Dear Queensland coroner, we implore you to hold a full inquest into the death of 17-year-old Gold Coaster, Joshua William Klumper on the 16th of September, 2017.

On a Saturday night, three days before Josh took his own life, he went to the emergency department seeking help. He was not offered comfort but drug tested, made to wait 4 hours then told words to the effect 'if we haven't been able to help you so far, we won't be able to fix you tonight'. At that point, he abandoned his attempt to seek help. By the time the health service attempted to follow up with Josh personally, it was too late. He had already taken his life, been resuscitated and was in intensive care. Josh never regained consciousness and died 11 days later.

We know that individuals working in mental health do care and are doing their best, but something is wrong with the system and it cost Josh his life. The Gold Coast Mental Health Suicide Prevention Strategy was ineffective for Josh. Safety measures that are in place were not followed. And an internal investigation, despite providing some welcome recommendations (including training on autism spectrum disorder - ASD), has not led to changes that would prevent the same mistakes happening again.

We just want to save people from preventable suicides. We could not save Josh, but we can save others if we learn from this tragedy. Josh would have wanted it.

'1.Love 2. Peace 3. Help the World. It will get better, can only get better.' #JoshsWish (read more here.)