The accidental death of a Tauranga boy playing a choking game has led to a coroner's request that teachers and parents throughout New Zealand be educated to recognise the warning signs.
Coroner Wallace Bain's recommendation follows the death of a "very intelligent and high achieving young man'' in Tauranga in 2009.
The findings of the coroner's inquest held last year were released to the Bay of Plenty Times yesterday and included that government departments be asked to identify the extent of the problem in New Zealand.
Evidence from a pathologist said there had been a significant rise in the number of deaths by hanging.
Some of those were related to experimenting with asphyxia in what he called the "choking game''.
Dr Bain recommended that the Ministries of Education and Health undertake a targeted education approach to school boards, with the boards to take responsibility for educating teachers and parents on the warning signs and how to counsel at-risk young people.
Details that could lead to the identification of the boy were suppressed, along with how the boy choked himself to death.
"This is indeed a tragic case,'' Dr Bain said in findings from the inquest.
He said there was no evidence that the boy was attempting to take his own life.
"All the evidence according to police pointed in the opposite direction that [the boy] had been planning for both a short and long-term future.''
Police felt that the only reason was that the boy had been experimenting to see how far he could push himself until he started to feel light headed.
"However, it had gone too far and he has lost consciousness and unintentionally asphyxiated himself.''
No phone calls were made by the boy immediately preceding his death and nothing was found in his bedroom to suggest anything other than a normal boy's writing and drawings. He never used the internet.
"Tragically, all the evidence shows that [the boy] was a very very gifted and talented child. What he attempted on this night had gone horribly wrong.''
His findings detailed the aftermath of the game, when the boy's mother entered his room to tell him a television programme had started.
He said the mother ran to get help from her husband and they scrambled to get the strap off his neck and ring for an ambulance.
The boy had vomited and the parents commenced CPR until the ambulance arrived.
"They worked on him for 45 minutes before determining they could get no response.
Evidence from the pathologist said that forensic asphyxia was a huge topic. It took relatively little pressure over the trachea to obstruct it and cause asphyxia and death.
Dr Bain also commissioned a report from Dr Johan Morreau, a paediatrician and chairman of the Rotorua Lakes Child and Youth Mortality Review Committee.
Dr Morreau, after consulting with colleagues and reviewing all the literature, said the facts behind the Tauranga boy's death "certainly reflected participation in the choking game''.
He said the social demographics - a male, the age and high achieving background - were entirely consistent with the tragedy.
Dr Morreau said young people were at serious risk of death and self harm if they indulged in this highly risky and experimental behaviour.
There was a risk of serious brain damage if they don't die. They risked a stroke, convulsion and significant loss of brain cells from the deprivation of oxygen, he said.
Reports of young people experiencing some euphoria from the loss of oxygen from choking was achieved at the loss of brain cells and was very, very unsafe, Dr Morreau said.
The boy's mother told the Bay of Plenty Times at the time of the inquest she wanted other parents to warn their children of the dangers of the game.
"Our son was the last person you could ever imagine this would happen to.''
She said it was important to talk about the issue as her son's death was "very much out of character''.
"He was highly intelligent and if this tragedy can find its way into my son's world, then it can find itself into anybody's. No one is exempt.
"I don't want another parent to ever have to go through what we have had to.''