THE mother of a Lavington teenager who took his own life in 2010 is upset with a coroner's finding into the death and considering appealing.
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Deputy state coroner Paul MacMahon handed down his finding on Friday into the death of Zac Birch, 15, after taking evidence in Albury over two days in June.
Zac's mother, Teena Conway, yesterday expressed her disappointment at the finding and spoke to her Sydney solicitor Bill de Mars.
"He is having a look to see whether I can appeal or not," Ms Conway said.
Mr MacMahon said no blame or criticism could be attributed to the Albury Base Hospital or the Child and Adolescent Mental Health Service.
But Ms Conway said her son was "totally let down".
He was taken to hospital by ambulance after an overdose on medication on April 5, subsequently discharged and returned home despite his mother's insistence he should stay.
Three days later he was found dead.
Ms Conway said he was not assessed by a psychiatrist at the hospital, had previously not been considered a child at risk by the Department of Community Services, and the Child and Adolescent Mental Health Service failed to make a phone call to check on him the day before he died.
Since her son's death she said procedures at the hospital, CAMHS and DOCS had changed.
"That in itself indicates to me they know they did the wrong thing.
"They let me down and they let him down.
"I kick myself for not demanding to be put on the stand to give evidence at the inquest."
Ms Conway said she had wanted her son assessed but evidence at the inquest contradicted that assertion.
Mr MacMahon said in his finding: "Zac's death was a tragedy".
"His actions in acting to end his life appear to have been associated with his mental health condition."
"It would seem that the deterioration in Zac's mental health was fairly sudden and unexpected," Mr MacMahon said.
"As Ms Conway had observed in the morning, he was very sociable, laughing and making plans for the future.
"As the afternoon developed, however, this changed with the tragic consequences that followed."
Mr MacMahon said the inquest looked at the quality of services provided by the hospital and CAMHS.
"It would seem to me that it is in the public interest for the public to be aware that such examination has occurred and the outcome of it," he said.
"This is particularly the case where services are found to be inadequate but it is also the case where, as in this case, the services provided are appropriate."
'No one to blame for death'