Teen’s grieving parents left asking just one question – what if?

Source: Radio New Zealand

Three years after Tauranga teenager Maddie Hall took her own life her parents are left with one unanswered question – what if?

What if Maddie had been given all the support she needed as soon as she went to Tauranga Hospital after trying to take her life in May 2020?

What if Maddie had received the comprehensive psychotherapy her clinicians agreed would be most beneficial?

What if Maddie’s early life was not upended by sexual trauma?

What if more could have been done to save her life? What if the mental health system was better?

Maddie died on 31 March 2023 at the age of 16.

Almost three years earlier in May 2020 she was found trying to take her life. It would later emerge she had earlier tried to kill herself in November 2019.

In findings made public on Tuesday following a 2024 inquest, coroner Marcus Elliott found Maddie died by suicide but there was “no aspect of the medical care which can be said to have ‘clearly linked to the factors that contributed’ to Maddie’s death”.

As a result, he had no power to make any comments or recommendations about Maddie’s death.

The Canterbury Suicide Postvention Working Group – a collection of agencies including health, education and care authorities that monitor and respond to suicides in the region – sought to suppress details of the coroner’s report and Maddie’s name.

The group submitted that four other young women had died by suspected suicide since Maddie’s death in circumstances that amounted to a “cluster” with links through direct peer connection, shared social networks or online

interactions.

The group also said a cohort of 44 other people in Canterbury connected to the “cluster” was at elevated risk of suicide contagion.

“These connections reflect an overlapping peer ecosystem in which distress, grief and identification with each other’s experience have been continually reinforced,” the group said.

The group was concerned about the “significant online and social media risk component associated with this case, particularly the unregulated dissemination and glamorisation of suicide related content on platforms such as TikTok and Instagram.”

Maddie’s parents, RNZ and Stuff opposed suppression.

In declining the application, coroner Elliott emphasised that while “there were areas in which service improvements were warranted, any shortcomings cannot be said to have contributed to Maddie’s death”.

“She received extensive mental health care, both in a public and private context. Her death does not support an argument that mental health care is unavailable to those who need it or that the mental health system is broken.”

‘Always room for improvement’ – family calls for change

In the three years before her death, Maddie was admitted to hospital 25 times and went to Tauranga Hospital’s emergency department more than 50 times.

She made more than 40 attempts on her life.

Her parents Gareth and Leanne Hall feel as if their daughter and family were an inconvenience to the public system.

Eventually they pursued treatment through a private psychiatrist but Gareth Hall believes it was too late to save Maddie despite the efforts of the “excellent and caring practitioner”.

“Health New Zealand and CAMHS (Tauranga’s Maternal, Infant, Child and Adolescent Mental Health Service), although they stood up in an inquest and said ‘we’ve looked back and there’s nothing we would have done differently’, well I’ll call bullshit on that,” he said.

“There’s always room for continuous improvement and everyone knows the mental health system in New Zealand, particularly for young children, needs massive improvement. Chris Luxon knows that. Matt Doocey knows that.

“In the first three months [following her May 2020 suicide attempt] there were six suicide attempts and a similar number of other incidents that required emergency services, police and/or ambulance, and there’s no support provided in those three months,” he said.

“So we knew something was lacking pretty early on in the piece.”

For three months after the May 2020 episode, Maddie did not have a key worker to co-ordinate her care and be a primary point of contact in the mental health sector.

The Halls would email clinicians to provide updates on Maddie’s condition and her symptoms.

“That seemed to be an inconvenience to them to hear from us. They eventually told us in a multi-disciplinary meeting a number of months into it just to stop sending them emails,” he said.

Maddie required comprehensive dialectical behaviour therapy (DBT), a dedicated psychotherapy for borderline personality disorder.

It was first recommended and accepted about six weeks after Health New Zealand became involved.

Maddie did not receive her first session until late November 2020, almost five months after it was accepted as a form of treatment, and following 13 hospital admissions.

“It is possible that Maddie would have been more amenable to DBT in July 2020 than she was almost five months later. It seems likely that, by the time of the first DBT session on 26 November 2020, her attitude may have been affected by the sense of ‘invalidation and trauma’ she was developing in relation to her public mental health service involvement,” coroner Elliott said.

“However, it is not possible to say whether the provision of comprehensive DBT from July 2020 would have prevented Maddie’s death. It is possible that it would, however a finding cannot be made to the required standard of proof about this.”

By February 2021, comprehensive DBT was no longer available to Maddie.

A ‘vibrant wee soul’

Leanne Hall said her daughter was a “vibrant wee soul” as a child.

“She was either going to be an artist or an early childhood teacher. She was a lovely, gorgeous little girl,” she said.

Gareth Hall said Maddie was kind, caring and empathetic, traits she maintained towards others even as her own world crumbled inside her head.

“A few of Maddie’s friends have said that they wouldn’t be here today if it wasn’t for Maddie. That’s how big an influence she was,” he said.

“She couldn’t help herself but she was unbelievable at helping others.”

Maddie’s decline could be traced to sexual abuse at the age of six.

Leanne Hall said they were unaware of the violation until Maddie told a friend when she was about 11-years-old and her friend told her father.

“If she didn’t have that sexual trauma at age six she wouldn’t have developed the PTSD and the complex mental health history,” she said.

The trauma catalysed into a deep darkness within her mind during her early teenage years.

As the Halls fought to save their daughter’s life they would sleep in her room at night to ensure she was safe.

“During those particularly quiet times and when she was struggling to sleep, she did tell us a lot of stuff and it was pretty harrowing to listen to that coming from your own daughter,” Gareth Hall said.

“When you hear your daughter repeatedly every day, say she wants to end her life, it’s hard to hear,” Leanne Hall said.

