritans: 0800 726 666
In an emergency, dial 111
- © Fairfax NZ News
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