A Coroner's report into the death of a teenager who had depression and died of a drug overdose, says Hutt Valley District Health Board should establish a broad case management system for patients.
Rachel Mackley, 17, was admitted to Hutt hospital three times in September 2010 for overdoses.
She died in hospital after overdosing on pills she had been prescribed to alleviate anxiety.
She had been assessed by a number of organisations including the DHB's youth health trust and the child and adolescent mental health service.
Coroner Garry Evans found the board's management plan for Ms Mackley was inadequate.
He says the board needs to implement broader case management to ensure patient care is co-ordinated and clinical responsibility is clearly identified.