However, in the years leading up to her death, her mental health was “fragile” and she was considered “extremely vulnerable”.
She received considerable counselling, psychiatric assessment, and medication.
At one point she was hospitalised.
Coroner Mary-Anne Borrowdale said the teen’s first contact with mental health services came in 2020 after her father learned she was accessing pornographic material online and had searched the internet for the means of suicide.
He also reported she was online overnight, interacting with adult men.
In the years leading up to her death, the teen told her psychiatrist she felt like a “bad person” and was having breakdowns.
She presented with “chronic suicidal ideation and some deliberate self-harm”.
She also heard voices in her head “with different personalities” and said one was “very mean”.
“The mean voice urged [her] to kill herself. [She] stated that she had never tried to do so and would not give in to the voice.”
In 2022 the teen was diagnosed with PTSD with associated anxiety.
It was noted she was “traumatised from having accessed pornography online by accident when aged 9-10 years, and again subsequently due to a compulsive curiosity to revisit such material”.
“[She] had also sexualised interactions with adult males on social media platforms,” said the coroner.
“She felt uncomfortable around males, and was traumatised, affecting her mood and sleep… [she] reported inconsistent changes in the voices that she was hearing, sometimes the mean voice was absent, at other times it was the dominant voice.”
The teen was reaching out for help for years. Photo / File
In mid-2022 she confided to a mental health helpline: “I’m a bad, bad person. I’ve been talking to sexual predators online”.
She said: “[The voices in my head] yell and scream, especially when I don’t have my headphones on. They’ve gotten worse since I started talking to people online. I can’t stop, though.”
A few months later she told the helpline she was feeling very anxious, because four nights before she had slipped away from home and met up with a significantly older male who she had met online.
Coroner Borrowdale revealed the man was thought to be about 48.
“She said that they had unprotected sex, with a second sexual encounter subsequently. [She] was opposed to telling her parents about this, and wrote: ‘I feel nervous and anxious because I feel like I shouldn’t be doing it but I like doing it’,” the coroner said.
“[She] confided in a friend, who advised that she must stop. She felt scared, as now the man knew where she lived. Shortly afterwards, [her] friend’s mother advised [the teen’s mother] about what had happened. [She] admitted the sexual relationship… [and] stated that she had acted willingly and consensually.”
The teen’s mother reported the matter to the police, but no action was taken.
“Police advised her that they could not take action against the man, given that [the teen] was above the age of consent and stated that she had consented to the sexual contact,” said the coroner.
The teen told her mother she had blocked all contact with the man.
However, she continued to exchange messages with him.
In 2023 she was admitted to a mental health unit after disclosing “intense suicidal thoughts”.
“[She] welcomed the admission. She wanted to get better and to be rid of suicidal thoughts,” Coroner Borrowdale said.
“[She] felt ambivalence in regard to her online grooming by older males. She wanted to stop interacting with adult men and pornography online and knew that her parents prohibited it; she felt tremendous guilt, but also an addiction or compulsion to continue. [She] could not reconcile her opposing thoughts and emotions.
“In hospital, [she] reported increased suicidal thinking, and flashbacks to when she had been groomed online at age 9… [her] wider family received advice on how to support her. She was started on medications.”
Eleven days after she was discharged, she contacted the helpline, reporting she was “feeling suicidal and can’t seem to distract myself”.
When asked if she had made a suicide plan, the teen replied: “Kind of. I know how, just not when”.
The teen was messaging adult men. Photo / 123rf
Over the next few weeks the teen reported “strongly suicidal thoughts and thoughts of harming her mother”.
She continued to have contact with the man grooming her and started self-harming again.
In early February she was taken to the emergency department and told staff the mean voices had returned and were telling her to harm herself and others.
She sent text messages that day saying she was adamant that someone “wants to hurt me… he hates me. He thinks I’m bad”.
She was offered a bed in an adult mental health ward – or to go home “with safety measures and follow up” the next morning.
“[She] wanted to go home, and for [her mother] to sleep outside her door to keep her safe. [Her mother] agreed to do so, and to remove anything that (she) could use to harm herself,” the coroner explained.
“The pressure placed on [the mother] by this safeguarding arrangement is extraordinary. It reflects poorly on the acute capacity within our mental health system that a severely mentally unwell teenager who wanted clinical assistance with suicidal urgings could not be given an adolescent inpatient bed anywhere in the South Island.”
The next day the teen said she was hearing “a single male voice, giving clear instructions as to how she should kill herself” and she was feeling “tactile sensations of a man touching her”.
“She felt unsafe, and paranoid that her mother might poison her. Urgent arrangements were made to access an inpatient bed,” Coroner Borrowdale said.
“[She] advised that the older man with whom she had sex had now told her that he was facing assault charges. This had triggered more voices and thoughts of harming herself and others. Clinicians agreed that the voices were caused by trauma rather than by psychosis.”
The coroner said during the admission the teen was co-operative and “worked hard”. After a few weeks it was agreed she could go on leave from the hospital and spend time at home.
She was told “if everything went well at home” she would be discharged.
Two days before she died she told her psychiatrist she was “concerned about whether she had acquired enough coping strategies” in hospital.
She denied feeling suicidal and the psychiatrist arranged to see her in two days.
The next day the teen’s mother checked in on her before she left for work. She was in her room playing a game on her phone and was “happy and fine”.
