Northland youths who died in suicide cluster got lost in the system, coroner finds

Warning: This story discusses suicide and teen deaths.

A coroner has found there are ongoing and wide-ranging barriers for young people accessing suicide prevention services in Northland in the wake of a tragic suicide cluster.

Coroner Tania Tetitaha held a joint inquiry into the deaths of five teenagers and a 12 year old, who died in 2018 and 2020 amidst "possible contagion".

The inquiry's name was gifted by a local kaumatua, the late Te Ihi Tito, Roimata Aroha mō te Whakamomori Taitamariki - meaning tears of love for youth lost to suicide.

It had been a long wait for those families since the joint inquest was held in November last year.

On Thursday, Coroner Tetitaha released her findings and they were stark.

"There were impediments to vulnerable rangatahi and their whānau accessing suicide prevention resources within Te Tai Tokerau and those impediments remain to this day," she wrote.

During the four-week inquiry, the coroner heard evidence from the families, Ministry of Health, Te Whatu Ora/Health New Zealand, Oranga Tamariki, ACC, the Ministry of Education and the Police, as well as experts.

The five young people were aged between 12 and 16 when they died and coroner Tetitaha found whanau and external agencies were aware of their self-harm risk but there was no lead agency.

Tetitaha found they effectively got lost in the system.

"All were required to approach multiple agencies to address any suicidal behaviour arising from substance abuse, sexual and physical abuse, bullying and relationship discord".

She found the barriers the vulnerable young people faced that remained to this day were wide-ranging.

"Impediments include lack of knowledge of suicide prevention resources; inability or unwillingness of rangatahi and whānau to access these resources; a multiplicity of agencies involved in suicide prevention and the impediments that flow from this including where there is a lack of information sharing between agencies and the confusion that occurred when navigating between them; and problems with resourcing and funding front-line suicide prevention resources for rangatahi."

Summer Metcalfe was just 15 when she took her life, she would be 22 now.

Her mother Paula Mills said she lived with ongoing grief and hoped the coroner's recommendations would be acted upon.

"It's not going to bring our children back but hopefully it does do something for the future, for others that are desperately trying to find something to get children the help that they need," she said.

"It's tragic, absolutely tragic so if we can do anything to help these rangatahi and their whanau, let's do it. The coroner's made some really good recommendations let's get them implemented."

The coroner also found schools were under-resourced to provide counselling and the government's child and adolescent mental health service, Te Roopu Kimiora, was overwhelmed in the region.

In Tai Tokerau at the time of the inquest in November 2024, Te Roopu Kimiora was treating approximately 700 patients with moderate-to-high risk of self-harm and receiving three to four new patients per week.

Its clinicians had around 40 cases each which the coroner said was well above average caseloads.

"There is evidence that schools are supporting increasing numbers of rangatahi at risk of suicide," Tetitaha said.

"There is also evidence that their funding model does not adequately provide for the permanent employment of counsellors and social workers to support this work - requiring them to utilise their operational budget to meet this need."

Secondary Principals Association president Louise Anaru is the principal at Kaitaia College and said many students needed mental health support.

"It's a huge concern ... we want to ensure our young people are thriving and mental health is so important."

The coroner recommended Health NZ extend the Te Roopu Kimiora school liaison roles into secondary schools in Northland.

Health NZ said it had bolstered staffing for the service with an extra eight-and-half full time roles in the region.

Louise Anaru wanted to see targeted funding for schools to employ counsellors and social workers.

"They're able to prevent a lot of issues happening, provide that immediate care and because they're already in the school they have trust from the students, they have relationships in place, so they're able to respond to any suicide risk ideation really promptly."

Northland's rate of suicide was still well above the national average - in 2018 the region's suicide rate was 19.8 per 100,000 head of population, well above the average rate for New Zealand 12.4.

At the joint inquest, Victoria University associate professor Dr Clive Aspin filed evidence that the deaths were a suicide cluster due to the higher than expected number in close proximity in time and location.

Aspin said there was possible risk of contagion at the time.

Paula Mills said the region's track-record should be enough to prioritise change.

"When we've got stats like that you'd think that these services would be really willing to do anything they can and listen to these recommendations and at least implement some of it and really have a long hard think about it."

