A coroner says a Lower Hutt woman who killed herself in 2012 made a final plea in a message to her family
Ian Smith says the Hutt Valley District Health Board dropped the ball while trying to organise counselling for Sara McInally.
Over more than seven weeks, the DHB made four counselling appointments for the 28-year-old after she had drunk anti-freeze and been admitted to hospital.
However, due to administrative mistakes and staff sickness, none of the appointments happened.
Mr Smith said the repeated delays clearly had an impact on Ms McInally's state of mind, as a final text she sent to her family read: "Love you all, try and change the system to make it easier to see a counsellor".
The DHB has apologised and promised to make improvements, but Mr Smith said those changes are overdue and would need continual monitoring when they are made.
