His remarks were included in the findings of the inquest into Toran's death on March 20, 2008. The report was issued yesterday.
Dr Jamieson was critical that, in the face of escalating developments on the day of Toran's death, the Waitemata District Health Board's service left his care in the hands of a relatively inexperienced "key worker" who spoke to Toran by phone.
"Toran stated, that day, that he lost faith in one of his key workers, feeling that she had abused his trust," said the coroner.
He said the situation would have been better dealt with by immediate consultation with a specialist psychiatrist, who could have taken direct action "such as arranging an urgent home visit together with immediate admission to a secure facility if required".