The deaths of six young Northlanders, including 14-year-old Summer Mills-Metcalf, is under inquiry at a coroner's hearing in Whangārei. Photo / Givealittle
The deaths of six young Northlanders, including 14-year-old Summer Mills-Metcalf, is under inquiry at a coroner's hearing in Whangārei. Photo / Givealittle
A coroner’s inquest into the deaths of six Northland young people, including Martin Loeffen-Romagnoli, has revealed systemic failures.
The inquiry is also examining the role of antidepressants, including fluoxetine, and seeks solutions for suicide prevention.
Hamuera Ellis-Erihe, 16, of Raumanga died in 2018. He loved dancing, rapping and singing.
Summer Mills-Metcalf, 14, of Kaipara, died in 2018. She was described as a happy, smiling girl who enjoyed pulling pranks on family members.
Ataria Heta, 16, of Moerewa died in 2020. She was a stand-out kapa haka performer with a kind nature.
Maaia Reremoana Marshall, 13, of Kaitāia died in 2018 after being under the care of Oranga Tamariki.
James Patira Murray, 12, of Ruakākā died in 2018. He loved rugby and was a Northland representative.
Martin Loeffen-Romagnoli, 15, of Kaipara died in 2018. He was a talented hockey player described as friendly and loveable.
WARNING: This article discusses suicide and may be upsetting to some readers.
When Paula Mills took her 14-year-old daughter Summer to get help for depression she had no idea the common antidepressant they were given could have deadly risks.
Four weeks after doctors doubled Summer’s dosage of fluoxetine, commonly knownas Prozac, Mills’ world shattered when her daughter took her own life.
Now, Mills is demanding better warning be given about the suicidal ideation effects of the drug, and a leading psychiatrist agrees with her.
Coroner Tania Tetitaha has been leading a Northland coroner’s inquest into the deaths of six youths who died by suicide in 2018 and 2019.
The teenagers were aged between 12 and 16 and the court has heard two of the girls involved – Summer Mills-Metcalf and Ataria Heta – were on prescription medication for depression and anxiety leading up to their deaths.
The four-week hearing involving Te Whatu Ora, Oranga Tamariki, ACC and the Ministry of Education has brought a range of professionals in to look at where possible failings occurred and seek solutions to impediments to suicide prevention, specifically in Te Tai Tokerau.
Coroner Tetitaha indicated early in the hearing there would be a finding the youths died by suicide.
Several witnesses have given evidence in relation to Summer’s death including her mother, a school principal and a leading child psychiatrist.
Her mother said earlier in the hearing her daughter had a short history of being prescribed Fluoxetine, a serotonin selective reuptake inhibitor (SSRI).
A happy, bubbly and outgoing girl, Summer’s mood dramatically turned after she was plagued by bullying at school and on social media throughout 2017.
Her mother was actively involved in seeking help for Summer and took her to the doctor on February 14, 2018, where the teenager was prescribed fluoxetine at 10mg with a note to increase to 20mg per day as tolerated.
Mills rang doctors twice in March and April requesting a review around upping her meds and over that time, increased her dosage to 20mg per day.
On May 1, after consultation with her doctors, Summer’s dosage was upped to 40mg a day with a note for a scheduled review in four to six weeks.
But Summer never made it to the review date. She ended her life on June 3, 2018.
‘Doubling her dose was a huge error’
Fluoxetine is a commonly used drug in New Zealand to treat depression, obsessive-compulsive disorder (OCD) or eating disorders.
When dispensed, the package comes with a six-page pamphlet inside with a warning on page four that if thoughts of suicide begin to occur, seek medical help.
In America, the drug comes with a black label warning on the box that the drug may increase the risk of suicidality.
Mills gave evidence that she had noticed Summer becoming more agitated but never thought her daughter would end her life. She said they were not advised about the risks of suicidal ideation by any health professional, a side effect she only discovered from her own research after Summer’s death.
“She was taking her medication but it wasn’t working. When they doubled her dose we asked if it was safe and the doctor said it wasn’t well-researched.
“I now believe doubling her dose was a huge error and more inquiries should have been done. I couldn’t understand why Summer hadn’t fought to live.”
The commonly prescribed anti-depressant fluoxetine, often known as Prozac, comes with a warning of suicidal ideation.
Written information needed
Doctor Andrew Craig Immelman, a member of the New Zealand Medical Council with multiple accreditations in child youth psychiatry, gave evidence in the third week of the hearing about his opinions relating to the clinical engagement with Summer.
Notes on the medical file said adverse reactions were discussed with Mills, however, Immelman said there was no evidence any handouts were given, something he believes is lacking in medical practice.
“I refer to a study where junior doctors were involved in simulated handovers with or without printed handouts and reiterate only 2.5% of the information was retained after five verbal-only cycles as opposed to printed handouts.
“I see it as a reflection of the memory of people involved, it points very clearly to written information being a prerequisite,” he said.
“It’s quite hard on whānau and a human characteristic is to not register information at stressful times of appointments.”
Immelman suggested providing patients with pamphlets at doctor’s clinics should be standard practice. These pamphlets should be concise – about two pages with about 1000 words – and available in multiple languages, ensuring information is clear and accessible to all.
“It would be best if we had a New Zealand formula, a handout that was less wordy and able to be used more easily by young people and anyone who requires medication.
“Putting myself in the position of a parent, it is information that I would want to receive.”
The suspected suicides of Northland teenagers Ataria Heta, Summer Mills-Metcalf, Hamuera Ellis-Erihe and James Murray are under inquiry in a coroner's court in Whangārei.
Changes are needed
Mills also made similar recommendations to the coroner and said if they had known the risks, they would have perhaps chosen a different path.
“There needs to be changes in our mental health system when handing out medications. These psych drugs can and do cause suicidal ideation, Medsafe states professionals should discuss clearly the adverse effects with their patients.”
Immelman was also critical of the six-week follow-up Summer had been given and said a check-in with her should have been done the following week.
Immelman also believed the possibility of a thorough treatment plan being dictated and written in front of the patient would help with engagement and therapeutic alliance.
“We need to change our practice and I’m sorry to be so forceful about it.
“There are things outside our control like workforce shortages ... I believe we need more people out there, we need more boots on the ground and we don’t have that so we tend to cut corners and often it works out okay but it’s not the best practice.”
Coroner Tetitaha will release her findings on the inquest into Ataria, Summer, Maaia Marshall, Martin Loeffen-Romagnoli, Hamuera Ellis-Erihe and James Murray in early 2025.
Shannon Pitman is a Whangārei based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.
