The Cobourg, Ont., family of a 12-year-old boy who took his own life two years ago is appalled that a coroner's report has concluded the mental health care he received was "good."

"We were quite disappointed, and somewhat bewildered and shocked would be the best three words to describe the decision from the coroner … they decided that the care that Chazz received was good, when clearly we've determined that it wasn't," says Frank Petrella from his home in the southern Ontario community.

Chazz Petrella, the youngest of five children, started to show attention and aggression problems when he started school, Frank Petrella says.

Chazz's mother, Janet Ashby-Petrella, told the fifth estate in March 2015: "He would say he can't shut his brain off."

As the boy got older, his behaviour escalated: His family says he would fly into a rage, break things and threaten to hurt himself and others.

The 12-year-old's family says Chazz Petrella never received a thorough psychiatric evaluation or diagnosis. (the fifth estate )

The Petrellas say almost a dozen agencies were involved with Chazz in the last few years of his life. They include Highland Shores Children's Aid Society, Kinark Child and Family Services, and the local school board. But the family says the child never received a thorough psychiatric evaluation or diagnosis.

They decided that the care that Chazz received was good when clearly we've determined that it wasn't. - Frank Petrella , Chazz's father

By the time he was 11½, Chazz had been in and out of three schools, two residential facilities and a psychiatric crisis centre.

He was diagnosed with a mental illness and doctors tried several medications, but they never pinpointed an exact diagnosis or treatment plan.

In the winter of 2014, Chazz was placed at the privately run school Bayfield, which specializes in working with children with behavioural issues.

Chazz Petrella's mother, Janet, says the number of children committing suicide in the province and the country is not dropping. She says an inquest into the gaps in her son's care could help improve access to services for other families. (the fifth estate)

His family says he thrived at Bayfield; he was getting A and B grades on his report card, and teachers described him as a "pleasure" in the classroom.

But it didn't last. The Petrellas were told they would have to cover the annual tuition of $21,000, which they couldn't afford.

One night that August, Chazz flew into another rage at home. In the morning, Petrella found his son hanging from a tree outside the family home.

Chazz had turned 12 the month before.

"There's so many different aspects of Chazz's story … that really highlight each gap in each part of the system whether it be education, whether it be health care, whether it be mental health, psychiatric, physical health; every aspect we dealt with, every individual part of his case had big failures that they couldn't connect to each other or they couldn't connect Chazz to those services," says Ashby-Petrella.

Call for inquest rejected

Ashby-Petrella has been calling for an inquest since the day the boy died two years ago.

Late last month, Dr. Paul Dungey, a regional supervising coroner in Kingston, informed the family there would be no inquest. He said the Pediatric Death Review Committee (PDRC) had reviewed Chazz's death and made recommendations to prevent future deaths.

​The PDRC answers to Ontario's Office of the Chief Coroner, which reviews the deaths of children and youth who have a file with a Children's Aid Society within 12 months of their death.

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Ashby-Petrella, who along with her husband met with Dungey about the case in the fall of 2015, says she's disappointed that no inquest will be held.

"We're the ones who were experiencing it. We're the ones that went to all the different agencies trying to seek help for him when nobody could help him, or agencies didn't have the doctors on hand, didn't have the services on hand."

The Petrellas say they're not the only family that has found significant gaps in the system that's supposed to help their kids.

"We are still getting people contacting us: What should they do? Where should they go? They can't get the help they need. All these questions that are still unanswered, so we felt an inquest would help bring awareness to ... the cracks in the system that Chazz fell through," says Chazz's father.

Request for review by chief coroner

"I'm disappointed by that decision," says Irwin Elman, Ontario's provincial advocate for children and youth.

Elman had also called for an inquiry into the suicide.

"For me, the lingering question that continues to be is: 'How have four sectors: health, education, child protection, mental health, nine services be involved in this child's life, and the day after he leaves the hospital emergency, he's found hanging from a tree? How can that happen in Ontario?'"

Elman and the Petrellas have asked the province's chief coroner to review the decision not to call an inquest.

The coroner's office says it could take up to two months.

Elman says: "Everything is not all fixed. It's time for an open process. Chazz and his family's struggle is Ontarians' struggle."

Watch the fifth estate documentary "The Boy Who Should Have Lived."