The mother considered working from home – but was also aware that the teen “did not want to be constantly supervised”.
Coroner Borrowdale said the mother felt “very overwhelmed and wanted guidance” and went to work on the advice of hospital staff who said the teen “needed normality”.
At 9.35am the teen’s grandparents called into the house and said she “appeared well and happy”.
At 10.47am she rang a suicide helpline and admitted she had tried to take her life.
“She said that she did not know what to do but didn’t want to live anymore or do school anymore,” said the coroner.
“The call-taker was empathetic and urged [her] to take that day’s medications… and to call or message again at any time, instead of feeling overwhelmed on her own or taking harmful steps,” Coroner Borrowdale said.
“At 11.05 and 11.09 am [she] rang [her psychiatrist] and left two voicemail messages. In the messages, [she] stated that she ‘was trying not to kill herself’.
“[The psychiatrist] picked up these messages at 11.20am but could not get hold of [the teen].”
She called the police and the teen’s mother, who raced home.
“At 11.44am [she] was the first to reach the house and found [the teen] unresponsive… [She] was unable to be resuscitated.”
Emergency services raced to help the teen but she could not be saved. Photo / File
The teen’s death was investigated for the coroner and as part of that police examined her digital devices and other records.
“It is clear that there had been repeated and escalating contact between [the teen] and an adult male online,” said Coroner Borrowdale.
“[She] had received photos of the man’s naked torso and face, most likely still images from a video clip, as well as an image of the man’s genitals.
“The man has been identified by police, but I do not name him here. He has denied having any contact with [the teen].
Coroner Borrowdale said in the two days before the teen died, the man exchanged messages with her “that were suggestive of a sexualised relationship”.
Police also confirmed that on the morning she died she made eight internet searches in less than two hours about a particular method of suicide and “viewed some content on mental health disorders”.
The coroner said the teen was “a vulnerable adolescent” who had suffered trauma from the age of 9, when she began online chat contact with adult males and viewing online pornography.
“As [she] grew into adolescence, she felt a compulsion to continue this contact, which on two occasions developed into physical sexual contact with an adult male,” she said.
In her psychiatrist’s assessment, these interactions were exploitative, traumatising, and left the teen struggling with her mental health.
“The sexualised online contact made [the teen] feel special, but also filled her with remorse and guilt. [Her] periods of high anxiety corresponded with those of grooming and exploitation.”
The psychiatrist told the coroner that the teen experienced guilt, increased anxiety and increased suicidal thoughts each time she connected with adult pornographic or adult chat sites.
“[Her] death brings attention to the incredible concerns related to the inherent risk with online predators. These individuals are adept at being able to locate, identify, and exploit vulnerable people,” she said.
“During the grooming process, victims gradually become less aware of cues which would normally alert a person [to] danger. Actions that would usually be recognised as perverse become normalised.
“Experienced predators can, eventually, con their victims into seeking inappropriate sexualised activity, so that they can then dismiss personal culpability and mislabel this as ‘consensual’. From what we can ascertain, this is what happened to [the teen].”
Coroner Borrowdale said it was “sadly clear” that the teen’s death followed intense mental health issues.
“[She] had the external symptoms of trauma… but she also had the deep internal symptoms of trauma, of which hearing voices, a desire to self-harm, and suicidal thinking were the most acute,” she said.
“In my assessment, [the teen] had come to despair of her chances of ‘beating her demons,’ and impulsively seized the opportunity of being alone to end her life.
“Her calls to Lifeline and to [the psychiatrist], on the morning she died, can only have been made because – in large measure – [she] wanted to be stopped from ending her life.
“Ultimately, [she] wanted to be free of her illnesses, and believed that in death she would achieve that freedom… [she] was overwhelmed by the feeling that recovery was not possible for her.”
Coroner Borrowdale said there were “no material failings” in relation to the teen’s mental health or medical treatment.
“All clinical specialists were attentive and appropriately concerned for [her],” she said.
“However, it is patently unsatisfactory that an acute inpatient bed in a therapeutic adolescent mental health facility was not immediately available for [the teen], when her mental health was imperilled, and she was acutely suicidal.
“[She] was not resistant to treatment. She was co-operative with clinicians, sought help, and was eager to be well.
“But it is no good for coroners and suicide advocates to urge young people to seek help, when the support they receive may be limited to texts, calls, and video-links, instead of face-to-face clinical assessment and treatment in a safe environment.”
While the coroner was critical of the system, she was clear that “no one is at fault in having failed to predict or to prevent“ the teen’s death.
She wanted the details of the tragedy made public to draw attention to online harms.
“[Her] online ordeal is a lesson to us all,” she said.
“[She] was from a very young age exposed to indecent adult sexual material online, and to contact with exploitative adult males, causing her enduring trauma.
“[Her] parents acted responsibly to try to limit her access to these harms. But, as many parents and caregivers know, the modern world operates largely online and legitimate, healthy online contact is necessary and encouraged.
“Regulation of a young person’s online exposure can be very difficult and, as technologies continually evolve, preventative vigilance and effectiveness are hard to maintain.
“NetSafe has published an Online Safety Parent Toolkit that is designed to help… I encourage all parents and caregivers with concerns that their young people may be vulnerable to digital harms to read and view these resources and, for further help, to contact NetSafe and seek assistance.”
Anna Leask is a senior journalist who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 20 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz