A CORONER says a lack of staff and work pressures were the likely reason an Albury teen suicide victim didn't receive a follow-up call on the day he died.
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Deputy state coroner Paul MacMahon has outlined the tragic tale of how Zac Birch suffered a depressive illness when just 13 ultimately taking his life two years later.
His mother, Teena Conway, was so concerned in 2008 that she arranged for him to see a paediatrician, who diagnosed depression and prescribed medication.
Zac was referred to the Child and Adolescent Mental Health Service and had a number of consultations.
Mr MacMahon said in 2010 Zac agreed to seek medical help again, receiving a referral in March to a psychiatrist but was unable to get an appointment until July.
He took an overdose on April 5, was taken to hospital by ambulance and assessed by a mental health team.
The 15-year-old was discharged despite his mother's opposition but was referred to CAMHS for follow-up care.
An officer from CAMHS rang the following day and spoke to Ms Conway but Zac refused to speak to her and terminated the call.
Mr MacMahon said evidence from a doctor indicated when examined at hospital Zac was not suffering from any medical or other physical condition which would require him to stay there.
He was assessed by the Mental Health Emergency Service with Brad Rothenberg part of it.
"Mr Rothenberg was not of the view that Zac's condition was such that he could be scheduled as an involuntary patient under the Mental Health Act," he said.
It was considered Zac's difficulties could be best managed in the community by CAMHS.
Mr MacMahon said what happened was subsequently reviewed by associate professor Michael Robertson, who considered it had been appropriate.
"I am satisfied that this was the case and that no adverse comments ought be made concerning the care provided to Zac at the hospital on April 5," Mr MacMahon said.
He said a CAMHS representative was to phone on April 7, the day after the terminated call.
"I consider that Zac's refusal to engage with CAMHS raised concerns as to his well-being that ought to have been followed up as a priority," Mr MacMahon said.
"I also accept that CAMHS officers were developing an assistance plan and were subjected to work and other resource pressure and that this may explain why there was no follow on April 7."