Mental Health Foundation chief executive Shaun Robinson said the cases were heartbreaking and there was not enough resourcing for suicide prevention.

"Are things getting better? I would have to say very marginally and in terms of the overall picture my confidence that we're going to turn our suicide stats around is pretty low."

He believed the government's Suicide Prevention Strategy and Action Plan "looks to me like what you do if you really don't want to commit much money to suicide prevention".

"This is moving at a snail's pace when we know that we've had stubbornly high suicide numbers for over a decade and a major part of that is with rangatahi and particularly with rangatahi Māori," Robinson said.

"We're just not budging that."

He said the government planned to bolster rangatahi suicide prevention in one unnamed region next year.

"It's extremely sad that we are moving so slowly that government can only commit to experimenting with improving parts of services for young people in one region by the end of next year."

Robinson said it would make a big impact if the number of trained staff working specifically with young people increased.

"These cases are really heartbreaking it is really important to remember that for every death there are hundreds of young people who recover from their time of suicidality and do go on to live their lives."

Coroner's recommendations

Coroner Tetitaha found a high degree of collaboration between agencies was necessary in relation to suicide prevention work to prevent similar deaths occurring in Te Tai Tokerau.

She detailed a care pathway in which a Kaiarahi (mentor) should be allocated to any rangatahi identified as at risk.

"I recommend that a coordinated care pathway for rangatahi in Te Tai Tokerau who are at risk (whether serious, moderate or low) of self-harm or suicide be developed," Tetitaha said.

"The objective of the care pathway should be to reduce suicidality for rangatahi. That care pathway should also be visible to the rangatahi and their whānau from entry to exit."

The coroner identified data gaps and recommended how agencies could better collect and use information to inform policy about suicide prevention in Northland.

She also recommended that Health NZ extend the Te Roopu Kimiora school liaison roles into secondary schools in Te Tai Tokerau.

"This would assist in developing relationships, improving communication and information sharing between Te Roopu Kimiora and the schools.

"It would also enable Te Roopu Kimiora to have more insight and overview of at-risk rangatahi. The school liaison should ensure that the Kaiarahi is advised of any relevant information and updates to inform the 'full picture'."

She said Health NZ had begun work in response.

"I welcome the indication that Te Whatu Ora are working to secure funding for the extension of Te Roopu Kimiora School Well-Being Liaison role. If this role provides the support required to prevent any further rangatahi deaths by suicide within Te Tai Tokerau, no further comment or recommendation by me will be required."

Health NZ response

Health NZ said it extended its heartfelt condolences to the whanau for their loss.

Its group director of operations Te Tai Tokerau, Alex Pimm, said they "recognise the deep impact these deaths have had, and will continue to have, on loved ones and the community".

"We acknowledge the Coroner's report and will give priority to considering the recommendations," he said.

"We are committed to providing safe, high-quality mental health and addiction care for the Te Tai Tokerau community."

Pimm said an in-depth review was carried out by the services that were involved after the tragic deaths, and lessons had been taken from these.

"Since ​these tragic deaths we have bolstered staffing for our child and adolescent mental health service, Te Roopu Kimiora."

That service had an extra 8.6 full time roles in the region.

He also said the national Suicide Prevention Action Plan, which was updated this year, was focused on addressing gaps and ensuring more people had access to support when they needed it.

Actions included:

• Improving access to suicide prevention and postvention supports
• Growing capable and confident suicide prevention and postvention workforces
• Strengthening the focus on prevention and early intervention
• Improving the effectiveness of suicide prevention and our understanding of suicide.

Pimm said since 2024 the government's budget for mental health had increased by $200 million to $2.8 billion.

Where to get help:

• Aoake Te Rā
• Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
• Lifeline: 0800 543 354 or text HELP to 4357.
• Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. 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 or text 4202.
• Samaritans: 0800 726 666.
• Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
• What's Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
• Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
• Rural Support Trust Helpline: 0800 787 254.
• Healthline: 0800 611 116.
• Rainbow Youth: (09) 376 4155.
• OUTLine: 0800 688 5463.

If it is an emergency and you feel like you or someone else is at risk, call 111.

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