Law changes are needed following the "unnecessary" deaths of three young people who took their own lives shortly after being released from care, Rotorua Coroner Dr Wallace Bain says.
Dr Bain's report into the death of 17-year-old Kayla Marie Wright in Tauranga in 2008 was released today.
The teenager's death followed two others in similar circumstances, which was "heartbreaking", Dr Bain said.
All three had been in a place their families regarded as secure for mental assessment, he said.
"Astoundingly and to the complete surprise of their families and friends, all three have been released after medical assessments which had deemed that at the time of their assessment they have not met the strict criteria to be detained and loss of their liberty.
"This despite the fact that it was as clear as day follows night that it was highly likely that they would attempt to commit suicide very soon after their release. All three did. All three lost their lives."
Their deaths were "unnecessary", Dr Bain said.
If they had been detained and received proper medical attention they could have been treated to a point where they could take their place in society, he said.
He made recommendations including that medical professionals be given the statutory authority to detain people until they are well enough to return to the community.
No person should be released from a mental institution until families and care givers had been contacted. The discharge decision should not be left to the patient themselves, Dr Bain said.
Clinicians should be able to impose conditions on releasing a patient, such as compulsory supervision. If conditions were breached the person would be returned to care, he said.
"Any suggestion of an infringement of liberty and personal rights surely has to pale into the background against the primary focus of trying to keep a person well and preventing self harm such as taking their own life, particularly when they have clearly signalled that is exactly what they want to do."
Dr Bain also recommended greatly widening the definition of mental disorder in regards to the law and an urgent review of the adequacy of community care services to patients who have a history of mental disorder.
NZPA