A coroner is calling for mental health professionals to share information with doctors following the suicide of a 30-year-old IT worker.
Hamilton man Jonathan Coates' eight year relationship had just come to an end when he was diagnosed with depression in January 2016.
Mr Coates and his girlfriend broke up in October 2015 but the couple continued to spend time together.
His ex-partner told Coroner Michael Robb that during their relationship she noticed mood swings and his short temper. He would also threaten to take his own life.
After the break-up, she urged him to get help.
He went to his GP who diagnosed him with moderate depression and prescribed antidepressants.
Mr Coates' GP told the inquest that Mr Coates' condition improved over the next few months and he was also looking forward to a trip to Vietnam with his ex-partner.
She had also enrolled them in counselling.
But his condition worsened when they returned from overseas.
Mr Coates had stopped taking his medication and she noticed his moods had gotten worse.
Mr Coates had three counselling sessions with his ex-partner and one by himself after noticing a car belonging to a mutual friend, parked outside his former-girlfriend's house at night.
In July 2016 he told a work colleague that he wanted to "kill them all" and burn his friend's house down. Instead he had driven away.
He then drove to Coromandel and his parents reported him missing.
In the following days Mr Coates text messaged his counsellor saying he had just had a "major meltdown".
Mr Coates' parents eventually found him in Coromandel and drove out to take him back to their home in Hamilton.
Two days later his ex-partner also made a 111 call, reporting that he had made threats of self-harming.
Mr Coates went to see his GP again and his medication was increased.
His GP believed he was getting counselling not only for the relationship break up but also for his depression.
But that assumption was incorrect.
Counsellor Alison Rowe told the inquest the counselling sessions were about providing Mr Coates with assistance, and to support him and his ex-partner through their separation.
The inquest also heard that Ms Rowe told them nothing of her qualifications or the limits of the services she could provide as a counsellor.
Mr Coates and his ex-partner had a final joint counselling session on 18 July where she said she found it difficult to move on because of his continued threats of suicide.
She also said she did not want to spend time with Mr Coates.
He committed suicide that night.
The coroner said Mr Coates had only been receiving relationship counselling - his mental health issues, depression and thoughts of suicide were not the focus of the sessions.
Coroner Michael Robb said Ms Rowe described herself as a counsellor trained in psychotherapy but that she was not a psychotherapist.
He said it was important health professionals understood and clearly identify their areas of expertise.
He recommended counsellors get training in suicide risk assessment and when to refer someone to a specialist.
He also recommended that there should be information sharing between specialists and GPs. He said this was in the best interests of the patient.
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
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)
Samaritans: 0800 726 666 (24/7)
Youthline: 0800 376 633 (24/7) or free text 234 (8am-12am), or email firstname.lastname@example.org
What's Up: online chat (7pm-10pm) or 0800 WHATSUP / 0800 9428 787 children's helpline (1pm-10pm weekdays, 3pm-10pm 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.