Bereaved Wellington father John Carter says the apology he has finally received over mental health system failings in the lead-up to his 23-year-old son's death is not enough.
Now the Wainuiomata resident is suing health authorities to make sure mental health patients are afforded the rights his son, Christopher, was denied before his death 10 years ago.
Christopher Carter was a bright, friendly young lad who loved his sport.
John remembers his son smashing sixes on the cricket pitch. On the rugby field, he was a nippy second-five for Scots College's 1st XV.
"He was a typical youth of his day I suppose and he had his problems with sorting out his way in the world and he was a very, very, very friendly and sociable and loving guy, Christopher was."
Christopher had a history of mental illness, first being hospitalised in 2006 and again in 2009.
Christopher died at his father's Wainuiomata home in 2010.
"He was 23 years old when he died, he was a very popular and loving member of the Carter family, we all really loved him."
Since his son's death, John has spent more than a decade trying to change the system he believes deprived Christopher of his rights.
Christopher was being treated through the Capital & Coast District Health Board's Mental Health Addictions and Intellectual Disability Service.
The district inspector's review of Christopher's care found he was never asked to sign a consent form for his treatment, a mistake his clinician blamed on "systemic administrative errors".
The district inspector's findings revealed Christopher raised serious concerns about taking medication and sometimes actively opposed taking it.
Medical notes failed to show whether or not he understood its benefits, effects and side effects.
John said none of this is good enough.
"My son died with all these rights being denied to him."
He strongly believes a drug Christopher was being administered - Risperdal Consta - made his son's mental health worse, not better.
"Even Medsafe warns that it shouldn't be given to patients who have a history of suicide ideations or attempts."
Medsafe documents show Risperdal Consta should be used with caution in some patients, and those with suicidal thoughts or past attempts should notify their doctor.
The medicines regulator lists anxiety and depression as side effects of the drug.
John has finally received an apology for his son's treatment, but he does not think it goes far enough.
"So it's just a sort expression of regret, which I think was a good start but it's not satisfactory, it's not enough."
One of the district inspectors' recommendations following Christopher's death was to consider updating patient rights information so it clearly sets out patient rights.
But Carter is going further, launching legal action against the Hutt Valley and Capital and Coast District Health Boards.
The Ministry of Health is listed as the third respondent in the case.
The court action seeks to make sure information supplied to mental health patients is a clear and accurate outline of their rights under the Mental Health Act.
In a statement, the DHB's Mental Health, Addictions and Intellectual Disability Service general manager Nigel Fairley told Checkpoint external reviews found Christopher's care was reasonable and consistent with expected standards.
"Through this external and internal review process it was found that some administrative aspects could be improved," Fairley said.
Fairley said changes have been made, such as better availability of information on the Mental Health Act and advocacy services, and extensive staff training on the Mental Health Act.
Clinicians did engage in discussions with clients about proposed treatment and therapy, as well as risks and benefits, Fairley said.
As for the apology to John Carter, Fairley believed it was fulsome and covered the administrative shortcomings in Christopher's treatment.
"We have expressed our sincerest condolences and sympathies to the family on a number of occasions during the past 10 years dating back to the tragic event."
John said it was too little, too late and he planned to keep fighting.
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 (24/7). 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 (24/7) or text 4202
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email email@example.com
What's Up: (3pm-10pm) or 0800 WHATSUP / 0800 9428 787 helpline (12pm-10pm weekdays, 3pm-11pm weekends)
Kidsline (ages 5-18): 0800 543 754 (24/7)
Rural Support Trust Helpline: 0800 787 254
Healthline: 0800 611 116
Rainbow Youth: (09) 376 4155
If it is an emergency and you feel like you or someone else is at risk, call 111.