I want to share with you a story. It’s a story about a little girl named Maddie, who lived in Tauranga and loved swimming in the ocean. One weekend, Maddie and her family went to the Mount for a swim.

Now picture this: it’s a beautiful day, the sun’s shining, there’s an offshore breeze creating perfect conditions. Maddie’s in her element, she’s splashing around and riding the waves. But as the wind picks up and the waves get bigger, Maddie begins to struggle.

She fights hard to get back to shore, but the waves are relentless. Just then, she spots a lifeguard and with all her might, she swims over and manages to make it over to him.

The lifeguard noticing she’s in trouble, quickly pulls her onto his ski and asks if she’s okay. Maddie explained that I’m ok now, I just felt overwhelmed by the waves. She told him she was grateful for his help and found comfort in knowing he was there before jumping back into the water.

As Maddie resumed swimming, the waves continued to grow, and once again, she found herself in trouble, so she swam back to the lifeguard, who once again restored her confidence and helped her back into the water. Over the next few hours, this cycle repeated itself, but each time she returned to the lifeguard seemed less sympathetic.

He told her to keep swimming and stop being a drama queen. He told her to look around at what a beautiful day it was, look at all the other kids all having fun, heaps of kids would love to be in her position, and he kept pushing her back into the ocean even when she told him she felt like she was drowning.

In one last desperate attempt, she grabbed onto his ski, and was begging him to paddle her back to shore. But he nonchalantly said, that’s impossible, it can’t be done. He said, if I help you, that means I abandon all of these other kids who might need me, and in my view, you’re no worse off than any of them. And then, for one the final time he pushed her back into the water, where tragically, Maddie gave up and drowned.

Now, while the story is fictional, the little girl and the lifeguard aren’t. The little girl represents the thousands of kids who, for various reasons, become overwhelmed by the waves of life and feel like they’re drowning. The lifeguard symbolises our dedicated mental health teams in hospitals all across the country, overworked and under-resourced by their masters at Te Whatu Ora, trying their best to handle the influx of struggling children, before facing the impossible task of deciding who to help and who to leave behind.

Now herein lies the irony: if the lifeguard, the little girl, and the event were real, the public outcry would be overwhelming. The story would dominate the news for weeks, with inquiries launched, and accountability and transparency demanded. The Lifeguard Association would be called to account and hauled off to court. Sentences would be passed, apologies extended, and systemic change immediately enacted to prevent such a tragedy from ever happening again.

Sadly, this isn’t a Lifeguard Association we’re talking about. This is Te Whatu Ora, formerly known as the Ministry of Health, an organisation that considers itself above the law, knowing they will never be held to account. This is an organisation that has devised a foolproof way to evade accountability by using our overburdened coroners as a convenient ‘get out of jail free card’ to buy themselves time. 

So when something happens;

“Unfortunately, we can’t comment on individual cases while the coroner is investigating, but our deepest sympathies go out to the family“

And when the report is finally made public; 

“We accept the coroner’s findings and acknowledge the failings in this case. In the five years since the unfortunate passing of Madeleine, we have addressed those failings, and we are confident it will never happen again”

And inevitably when it does, “Unfortunately, we can’t comment on individual cases” like a well-worn record from an agency who are never held to account. Every year, more than a hundred children drown after being turned away by an overworked mental health system. 

And it is time to demand change! It is time for organisations like Te Whatu Ora and the Ministry of Health to be held to the same standards as everybody else and be hauled before the courts. It is time to demand justice for Maddie and all the children who have been failed by the system. We cannot allow them to continue hiding behind bureaucracy and evading accountability.

Madeleine Grace Hall first sought help from the hospital, on May 13, 2020. She went back 118 times, until eventually, the system broke her. Maddie drowned on March 31st, 2023. Maddie was 16 years old, and she was Gareth and Leanne’s little girl. 

We must never let Maddie be forgotten. We are the voice of change, and we must demand it.

I’m Mike King for The Common Room.