In 2018 and 2020, it was identified that suicide clusters were occurring within Northland, with both years capturing the highest numbers for New Zealand.
In November 2024, Coroner Tania Tetitaha held an inquiry into the deaths of six youths from a recent cluster.
The six rangatahi (youth) identified were Hamuera Ellis-Erihe, James Patira Murray, Summer Metcalfe, Martin Loeffen-Romagnoli, Ataria Heta and Maaia Marshall.
Following the inquiry, findings into their deaths and recommendations were released this week, calling for Te Whatu Ora to implement changes to the suicide response in Northland.
The six youths were all involved with several agencies, and evidence was heard at the inquiry that their files were often closed by the agencies without follow-up, and that there were issues with information-sharing.
This led to disengagement, gaps in services and no follow-up to ensure the rangatahi had exited treatment effectively.
Frontline services in Northland working with the teens included child and adolescent mental health service Te Roopu Kimiora, Fusion, which is a collaboration of agencies that identify at-risk youth, addiction services Rubicon and the suicide prevention team, which works with whānau who have recently lost someone to suicide.
The suicides of Northland teenagers Ataria Heta, Summer Mills-Metcalf, Hamuera Ellis-Erihe and James Murray were investigated by the coroner.
Many of the teens were also working with Oranga Tamariki, ACC, counsellors or their GP, depending on their own needs.
A key recommendation the coroner made, particularly for the north, was a single care pathway with a kaiārahi navigator role to take the lead for whānau and at-risk rangatahi.
However, Te Whatu Ora responded that although Te Roopu Kimiora had since been bolstered by more staff, the kaiārahi role was unworkable due to funding issues.
“This is because significant further resources would be required to implement the role in its current form. This would require the cessation of current roles which would impact existing services,” the agency said in response.
Te Whatu Ora also rejected the coroner’s recommendation for an in-depth nationwide youth suicide data collection project, again claiming funding was not available.
But the Minister for Mental Health, Matt Doocey, told NZME that Health New Zealand had assured him changes had been made since the deaths of the six teens.
He rejected the idea that there was no funding available and made it clear his expectation was for the coroner’s recommendations to be taken seriously.
“I have raised with officials that I strongly disagree with any suggestion that there is no funding available,” Doocey said.
Minister for Mental Health Matt Doocey said he disagrees with the suggestion there is no funding available. Photo / NZME
“The mental health ringfence funding has increased by around $200 million each budget since coming into Government.
“I am very clear that where a need is identified, funding must go towards that region or initiative, particularly when it comes to suicide prevention.
“I expect Health New Zealand to take the Coroner’s recommendations seriously and make the best possible decisions on whether to implement them, that includes new roles.”
The minister said every New Zealander should have access to mental health support.
“This is non-negotiable for me.”
He said the Government’s suicide prevention action plan aimed to improve access to suicide prevention and postvention support, grow a workforce able to support those at risk and strengthen focus on prevention and early intervention.
“Every single life lost to suicide is one too many. I feel deeply for the friends, families, and loved ones who have to deal with the grief of losing someone to suicide. Losing a child truly is every parent’s worst nightmare,” he told NZME.
“I expect that Health New Zealand will utilise this action plan within the regions, including in Northland.”
Alex Pimm, group director of operations for Health New Zealand Te Tai Tokerau, said they were working with the national action plan and will consider the coroner’s recommendations. Photo / Denise Piper
Following the release of the findings, Alex Pimm, group director of operations for Health New Zealand Te Tai Tokerau, said they were committed to high-quality mental health and addiction care for the Te Tai Tokerau community.
“We acknowledge the Coroner’s report and will give priority to considering the recommendations,” Pimm said in a statement to NZME.
Carmen Heta, mother of Ataria, told NZME she was proud to use her voice and assist the coroner with the inquest.
“I loved being part of the inquest because it was new to me, but it was a shock knowing that many numbers [the suicide rates],” she said.
Before Ataria’s death, the whānau were working with 12 agencies and gave evidence that they were confused over who was doing what.
“It was so new to us, we didn’t know which way we were going, even with our daughter. Her moods would go up and down; we had to go with that,” Heta said at the inquest.
Ataria Heta’s parents were overwhelmed with the number of agencies they were dealing with and supported the kaiārahi role. Photo / supplied
Following self-harming incidents, they took Ataria to the Bay of Islands hospital, which had no staff available to see her.
“Lack of resources, lack of professional help, even at the hospital here. They never had anyone; we had to take her home and monitor her. What I’m hoping is they have someone now,” she said.
“I agree with the inquest because I knew my daughter; there were those mental health problems, but we never got the help.”
Heta said since her daughter’s death, they have lost three more youth in her family to suicide, and another four had made attempts.
She hoped agencies would take on board the coroner’s recommendations and was hopeful the kaiārahi role would be implemented, and that one would be available in the Far North.
Heta said she did not have all the answers for families navigating youth at risk of suicide, but urged others to open up and talk.
“I’m open to talk because I’m not going to hide under a rock; it needs to be spoken about.”
Paula Mills said they fought hard to keep 14-year old Summer Mills-Metcalf alive but were let down. Photo / Give a little
Paula Mills, mother of Summer Metcalfe, told NZME she was disappointed with aspects of Te Whatu Ora’s response and urged the agency to adopt the coroner’s recommendations.
Summer, who had faced multiple stressors, was prescribed the antidepressant Fluoxetine, and her dosage was increased four weeks before her death.
Mills said in evidence that the GP had not warned the family about the medication’s risks, including suicidal ideation.
“We knew from the beginning where the failings were. My daughter was failed, I strongly believe that,” Mills said.
“This whole inquiry wasn’t going to bring our children back; it was all about finding ways to move forward to help other families not go through what we went through.
“I really want them to take on board what the coroner says and make some positive changes, otherwise, this has all been a fruitless exercise.
“Her [the coroner’s] recommendations need to hold some weight.”
Mills said it had taken years to get to the inquiry phase and hoped the coronial inquest process could move faster in the future.
She supported the kaiārahi role but also called for more anti-bullying programmes and emotional intelligence education in schools.
“We need to go back further and get something more in prevention for these children which is where I was pushing for more social and emotional learning.
“Most of them, once they get through those ages and stages, they come out the other side fine.”
Mills had a final message for anyone struggling through difficult times.
“For anybody who is thinking of a permanent solution to a temporary problem, I just want them to know you are loved, you are enough, you’re not a burden, please reach out, get help, talk. We need these young people here.”
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.