A coroner has found a teenager who took her own life in Masterton in 2011 should have been given a formal psychiatric assessment.
Garry Evans said the 14-year-old was depressed and stopped taking her medication a few days before her death.
Mr Evans recommended the Wairarapa District Health Board ensures that young people sent to mental health services are seen quickly, and all those given anti-depressants get a psychiatric assessment.
It appears the girl didn't get such an assessment, he said.
The girl's family first went to the DHB's Child and Adolescent Mental Health Service for help in 2009.
Her grandmother complained to the Health Commissioner, saying the service fell well short of providing adequate care.