A review of the Waitemata District Health Board's care of a depressed teenager has found it was deficient.
Toran Henry, 17, died suddenly just before Easter, a day after getting into a fight at school.
The report has concluded the DHB's mental health services were under-resourced and this had a direct impact on Toran's care.
It found a registrar's advice that he need not take his anti-depressants on the days he drank alcohol did not make sense, and says this could have reduced the effectiveness of the medication.
DHB clinical director Murray Patton says he does not accept all of the report's findings and recommendations.
Several other reports have been commissioned and an inquest will take place later this year.