Hillmorton Hospital's failure to protect a young woman who had attempted suicide is a symptom of a much larger issue, according to a mental health expert.
The Life Matters Suicide Prevention Trust will make a complaint to Canterbury DHB after the 19-year-old was discharged from hospital just hours after attempting to kill herself.
The teenager was seen on a bridge with self-inflicted injuries planning to jump off, and was only stopped by a passerby.
She returned to the bridge after being discharged and attempted again.
Dr Jemaima Tiatia-Seath told Mike Yardley she heard similar stories from across the country when she served on the mental health inquiry panel.
She says that this does not surprise her one bit.
"This is just one blatant example of how the mental health and addiction sector is completely failing."
Dr Tiatia-Seath says that this incident could have been much worse.
She says that most services around the country are completely over stretched.
"It's unfortunate that this has come to light, but there are many, many stories like this."
The Canterbury DHB has not commented on the matter, citing privacy issues.
Dr Tiatia-Seath says that she expects they won't say a lot about their standards or procedures until after the Government comes back in March with their intentions moving forwards on mental health.
It comes after the panel Dr Tiatia-Seath was a member of made 40 recommendations in their report delivered last year.
However, she says that Hillmorton and the DHB are not entirely to blame for thIS.
"You cannot blame a DHB. Communities are responsible. Families are responsible. We've only just seen the tailend.
"We need to understand as a country when to intervene. We need to intervene so they aren't standing on that bridge."
Dr Tiatia-Seath says that the intention of the inquiry was to completely change the mental health system.
LISTEN TO DR JEMAIMA TIATIA-SEATH TALK WITH MIKE YARDLEY ABOVE