VICTORIA - A 17-year-old boy who took his own life on the grounds of a children's hospital in Vancouver didn't get the mental health treatment he needed from the time he was two years old, says British Columbia's representative for children and youth.

Bernard Richard's report released Wednesday investigates the death of a teen identified by the pseudonym Joshua who died in July 2015 at the BC Children's Hospital where he had been staying for 122 days.

The review of his death found there were significant gaps and lack of co-ordination in the health system, which Richard said need to be corrected or more children risk falling through the cracks.

The report says Joshua, whose mother was his primary caregiver after his parents separated and later divorced, began showing signs of mental illness when he was two years old but he and his family didn't receive adequate early and long-term help as his illness escalated into his teens.

“Joshua exhibited signs of serious mental health issues at an extremely young age,” the report says. “He was just two years old when his mother sought help from the Ministry of Children and Family Development because her son was hitting himself and banging his head on walls. He did not receive the early intervention services that may have altered his life trajectory.”

Previous suicide attempts led the teenager to be hospitalized, but he was kept in an adult psychiatric ward because facilities more appropriate for youth were lacking, it says.

It recommends the new Ministry of Mental Health and Addictions implement a comprehensive system that offers a full continuum of mental health services for children and youth. It is the report's only recommendation and the government said it will act on it.

“If this sounds familiar, it is because you have heard it from this office before,” Richard said at a news conference.

Richard said he's “encouraged” that the recommendation will finally be acted on because several officials involved in reports making similar recommendations are now cabinet ministers.

Despite the complexity of Joshua's illness, Richard said he “believes that government can do better for its children than what it did for Joshua and his family.”

When Joshua's health-care providers were planning to discharge him from the hospital, his mother wasn't able to cope with him at home and officials struggled to find a safe place for him.

“The fact that he languished in hospital for four months, potentially losing what remaining hope he possessed while psychiatrists and social workers wondered where he could be safely placed, clearly shows that there is a dire need in B.C. for 'step-down' residential services - those that would enable a child or youth to ease out of a hospital setting and prepare for a return to their family and community,” the report says.

In the years before his death, the report says Joshua's mother was offered “extremely limited support” to meet his considerable needs, despite having asked for help.

The report also criticizes the Ministry of Children and Family Development for prolonging its assessment of the family's ability to meet the teen's need, which in turn allowed the under-funded ministry to avoid the costs of providing appropriate services.

“The lack of available, appropriate, community-based residential services unnecessarily prolonged Joshua's stay in hospital, which in turn may have contributed to an overall decline in his well-being by July 2015,” the report says.

Mental Health Minister Judy Darcy said no family should have to go through what Joshua's family did.

The government said the recommendation aligns with one of Darcy's mandate priorities assigned by the premier when the New Democrats took office in July.

“We absolutely agree that we need to collaborate across government and across service providers to create a system that supports families like Joshua's with the full range of mental health services they need,” Darcy said in a statement.

Darcy told a news conference she is committed to having a strategy to create a better system ready within 12 months, but would not say if the report's 24-month deadline to implement a new system could be met.