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flag A high-risk New Zealand woman died by suicide in 2021 after being wrongly discharged from a psychiatric unit, prompting national mental health system reforms.

flag A 28-year-old New Zealand woman died by suicide on Christmas Eve 2021 after being granted leave from a psychiatric unit in Palmerston North, despite being assessed as high risk for suicide and psychosis. flag The coroner found the decision to release her was unwise, criticizing the lack of communication with her family, including her father, about her recent suicide attempt and ongoing mental health risks. flag Gabriella, who had a history of psychosis, substance use, and multiple hospitalizations, was discharged in September 2021 and later readmitted after another suicide attempt. flag Her family was unaware of her prior attempt or the severity of her condition. flag The case prompted Health NZ to implement new discharge and communication protocols, with calls for systemic reform in mental health care.

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