Gareth Hall said they both know it paled in comparison to how hard it was for their daughter.

“People don’t understand how much these kids suffer and that’s the thing that still burns us is how much Maddie suffered,” he said.

“There has to be something done to prevent these kids suffering as much as they do because if it was a medical disease you know everything in the doctors’ power would be done to try to reduce the suffering.”

No evidence deficiencies contributed to Maddie’s death – Health NZ

Health New Zealand submitted to the coroner that “there is no evidence that was presented during this inquiry that any alleged deficiencies in this care contributed to Maddie’s death”.

A serious incident review highlighted “service improvements”.

The review’s findings included recommendations relating to communicating with patients and their families, trauma-informed care and specialist pathways of care.

While coroner Elliott endorsed the review’s recommendations, he said any shortcomings in the care provided by Health NZ could not be said to have contributed to Maddie’s death because:

– The causes of Maddie’s illness were identified and treatment was provided

– The nature of Maddie’s illness meant that she was at a very significant risk of taking her own life

– The illness might not necessarily have been resolved by medical treatment

In a statement, Health NZ group director of operations for Bay of Plenty Andrew Boyd told RNZ the serious incident review had resulted in “learnings to start making practical improvement”.

“This was a highly complex case involving multiple agencies, providing care and treatment to Madeleine during the three years from her initial referral to the Maternal Infant Child and Adolescent Mental Health Services Tauranga,” he said.

The Halls did not accept that Maddie’s life could not have been saved and disagreed with the coroner’s decision not to make comments or recommendations.

“It’s possible that if Maddie had more help at those earlier stages and had a clinician at CAMHS who could have built a rapport with her in the first instance, which was critical and lacking, that there could have been a different outcome, but that’s all speculation,” Gareth Hall said.

“The coroner deemed there was no gross negligence that contributed to Maddie’s passing, we think that as parents having witnessed everything we did, we still disagree with that. That’s the coroner’s rulings based on the balance of probability but there’s always possibility.”

A handful of incidents stood out to the Halls, including a time when Maddie was strip-searched at Starship Hospital.

“It was barbaric. There was no kindness. It was like she was in a prison or something. For somebody that has gone through trauma and had PTSD to be faced with that, it’s huge,” Leanne Hall said.

On another occasion Maddie had surgery at Rotorua Hospital after harming herself, followed by a request to transfer her to Starship.

After Rotorua clinicians spoke to a nurse in Tauranga she was instead discharged and found wandering on railway tracks later that night.

The coroner’s report also said a police officer gave evidence to the inquest about two incidents in which the officer believed “that health practitioners argued with Maddie in a disrespectful and unprofessional way about her medication and that another practitioner who Maddie disliked and distrusted deliberately came into Maddie’s view ‘as if on purpose to wind Maddie up’.”

The coroner made no findings about the two incidents but said: “Any lack of professionalism or disrespect for Maddie would have been unsatisfactory. However, while health practitioners should act with patience and compassion towards a patient, there are reasons why this may not always happen.”

An ‘appalling’ youth suicide rate

While Gareth and Leanne Hall could not save their daughter’s life, they take solace knowing she knew how much they loved her.

“The one thing that we did achieve before Maddie passed away was that she knew she was loved because earlier on, due to her mental illness, she felt completely unlovable and didn’t feel loved,” Gareth Hall said.

“She saw what we did for her and despite the negativity of her mind she did realise that she was loved and that gives us some comfort because you wouldn’t want your daughter to go feeling that she wasn’t loved.”

The couple now hope to channel their love and Maddie’s memory into driving meaningful change in mental health services.

“Maddie would have wanted a change and improvements in the mental health system, she hated other kids suffering and we don’t want other kids to suffer like Maddie did either. So if something good can come from Maddie’s passing I think that will help us,” Gareth Hall said.

He said New Zealand had an appalling youth suicide rate.

“That is something that as a country we should be extremely embarrassed by and we need to do whatever we can to improve that statistic,” he said.

“That’ll improve a statistic but it will improve the lives of not just the children who are going through extreme mental illness but all their parents and family and friends.”

In his findings coroner Elliott referenced the government’s 2018 inquiry into the country’s mental health and addiction sectors.

“Mental health legislation was referred to as ‘outdated and inadequate’ and reform was recommended. Health New Zealand accepted the inquiry’s recommendation in this respect,” the coroner said.

“However this has not yet been implemented and the Act has not been amended. In relation to Maddie, Health New Zealand was working under the law as it applied at that time.”

In a statement, Mental Health Minister Matt Doocey said “every single life lost to suicide is one too many”.

“Losing a child truly is every parent’s worst nightmare and my thoughts are with Maddie Hall’s friends and family.

“For me as Mental Health Minister, the most important part of my role is listening to those who have been directly affected by suicide. I have met with the parents of Maddie Hall to hear first-hand what they feel we need to do to improve New Zealand’s mental health system. I believe the key part of improving the mental health system is incorporating voices of lived experience. The reality is that we cannot make the changes needed on the ground without listening directly to families who have unfortunately gone through what families like the Hall’s have experienced.

“I acknowledge that New Zealand continues to face high suicide rates, particularly among youth. We can and must do better.

“I think it’s particularly clear, we are long overdue for a better crisis response. No one in New Zealand should face barriers when seeking help for themselves or others and that’s exactly what this government is focused on doing.”

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 or text HELP to 4357.
• Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. 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 or text 4202.
• Samaritans: 0800 726 666.
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
• What’s Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
• Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
• Rural Support Trust Helpline: 0800 787 254.
• Healthline: 0800 611 116.
• Rainbow Youth: (09) 376 4155.
• OUTLine: 0800 688 5463.

If it is an emergency and you feel like you or someone else is at risk, call 111.

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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand