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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 \u201cdistant dream\u201d as they grieved her loss almost three years ago.<\/p>\n
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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.<\/p>\n
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Now, they\u2019re instead dealing with the disappointment their efforts to seek change in the health system appear to have gone nowhere.<\/p>\n
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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.<\/p>\n
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Madeleine Grace Hall, who was known as Maddie, died in\u00a0Tauranga<\/a>\u00a0on March 31, 2023.<\/p>\n
Coroner Marcus Elliott<\/a>\u00a0said in findings issued in May 2025, but only now able to be reported, the evidence established that Maddie\u2019s death was self-inflicted in circumstances amounting to suicide.<\/p>\n
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\u2019s findings, which expired today.<\/p>\n
The\u00a0Canterbury Suicide Postvention Working Group<\/a>\u00a0(CSPWG) said it had \u201cdeep empathy and respect\u201d 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\u2019s death.<\/p>\n
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.<\/p>\n
The working group argued the cohort was connected to a \u201csuicide cluster\u201d and \u201cestablished links can be evidenced\u201d in the deaths of four young women by suspected suicide, in which Maddie\u2019s death was the \u201cindex case\u201d.<\/p>\n
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\u2019s death and those of the other young women.<\/p>\n
Nor did he find any medical evidence about the specific risks to any member of the cohort.<\/p>\n
The coroner concluded following a detailed inquiry that while there were areas in which improvements were warranted, there was no aspect of Maddie\u2019s mental health care which contributed to her death.<\/p>\n
He did however identify a shortcoming related to the late provision of a \u201cdedicated psychotherapy\u201d or other specialised therapeutic approach in Maddie\u2019s treatment, but the nature of her illness meant it might not have been resolved by medical treatment.<\/p>\n
The coroner found Maddie had received \u201cextensive mental health care\u201d, both in a public and private context, and her death did not support an argument that \u201cmental health care was unavailable to those who needed it or that the mental health system was broken\u201d.<\/p>\n
He said he was therefore unable, by law, to make any recommendations.<\/p>\n
Maddie\u2019s parents told NZME they had come to terms with the fact she was no longer with them, but not with how much she suffered.<\/p>\n
They believed it might have been reduced with more kindness, compassion and empathy.<\/p>\n
They described their daughter as \u201cthe kindest, most giving person in the world\u201d.<\/p>\n
Gareth Hall said she had a huge capacity for helping others in her peer group, even though she couldn\u2019t help herself.<\/p>\n
Coroner Elliott said that before attempting to consider the issue of Maddie\u2019s professional care it was important to recognise that she suffered from an \u201cextremely serious, severe and complex illness\u201d.<\/p>\n
A consultant psychiatrist who saw Maddie said there was \u201cnot a diagnosis which captures the challenges Madeleine faced particularly well\u201d.<\/p>\n
Coroner Elliott first considered if Maddie\u2019s 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.<\/p>\n
The Halls agreed with some of the findings, and some of the information in the coroner\u2019s report was useful, but they were disappointed he was unable to make recommendations.<\/p>\n
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.<\/p>\n
\u201cI think it\u2019s 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\u2019t.\u201d<\/p>\n
He said there was no one silver bullet that would have saved Maddie, but it was an accumulation of many things.<\/p>\n
Maddie became \u201cseriously mentally ill\u201d, to the degree it had a \u201cprofound and debilitating effect\u201d on her.<\/p>\n
It also had a significant impact on her family, and her parents\u2019 lives became dominated by the \u201curgent, desperate and ongoing need\u201d to try to get help for Maddie.<\/p>\n
\u201cOne can only express admiration for the courage and fortitude they showed during a tumultuous and distressing time,\u201d Coroner Elliott said.<\/p>\n
Gareth Hall described the extreme scenarios the family had faced on multiple occasions .<\/p>\n
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.<\/p>\n
Emails sent to health authorities reveal repeated calls for help, including for respite assistance for themselves.<\/p>\n
Hall said instances when Maddie was in a disassociated state were especially challenging.<\/p>\n
\u201cSometimes she would snap out of it and have no idea where she was or how she got there.\u201d<\/p>\n
Other times, medical intervention was needed to sedate Maddie who could lash out at those restraining her.<\/p>\n
The coroner said\u00a0Health NZ\u00a0<\/a>did not challenge the Halls\u2019 statement that they had observed an \u201caccumulation of negative factors\u201d, particularly in 2020 and 2021 which impacted upon Maddie.<\/p>\n
Nor did Health NZ challenge the evidence of a consultant psychiatrist engaged by the Halls, Davin Tan, who said Maddie was \u201chighly resistant of public mental health service involvement because she felt invalidated and traumatised by staff there\u201d.<\/p>\n
He said this made it more difficult for him to treat Maddie.<\/p>\n
Health NZ, in turn, was critical of some of Tan\u2019s actions.<\/p>\n
Tan, who was heavily involved in Maddie\u2019s care from 2021, said her parents remained her greatest support and her situation would have been much worse without them.<\/p>\n
Maddie received treatment for her illness from May 2020 until her death in March 2023.<\/p>\n
The coroner said care provided in that time included\u00a0multiple hospital admissions<\/a>, trials of various types of medication and psychological counselling.<\/p>\n
Gareth Hall said she was in and out of hospital more than 100 times.<\/p>\n
\u201cEach one on their own, for any parent, would be a traumatic experience and we had over 100 of them.\u201d<\/p>\n
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.<\/p>\n
He was primarily responsible for Maddie\u2019s care up until her death, with care supplemented by Health NZ.<\/p>\n
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.<\/p>\n
Police gave evidence about incidents at\u00a0Tauranga Hospital<\/a>\u00a0where health practitioners argued with Maddie in a \u201cdisrespectful and unprofessional way\u201d.<\/p>\n
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.<\/p>\n
However, there were reasons why this might have occurred, including when a patient was \u201cuncontrollably angry for no discernible reason\u201d, especially if the anger was directed at the practitioner.<\/p>\n
Contact the Open Justice team<\/p>\n
The coroner said it was \u201cdifficult to disentangle legitimate care concerns\u201d from the complexity of Maddie\u2019s illness.<\/p>\n
Health NZ arranged a Serious Incident Review of the care provided to Maddie by the Child & Adolescent Mental Health Service.<\/p>\n
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.<\/p>\n
Gareth Hall said he and his family thought about Maddie all the time.<\/p>\n
\u201cYou have your days where you just feel s**t and don\u2019t feel up to much. That happens every now and then.<\/p>\n
\u201cGrieving is not linear.\u201d<\/p>\n
He said they were perhaps lucky they had the capacity to \u201cget on with things\u201d, and were able to still work and plan things to look forward to.<\/p>\n
\u201cWe still keep in touch and regularly see some of Maddie\u2019s friends, and we still support them,\u201d he said.<\/p>\n
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ\u2019s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.<\/p>\n
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\nNo lack of care
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\n\u2018Kind, caring teen\u2019
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<\/p>\nMaddie, 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.<\/p>\n
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\nComplex case
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<\/p>\nMaddie 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\u2019t help herself. Photo \/ Hall family<\/p>\n
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\n\u2018Urgent, desperate and ongoing need\u2019
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<\/p>\nCoroner 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<\/p>\n
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\nThree years of treatment
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<\/p>\nTauranga 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<\/p>\n
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\nDo you have a justice story we should know about?
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\nSend email<\/a>
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\nMemories of Maddie live on
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\nSUICIDE AND DEPRESSION
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\nWhere to get help:
\n\u2022\u00a0Lifeline<\/a>: 0800 543 354 (available 7am to midnight)
\n\u2022\u00a0Suicide Crisis Helpline<\/a>: 0508 828 865 (0508 TAUTOKO (available 24\/7)
\n\u2022 Youth services: (06) 3555 906
\n\u2022\u00a0Youthline<\/a>: 0800 376 633
\n\u2022\u00a0What’s Up<\/a>: 0800 942 8787 (11am to11pm)
\n\u2022\u00a0Depression helpline<\/a>: 0800 111 757 (available 24\/7)
\n\u2022 Rainbow Youth: (09) 376 4155
\n\u2022 Helpline: 0800 000 053
\n\u2022\u00a0Samaritans crisis helpline<\/a>: 0800 72 66 66 (available 24\/7)
\n\u2022\u00a0Aoake te R\u0101- bereaved by suicide service\u00a0<\/a>: 0800 000 053
\nIf it is an emergency and you feel like you or someone else is at risk, call 111.
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