The Canterbury District Health Board (DHB) has apologised to the family of a young man who died under their watch, after a coroner found there were shortcomings in the care he received from hospital staff.
Harry McLean died in Christchurch Hospital's Intensive Care Unit on 24 November 2013, three days after being admitted to the hospital's emergency department.
Prior to that, the 18-year-old had spent most of November at the city's psychiatric hospital, Hillmorton, and had been admitted to the same hospital twice in August that year.
Mr McLean was diagnosed with depression and was under varying levels of observation.
On the morning of 21 November, Mr Mclean was reviewed by his psychiatric consultant, a nurse and a trainee medical student.
During the consultation Mr McLean revealed he was thinking about suicide at night, and on the previous night he had formulated a plan.
A subsequent Serious Incident Review into his death found that this meeting was not documented well, and the response to Mr McLean's disclosure was not detailed.
Coroner Sue Johnson reported that there was no note "showing any attempt to reduce the risk of Harry becoming suicidal again that evening".
During the day Mr McLean went on leave from Hillmorton with a friend from the hospital for several hours in the afternoon. When he returned a nurse asked him if he had been drinking, because he had consumed alcohol while on earlier leave, but he denied that he had.
Mr McLean was given lorazepam at 9pm, and asked to be given a sleeping tablet later in the evening.
At this stage he was under the standard observation of every 30 to 60 minutes, he was sighted at 9.30pm and at 10pm. However, he was only sighted by a nurse aide, not a qualified nurse, and he only needed to be seen, not engaged or interacted with.
At 9.45pm a staff member found Mr McLean's room was locked. The staff member was going to override the lock, but Mr McLean came out and said he was okay.
At 10pm he was given the sleeping tablet he had asked for by the nurse, and at 10.15pm he was taken from Hillmorton to the Christchurch Hospital's emergency department by ambulance.
At the emergency department it was found he had an alcohol blood level of 69 milligrams per 100 millilitres of blood.
The review conducted into Mr McLean's death found there were some "shortcomings in the care delivery service provided."
It found that it should have been possible to determine that Mr McLean had been drinking, but it did not state who should have determined that or how.
The staff who saw him that evening said they could not smell alcohol and there was no indication he had been drinking.
Coroner Johnson found there was no plan by hospital staff for Mr McLean if he felt suicidal again.
She ruled his death was self-inflicted, but not suicide.
Coroner Johnson said that she "cannot be satisfied to the requisite standard that Harry had sufficient judgment to form a true intent to end his life".
The coroner was still considering elements of the case.
In a statement, Canterbury DHB chief medical officer Dr Sue Nightingale said "our condolences and sincere apologies go out to Mr McLean's family who experienced this tragic loss of their relative while they were a patient in our care".
"We accept and acknowledge the Coroner's findings. We would also like to reassure that we are always working hard to improve the care we provide to reduce the chances of a tragedy like this occurring again."
Where to get help:
Lifeline: 0800 543 354
Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO (24/7). This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
Depression Helpline: 0800 111 757 (24/7)
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email firstname.lastname@example.org
What's Up: online chat (7pm-10pm) or 0800 WHATSUP / 0800 9428 787 children's helpline (1pm-10pm weekdays, 3pm-10pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.