Her father Gareth Hall told NZME the extremity of the scenarios he and his wife Leanne faced with their severely mentally ill daughter are now a “distant dream” as they grieved her loss almost three years ago.
He described the agony of navigating health services only to have the situation end how it did, and then have to traverse the complex world of the coronial process.
Now, they’re instead dealing with the disappointment their efforts to seek change in the health system appear to have gone nowhere.
Madeleine (Maddie) Hall with Pusskins, her therapy kitten. The 16-year-old’s death in March 2023 was found by a coroner to have been self inflicted, despite efforts by her parents and health professionals to address her severe mental illness. Photo / Hall family.
Madeleine Grace Hall, who was known as Maddie, died in Tauranga on March 31, 2023.
Coroner Marcus Elliott said in findings issued in May 2025, but only now able to be reported, the evidence established that Maddie’s death was self-inflicted in circumstances amounting to suicide.
The Halls have wanted to tell their story for some time, but were restricted by a non-publication order sought by a suicide prevention group against the coroner’s findings, which expired today.
The Canterbury Suicide Postvention Working Group (CSPWG) said it had “deep empathy and respect” for the Halls and did not want to inhibit their ability to speak openly, but applied for suppression of certain aspects of the findings relating to Maddie’s death.
CSPWG relied on a number of grounds in support of its position and argued that suppression should be granted based on its contention there was a cohort of 44 young people who were at an elevated risk of suicide contagion if a story was published.
The working group argued the cohort was connected to a “suicide cluster” and “established links can be evidenced” in the deaths of four young women by suspected suicide, in which Maddie’s death was the “index case”.
However, in declining the application for permanent non-publication Coroner Elliott said that while he accepted a risk exists, he found no evidence of any causative link between Maddie’s death and those of the other young women.
Nor did he find any medical evidence about the specific risks to any member of the cohort.
No lack of care
The coroner concluded following a detailed inquiry that while there were areas in which improvements were warranted, there was no aspect of Maddie’s mental health care which contributed to her death.
He did however identify a shortcoming related to the late provision of a “dedicated psychotherapy” or other specialised therapeutic approach in Maddie’s treatment, but the nature of her illness meant it might not have been resolved by medical treatment.
The coroner found Maddie had received “extensive mental health care”, both in a public and private context, and her death did not support an argument that “mental health care was unavailable to those who needed it or that the mental health system was broken”.
He said he was therefore unable, by law, to make any recommendations.
‘Kind, caring teen’
Maddie’s parents told NZME they had come to terms with the fact she was no longer with them, but not with how much she suffered.
Maddie, Gareth, Jacob and Leanne Hall on the jetty at Lake Rotoiti, St Arnaud, during a family holiday to the Nelson Lakes area in 2019. Maddie’s death in March 2023 was found by a Coroner to have been self inflicted, despite heroic efforts by her parents to keep her alive. Photo / Hall family.
They believed it might have been reduced with more kindness, compassion and empathy.
They described their daughter as “the kindest, most giving person in the world”.
Gareth Hall said she had a huge capacity for helping others in her peer group, even though she couldn’t help herself.
Complex case
Coroner Elliott said that before attempting to consider the issue of Maddie’s professional care it was important to recognise that she suffered from an “extremely serious, severe and complex illness”.
A consultant psychiatrist who saw Maddie said there was “not a diagnosis which captures the challenges Madeleine faced particularly well”.
Coroner Elliott first considered if Maddie’s illness was incorrectly diagnosed or characterised, but there was no evidence to suggest that this was the case, or that other alternatives should have been considered.
The Halls agreed with some of the findings, and some of the information in the coroner’s report was useful, but they were disappointed he was unable to make recommendations.
Gareth Hall said a key issue which had arisen, and which they wanted addressed, was the lack of interface between the public and private system.
Maddie Hall with father Gareth Hall in a Tuk tuk, during a family holiday to Cambodia in 2016. He described her as having a ‘huge capacity’ for helping others in her peer group, even though she couldn’t help herself. Photo / Hall family
“I think it’s an improvement that needs to be made. In New Zealand, we need all the resources we can get in this area, and we need those resources to work together, and they just don’t.”
He said there was no one silver bullet that would have saved Maddie, but it was an accumulation of many things.
‘Urgent, desperate and ongoing need’
Maddie became “seriously mentally ill”, to the degree it had a “profound and debilitating effect” on her.
It also had a significant impact on her family, and her parents’ lives became dominated by the “urgent, desperate and ongoing need” to try to get help for Maddie.
“One can only express admiration for the courage and fortitude they showed during a tumultuous and distressing time,” Coroner Elliott said.
Gareth Hall described the extreme scenarios the family had faced on multiple occasions .
They slept in her room each night, risked their own safety on occasions they had to coax her out of life-threatening situations and physically restrained her from others while waiting for emergency help.
Emails sent to health authorities reveal repeated calls for help, including for respite assistance for themselves.
Coroner Marcus Elliott concluded following a detailed inquiry that while there were areas in which service improvements were warranted, any shortcomings could not be said to have contributed to Madeleine Hall’s death. Photo / George Heard
Hall said instances when Maddie was in a disassociated state were especially challenging.
“Sometimes she would snap out of it and have no idea where she was or how she got there.”
Other times, medical intervention was needed to sedate Maddie who could lash out at those restraining her.
The coroner said Health NZ did not challenge the Halls’ statement that they had observed an “accumulation of negative factors”, particularly in 2020 and 2021 which impacted upon Maddie.
Nor did Health NZ challenge the evidence of a consultant psychiatrist engaged by the Halls, Davin Tan, who said Maddie was “highly resistant of public mental health service involvement because she felt invalidated and traumatised by staff there”.
He said this made it more difficult for him to treat Maddie.
Health NZ, in turn, was critical of some of Tan’s actions.
Tan, who was heavily involved in Maddie’s care from 2021, said her parents remained her greatest support and her situation would have been much worse without them.
Three years of treatment
Maddie received treatment for her illness from May 2020 until her death in March 2023.
The coroner said care provided in that time included multiple hospital admissions, trials of various types of medication and psychological counselling.
Gareth Hall said she was in and out of hospital more than 100 times.
“Each one on their own, for any parent, would be a traumatic experience and we had over 100 of them.”
In the period up to April 2021, this treatment was provided by Health NZ, after which they engaged Tan, a specialist child and adolescent psychiatrist.
He was primarily responsible for Maddie’s care up until her death, with care supplemented by Health NZ.
Tauranga teen Madeleine Hall, whose death was found by a coroner to have been self-inflicted, despite heroic attempts by her parents, plus a multitude of health professionals to intervene during her severe illness. Photo / Hall family
Gareth Hall said much of their concern came down to what they described as a lack of care, compassion and empathy in the public health system.
Police gave evidence about incidents at Tauranga Hospital where health practitioners argued with Maddie in a “disrespectful and unprofessional way”.
Coroner Elliott said in his detailed 50-page findings, there may well have been occasions where she was not treated with patience and compassion, which was unsatisfactory.
However, there were reasons why this might have occurred, including when a patient was “uncontrollably angry for no discernible reason”, especially if the anger was directed at the practitioner.
The coroner said it was “difficult to disentangle legitimate care concerns” from the complexity of Maddie’s illness.
Health NZ arranged a Serious Incident Review of the care provided to Maddie by the Child & Adolescent Mental Health Service.
The review team said while it could not be assumed that all mental health conditions were fully treatable in all individuals, it concluded there were areas in which service improvement recommendations were warranted.
Memories of Maddie live on
Gareth Hall said he and his family thought about Maddie all the time.
“You have your days where you just feel s**t and don’t feel up to much. That happens every now and then.
“Grieving is not linear.”
He said they were perhaps lucky they had the capacity to “get on with things”, and were able to still work and plan things to look forward to.
“We still keep in touch and regularly see some of Maddie’s friends, and we still support them,” he said.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.