A coroner has made a series of recommendations to the Government to help crack down on butane substance abuse after looking into the deaths of three Christchurch youths who died while huffing the gas.
Coroner Sue Johnson says the first step is to raise awareness of the issues of butane misuse among specialists who have dealings with young people.
There have been 63 butane-related deaths in New Zealand between 2000 and 2012, with 87 per cent of victims aged under 24.
The issue was highlighted last year, after 12-year-old Darius Logan Claxton became the youngest huffing-related fatality, and was followed soon after by the death of Poihaere Eru, 17.
They both died accidentally in separate incidents after using the gas while out with friends in Christchurch. Samuel John Gold, 19, died after abusing the substance at his parents' home in November 2010.
All three cases were looked at by Coroner Johnson at a joint inquest earlier this year.
Now, the coroner has recommended that the Government leads a "well organised approach" to butane, and other volatile substances, abuse as a priority.
Local councils and Safe Communities Foundation NZ need to work with retailers and educate them on how they can sell the substances responsibly, she says in her findings out today.
The Ministry of Social Development should include the issue of butane substance abuse in the Children's Action Plan it's currently working on.
Coroner Johnson says that department should also work with Ministry of Health to convene a high level summit or hui to come up with an evidence-based, consistent approach to lowering butane misuse across the country.
They should also look at whether there needs to be support for Maori communities to develop their own solutions to the problem of butane and other volatile substance abuse, in the same way they are being supported in relation to suicide.
"This is because statistics have shown that 30 out of the 63 butane related deaths between 2000 and 2012 were of people of Maori ethnicity," the coroner says.
All three youngsters in the recent inquest died of acute cardiac arrhythmia after huffing butane.
Forensic pathologist Dr Martin Sage gave evidence that there was a risk of developing an abnormal heart rhythm "each time" butane is used.
"It could happen any time it is used to anyone who uses it. The risk is there every time," the coroner heard. Dr Sage said butane is so difficult to predict whether it's going to be safe to use or not, making it "a real wild card... compared to some of the other recreational substances that are being used in the community."
Ross Bell, executive director of the New Zealand Drug Foundation, told the inquest that reducing the harm from all volatile substance abuse is a "very complex" issue, given that they are cheap, legal, and readily available.
There's also a low awareness of butane misuse right across the society, including by parents, teachers, young people themselves, even health professionals, Mr Bell said.