A coroner's report into the suicide of a Porirua teenager has revealed many shortcomings in Child, Youth and Family's care of him.
Denbora Oum, 14, died in 2005 and Coroner Gary Evans recommends the department develops a risk assessment and risk management plan for everyone in its care.
Child Youth and family was involved in Denbora's life from an early age.
Then his school raised the alarm when, at age 10, he revealed he was being bullied by a sibling at home and wanted to die.
However, the coroner has found a recommended referral to mental health services was never made and no counselling reports were kept on his file.
Child Youth and Family head Ray Smith says CYF was struggling in 2005, but improvements have been made to the service since then and cases no longer queue for attention.