The mothers of two young men who killed themselves while under mental health care say that when the system fails it should be easier and quicker to find out what went wrong.
They said the investigations into their deaths took too long and were exhausting.
Maria Dillon's 18-year-old son Harry died in Christchurch's Hillmorton Hospital in 2013.
Before he killed himself he told medical staff he had been having suicidal thoughts the night before but Mrs Dillon said no suicide prevention plan was put in place for him.
He had been wrongly diagnosed as having narcissistic personality disorder and that had sent him into a downward spiral, she said.
She had to wait three-and-a-half years before being allowed to speak publicly about his death in hospital care - that's how long it took before the coroner lifted suppression order, she said.
The arduous investigation process began soon after her son's death when the coroner called, asking if she had questions about his care, Mrs Dillon said.
"It was only a week after he died, I couldn't talk I was crying and so I wrote him an incredibly long email, but at that point I didn't have Harry's notes, I didn't have any information to go on other than what I had observed, what Harry had told me and that gut instinct," she said.
She said she was surprised the email ended up being the backbone of the Canterbury DHB review and the coroner's inquest.
She was lucky she had a passionate lawyer but the process was still incredibly painful, she said.
"It was hours and hours sitting on my lounge room floor going through Harry's notes or the serious incident review and cross referencing and the notes say this, but you've said that, and then there's the autopsy report, it went on for such a long time.
"In a big way as a parent you do everything you can possibly do for your child and that was what I could do for Harry," she said.
The coroner made a series of recommendations, including informing staff response plans are to be put in place when patients show signs of being suicidal.
The Canterbury DHB said it has been done but Mrs Dillon said she was still not sure the changes would guarantee other young adults were not misdiagnosed.
Corinda Taylor from the Suicide Prevention Trust said five years after her son Ross died in Dunedin she is also still waiting for answers.
She said before his death the family had contacted the Southern DHB many times worried he was going to take his own life.
She took her son's case to the Health and Disability Commissioner who found fault with his care and said a psychiatrist should apologise to the family.
That still hasn't happened to the required standard, she said.
The DHB's Dr Brad Strong said staff have met with Mrs Taylor many times, provided her with information as requested, and done everything the Commissioner's asked.
But she didn't accept that.
"They simply have refused to answer any of the questions, we've had to result to doing official information act requests and that is kind of upsetting because in the media they say they are working together with us, which couldn't be further from the truth," she said.
The commissioner's office has told RNZ News that it is assessing whether some of the recommendations have been met.
Five years on the case is still before the coroner and Mrs Taylor is waiting to find out if there will be an inquest.
The whole process has almost broken her family, Mrs taylor said.
She said other families she works with don't even get to the stage where their complaints are heard.
"Simply because it is too hard to make a complaint.
"When you want to make that complaint you need to have your wits about you, resources, financial assistance, legal support and emotionally most people are so fragile when they make these complaints, they possibly don't do the complaints as well as they could," she said.
The Health and Disability Commissioner's office said only around one in 20 complaints it receives are formally investigated.
But it said that DHBs comply with 99 percent of its recommendations when it does investigate.
Where to get help:
Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
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 email@example.com
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.