WARNING: This article discusses suicide and may be upsetting to some readers.
Six rangatahi (youth) who never knew each other walked the same troubled path, marked by bullying, loneliness, abuse, and fractured relationships.
Despite being identified as high risk, each encountered fragmented services and poor information‑sharing that left them without a clear route to support.
Their deaths formed a tragic cluster that has revealed the deep cracks in Northland’s suicide prevention system, prompting Coroner Tania Tetitaha to call for a single, co‑ordinated care pathway that ensures continuity of support.
However, Te Whatu Ora has responded to the coroner’s recommendations by acknowledging the importance of collaboration but says it had no additional funding to create new roles or services.
Of the six rangatahi, Coroner Tetitaha said: “It was a privilege to learn about their lives from their whānau pani (bereaved family) including those who took time to attend the pre-hearing conferences and inquest in person and by audio visual link”.
“E ngā pare raukawa o te mate, haere haere atu rā - To our precious loved ones who are no longer with us, I farewell you all.”
The scale of the crisis in Te Tai Tokerau is nothing new.
In 2012 a youth suicide cluster was identified after 19 teens took their lives. In 2018, Northland again recorded the highest rate in the country at 19.8 deaths per 100,000 people.
By 2020, the toll had risen to 36, with the rate climbing to 20.8 per 100,000, again the highest in New Zealand.
The national average that year was 11.5.
By 2024, figures showed no significant change.
The six rangatahi identified in the most recent cluster were Hamuera Ellis‑Erihe, James Patira Murray, Summer Metcalfe, Martin Loeffen‑Romagnoli, Ataria Heta and Maaia Marshall.
In November 2024, several agencies working with the teens gave evidence at the coroner’s inquest, which sought to investigate the gaps in their care.
The findings revealed that possible contagion was occurring, as all six knew of someone who had committed suicide or was self-harming.
Associate Professor Clive Aspin, who conducts research for the coroner into youth suicide, identified the young people had several, if not all, risk factors present at their time of death.
These included bullying, depression, anti-social behaviour, socio-economic deprivation, family violence, abuse and substance abuse.
Each of the six had previously expressed suicidal ideation or engaged in self-harm, which was known to whānau and external agencies but barriers obstructed access to suicide prevention resources.
Families and schools struggled with limited knowledge of available support, reluctance or inability to engage with services, and the complexity of navigating multiple agencies.
These systemic barriers, the coroner noted, have persisted for some time and remain unresolved.
Two organisations came to the forefront of the inquest.
Te Roopu Kimiora (TRK), which provides frontline mental health services to rangatahi, was criticised by several witnesses for its high thresholds and limited responsiveness.
Schools reported frustration that assessments were often conducted by telephone and that admission required meeting a severe threshold of mental health difficulties.
Many rangatahi struggling with distress did not qualify, leaving school counsellors to manage arrangements with little direct engagement from TRK.
Meanwhile, Te Whatu Ora’s suicide prevention team, led by Crystal Paikea, gave evidence her team of three did not have the resources to meet the demand of a standard caseload of 40 clients at any one time.
Their services, however, are only activated when a suicide has occurred.
The findings pointed to a significant gap where high thresholds, limited capacity, and poor follow-up left vulnerable youth and their families without adequate support.
The coroner recommended the creation of a co-ordinated care pathway for Te Tai Tokerau rangatahi who are at risk of self-harm or suicide, regardless of severity.
The pathway should be accessible to both rangatahi and their whānau, ensuring continuity of care from entry to exit.
The inquest revealed the teens were engaged with multiple agencies addressing issues of substance abuse, violence, bullying, and relationship difficulties.
Yet the evidence showed there was no lead agency following these rangatahi from the time suicidality was detected until they were sufficiently well.
For those who were transient or victims of crime, the number of agencies increased dramatically.
Marty Loeffen‑Romagnoli, for example, had worked with 17 agencies in his short life.
Referrals made through Fusion, a collaborative group of agencies in Northland identifying at-risk youth, often failed to result in services being offered.
In the case of James Murray, uncertainty over which Oranga Tamariki site held responsibility meant no effective action was taken.
Even after confirmation Murray had been excluded from school, no safety plan or re-engagement strategy was put in place, and subsequent reports of concern were not acted upon.
His mother gave evidence that she was not kept in the loop about what was happening with her son.
To address these failures, the coroner recommended the introduction of a Kaiārahi – a guide or mentor – for any rangatahi identified as being at significant risk of self-harm or suicide.
The Kaiārahi would act as a central liaison, sharing information across agencies under agreed protocols and ensuring continuity of care if the rangatahi moved to another area.
The role would not require a clinical background but would demand a deep understanding of processes across organisations and the ability to advise whānau effectively.
The Kaiārahi would also investigate situations where rangatahi disengaged from services, obtain updated risk assessments, and work with whānau to explore alternatives.
The inquest highlighted the lack of data collection in Te Tai Tokerau targeting youth.
Several agencies gave evidence that their workload was increasing, yet no data was being systematically gathered.
Aspin stressed that information is critical to understanding youth suicide and identifying opportunities for early intervention.
The coroner recommended the Ministry of Health fund an in-depth nationwide data collection project, noting suspected self-inflicted deaths among rangatahi aged 12 to 24, stressors, service access, and barriers faced. Reports would feed into the ministry to inform regional and national strategies.
Schools emerged as a crucial frontline in the inquest as all the teens used their school counsellor as the first point of therapeutic help.
Yet schools gave evidence they are increasingly supporting rangatahi at risk of suicide without adequate funding structures to provide for permanent counsellors.
