A teen who committed suicide should have been referred to a psychiatrist after being prescribed antidepressants, a coroner says.
However, the mother of Jessica Wilkinson, 14, says her main concern is that teens be confronted with suicide's harsh reality.
"If she'd [Jessica] had a black and white account of the blunt facts of what happens when you do it [commit suicide], from the minute you do it until now, because it doesn't ever stop," Paula Vermeer said.
"And you can't take it back."
The findings come days after the Law Commission recommended more open discussion of the causes of suicide.
In findings released today into Jessica's death at her Masterton home on August 24, 2011, coroner Garry Evans authorised publication of all aspects of his findings, except the mode of Jessica's death.
"The community is not protected against youth suicide by suppression of knowledge. It is imperilled," he said.
In his findings, he said Vermeer had told police that in the fortnight before her death Jessica had been "given a hard time" by a group of girls at her Masterton high school.
But speaking to Fairfax Media today, Vermeer said she did not blame the girls, and that Jessica had not been bullied "as such".
"But you never know what somebody else is going through or how things affect ... them ... and some people just aren't as well equipped to cope as others," Vermeer said.
The coroner found Jessica had also been affected by the suicide of the 16-year-old brother of a friend two months before her death.
When Vermeer had sought medical help, Jessica "clammed up" and wouldn't discuss her problems because she was alone in a room with three professionals, the coroner said.
In a letter from Jessica to a friend , Jessica said she was "going to miss her friend with all her heart".
The letter was found by Vermeer on the morning of the day Jessica she died
Concerned, Vermeer took Jessica out for tea after school, but she seemed happy at a family birthday that evening.
When Vermeer went to check on Jessica later that evening, she found the bed empty.
After a search Jessica was found in the garage, but was not breathing. Attempts to revive her failed.
The coroner said the community needed to reflect on complex factors that made young people vulnerable to suicide, warning signs and the need for access to treatment, advice and community support.
He called on Wairarapa District Health Board chief executive Graham Dyer to make improvements in mental health services.
The public should know about steps taken to rectify deficiencies, the coroner said.
The board should make sure all young people on medication for depression or other mental health issues, and involved with the board's child and adolescent mental health services, were also seen "promptly" by a psychiatrist.
That did not happen in Jessica's case, he found.
He also called on the board to review criticisms of it by Jessica's grandmother, Trish Wilkinson, a registered nurse, who said the board had stopped following protocols developed after a Health and Disability Commissioner investigation into Jessica's death.
Lifeline: 0800 543 354 - Provides 24 hour telephone counselling
Youthline: 0800 376 633 or free text 234 - Provides 24 hour telephone and text counselling services for young people
Samaritans: 0800 726 666 - Provides 24 hour telephone counselling.
Tautoko: 0508 828 865 - provides support, information and resources to people at risk of suicide, and their family, whānau and friends.
Whatsup: 0800 942 8787 (1pm to 11pm)
Kidsline: 0800 543 754 (4pm - 6pm weekdays)
If it is an emergency or you feel you or someone you know is at risk, please call 111
For information about suicide prevention, see http://www.spinz.org.nz.
- Fairfax Media
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