A mother who lost two sons in a police pursuit earlier this year has lodged a complaint with the Health and Disability Commissioner, saying the Christchurch DHB failed her family.
Juanita Hickey's sons Glen and Craig McAlister died in January.
Ms Hickey said her younger son, 13-year-old Craig, suffered from a mental illness and she had warned staff at the DHB he would die in a car accident or injure others just a month before the fatal crash.
She told First Up that Craig said he was hearing voices in his head, but he was still repeatedly discharged from the DHB's services and a doctor wrongly prescribed him medication without seeing him.
His brother Glen McAllister, 16, and their friend Brooklyn Taylor, 13, also died instantly when the car exploded after hitting road spikes and crashing into a tree in central Christchurch in January.
Just four weeks before the crash, Ms Hickey said, she told a DHB therapist at a meeting at her home she was scared the 13-year-old would kill himself in a car accident.
Craig had stolen vehicles before and had been pulled over by police.
The therapist who visited Ms Hickey in December documented her concerns in a letter sent to police.
Craig had had ongoing mental health issues but had been repeatedly discharged from the DHB's Youth Mental Health services, CAFLink South.
Ms Hickey said she kept calling the therapist after that home visit to follow up.
The DHB has declined to comment on the case.
Ms Hickey said that staff member had promised one-on-one sessions with her son that never eventuated.
"I kept calling saying: 'when's he going to get a doctor's appointment?' CAFLink South had discharged Craig so the youth forensics team had picked him up. So I was like: 'when is he going to see a doctor?' I was told there were no doctors available. There was only one doctor on that team and he was on holiday."
Craig had already been diagnosed with ADHD and conduct disorder, but with a family history on both sides of depression and anxiety disorder as well as schizophrenia, Ms Hickey suspected he had more problems.
He'd told doctors he had difficulty sleeping due to what he described as 'racing thoughts'.
In the months prior to his death, Ms Hickey said she had repeatedly requested for the DHB to reassess his conditions and his medication.
"I always wonder, had they had intervened or given some help in between that time, would my boys still be alive?"
Craig's intermediate school wrote to the DHB saying his behaviour was indicative of a behavioural neurological disorder.
The teenager had also repeatedly confided in his mother that his current medication didn't make him feel good and described hearing a voice in his head often compelling him to do certain things.
Ms Hickey said she continued to call the therapist.
"And I wouldn't get a reply or I'd just get told 'sorry, the doctor's away, we will write a script of Methylphenidate for your son'. Which I wasn't happy with, because the initial meeting when she came to my house she had told me that there was other medication that Craig could be on and Craig was quite happy about the thought of trying something else, and we had some hope - that that was my hope, that maybe another medication might work."
But Craig never got to try a different medication. His doctor left the hospital and a new doctor was assigned to his case.
That new doctor, whom the DHB has asked First Up not to name, prescribed medication for Craig twice without meeting him or his mother.
"I was not impressed at all. I just carried on with the best that I could do," Ms Hickey said.
She said she also worried that the dose was not correct.
DHB records show Juanita had called the hospital to ask whether the new prescription was correct because it was different to what Craig had normally been prescribed. The therapist confirmed that it was.
Before Craig's death, a meeting had been scheduled between Ms Hickey, Craig's new doctor and the therapist who visited her home in December.
On learning of the boys' death, the DHB planned to cancel the meeting - but Ms Hickey appealed and insisted it go ahead.
It took place three weeks after the crash and was secretly recorded by Ms Hickey.
First Up can reveal the recording shows the new doctor who prescribed medication for Craig before he died admitting it wasn't normal practice for him to prescribe medication to a patient without having seen or assessed them.
Minutes of the meeting were later sent to Ms Hickey but that recorded admission was left out.
The prescription Craig was given was 80mg of Methylphenidate to be taken in the morning - a dose that is unusually high, even for an adult.
The family were Ngati Rangatahi from Te Arawa and Ms Hickey had hoped that building more of a cultural connection for Craig might help him. But by January, it was too late.
The DHB has repeatedly declined a request for interview.
In a statement, Medical Council chair Dr Curtis Walker said while the council could not comment on this case, it had clear standards that outlined the expectations for doctors on prescribing.
Before prescribing medication for a first-time patient, it is expected that the doctor would have had an in-person consultation with the patient.
But there are exceptions to this, when this is not possible or practical.
Ms Hickey said she did not believe that her son's case fit the exceptions, and has filed a complaint with the Health and Disability Commissioner, demanding an inquest be held into her son's deaths.