The Ministry of Education’s guidance allowance can only be spent on teacher salaries and excludes non-teaching staff.
Some schools were being forced to use operational budgets to cover these roles, such as Whangārei Boys’ High which spent $300,000 on two counsellors and a social worker.
Coroner Tetitaha recommended Te Whatu Ora extend Te Roopu Kimiora’s school liaison roles into secondary schools across Te Tai Tokerau.
This would give TRK greater oversight of at-risk rangatahi, and ensure the Kaiārahi is kept informed with relevant updates to provide a complete picture of each young person’s needs.
The coroner also noted that the Ministry of Education should consider law reform to resolve the funding issue.
Medication oversight was another area of concern.
Evidence was presented that 14-year-old Summer Metcalfe and her whānau were unaware of the risks associated with increasing her dose of fluoxetine. Within four weeks of the dose increase she began exhibiting concerning behaviours and then ended her life.
Coroner Tetitaha recommended that Te Whatu Ora review its guidelines for prescribing SSRI medications to teens and ensure doctors check in with patients every week for the first four weeks.
Te Whatu Ora responded to the recommendations by acknowledging the importance of collaboration but stated it had no additional funding to create new roles or services.
It argued that the proposed Kaiārahi role was unworkable under current conditions due to resource demands, privacy restrictions, and legislative limits, though it supported strengthening existing models like the TRK school liaison role.
Te Whatu Ora agreed data needed to be collected but said there was no funding or staff to fulfil this role. It warned that any other data collection project could result in duplication with the National Suicide Prevention Action Plan.
The agency agreed to review discharge processes to ensure whānau are better informed and supported extending school liaison roles. They also agreed on the need for clear advice and robust follow-up when prescribing medications such as SSRIs but said the responsibility fell with MedSafe.
Coroner Tetitaha rejected Te Whatu Ora’s claim that the Kaiārahi role was unworkable, stating it aligned with the National Suicide Prevention Action Plan and did not require extra funding.
The coroner said the role was already in action within the suicide prevention team and was the most capable of being expanded.
She stressed information-sharing gaps in suicide prevention remained and urged Te Whatu Ora to use the inquest’s findings to guide its planned mapping of services.
She also highlighted concerns that its review of discharge and transfer processes might not fully address engagement problems.
Finally, she made clear that data collection for suicide prevention was best conducted by Te Whatu Ora.
“I remain of the view that the recommendation regarding the analysis of the information held by Te Whatu Ora for suicide prevention purposes would prevent similar deaths from occurring,” she said.
For mothers Paula Mills and Carmen Heta, the findings come after a seven-year wait.
Summer’s mother Paula said she wanted to acknowledge all the whānau who participated in the inquiry.
“We all went through the process in the hope that other families wouldn’t go through what we have, I want to thank the coroner and her staff for all the hard work they have put in,” Mills said.
Mills, who pushed for anti-bullying programmes in schools, agreed with the recommendations but said the amount of time to inquiry was constantly retraumatising.
She said Te Whatu Ora’s response was disappointing and they needed to take the recommendations seriously otherwise nothing will change.
“They are the ones that are face-to-face with our children as their patients.
“Our children were failed by the services. They’re ambulances at the bottom of the cliff and we need to go back further and get something in prevention.
“This whole inquest wasn’t going to bring our children back, it was all about finding ways moving forward to help other families not go through what we’ve been through,” Mills said.
Ataria Heta’s mother Carmen said since her daughter’s death, she has experienced a further three suicides in her whānau and four attempts.
Heta said the Far North particularly had a lack of resources. She was shocked to learn schools had to find their own funding for counsellors.
“Now I understand why, if schools have them, they’re only there for a certain time,” she said.
“What I did understand in the final findings was the combined answer to it was the lack of resources and professional health.”
Natasha Hemara, chair of Te Manihi Tumaki/Northland Secondary Schools Principals’ Association, said the findings were welcomed.
Hemara said if school counsellors were fully funded in entitlement, it would go a long way in enabling schools to provide consistent support.
“The expansion of Te Roopu Kimiora into schools will also be a critical communication link not only with the agency itself and schools, but also could be beneficial in supporting students across schools and other educational organisations, especially if there are transitions that may occur for a young person,” Hemara said.
Hemara also supports the Kaiārahi role being established and said one point of contact would help whānau not become overwhelmed at an already stressful time.
“The findings that have been shared with me are welcomed, as they are about finding solutions to support the wellbeing of our young people.”
Group Director of Operations for Te Tai Tokerau, Alex Pimm extended their condolences to the whānau affected, acknowledging the profound impact the deaths have had on loved ones and the wider community.
“An in-depth review was carried out by the services that were involved after these tragic deaths, and learnings have been taken from these,” Pimm said.
Pimm said the organisation remained committed to delivering safe, high‑quality mental health and addiction care across Te Tai Tokerau, and staffing at Te Roopu Kimiora had since been bolstered with additional clinical, support and cultural roles to better meet community needs.
He said the service was engaged with the national Suicide Prevention Action Plan, updated this year, which focuses on closing gaps and ensuring people can access support when they need it.
The plan includes improving access to prevention and postvention services, strengthening early intervention, and building a capable workforce.
The coroner’s investigation was named Roimata Aroha mō te Whakamomori Taitamariki by the late Iti Tito, who worked in pastoral care at Whangārei Hospital.
The name, Coroner Tetitaha explained, captures both the sadness of the loss of young lives and the continuing love of grieving whānau.