Four 15-year-old Flaxmere girls who ended their own lives shared a violent social backdrop of alcohol and online bullying, a coroner has found.

A report released yesterday by Coroner Carla na Nagara told of the "immutable" personal circumstances of Lesha Ruben Ngatuere, Jahnaya Wikitoria Staples, Ebony Rose Karangaroa-McKenzie and Deichan Jarnika Teri Whaanga, who died in Flaxmere between July 2013 and August 2014.

The "multiple stressors" cited included parental separation, difficult relationships with step-parents, weak relationships with biological parents, high levels of responsibility for younger siblings, online bullying and alcohol and drug abuse.

While Coroner na Nagara said it would be "facile" to suggest the deaths were a consequence of one factor - and that each of the girls was "loved and mourned" by their families - domestic violence was a "striking" feature.

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The inquest's expert adviser, Professor Sunny Collings, said the degree of tolerance and acceptance of violence and abuse in the teenagers' relationships and family settings was "remarkable". She said it was normalised for the girls, and asked what degree agencies accepted it as normal too, "simply by virtue of being repeatedly exposed to it." She also claimed there was "tacit acceptance" of alcohol abuse.

Two of the girls attended Flaxmere College, one was a former student of the school while the other was enrolled in an alternative education programme. Three of the teenagers knew each other.

The findings also claimed there were issues with "negative and destructive social media communications".

"The view I formed of the evidence to me is that each girl was at various times a victim of bullying and abuse on social media, principally Facebook. This destructive communication was derogatory, accusatory, harsh and nasty, reflecting a pack mentality borne of jealousy, insecurity, low self-esteem and a desperate, misguided grasp for acceptance by others," the coroner said.

She added bullying was not a reflection of the school's culture.

While there was cross-agency involvement with the girls, the coroner said agencies currently acted on a model of intervention that focuses on "discrete events ... and not a cumulative picture".

"I'm concerned that in these cases risk of suicide seems to have been perceived to exist only when suicide was attempted". She said this was "too high a threshold".

Dr Simon Shaw, area director for Hawke's Bay District Health Board's Mental Health Services (MHS), cited a "systemic problem" in communication between MHS and the emergency department. Following a suicide attempt in February 2103, Deichan was admitted to Hawke's Bay Hospital and subsequently discharged. A review showed plans from MHS clinicians were not passed on to emergency department clinicians, who were responsible for her.

A statement released yesterday by the DHB said steps had since been taken "to address some of the gaps" in recognising at risk youth who presented to the emergency department. A working team would be set-up to discuss the coroner's recommendations, one of which was for the DHB to establish a whanau well-being facility in Flaxmere.

Another recommendation was that a co-ordinator be appointed to establish a multi-agency platform for the reporting and co-ordination of responses.

The report said the issues were not unique to Flaxmere, "and it would be wrong to consider the findings irrelevant to other communities with similar levels of social deprivation and disadvantage."

Where to get help:

- Lifeline: 0800 543 354 (available 24/7).
- Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO), available 24/7).
- Youthline: 0800 376 633.
- Kidsline: 0800 543 754 (available 24/7).
- Whatsup: 0800 942 8787 (1pm to 11pm).
- Depression helpline: 0800 111 757 (available 24/7).
- If it is an emergency and you feel like you or someone else is at risk, call 111.