Northland youths who died in suicide cluster got lost in the system, coroner finds

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Warning: This story discusses suicide and teen deaths.

A coroner has found there are ongoing and wide-ranging barriers for young people accessing suicide prevention services in Northland in the wake of a tragic suicide cluster.

Coroner Tania Tetitaha held a joint inquiry into the deaths of five teenagers and a 12 year old, who died in 2018 and 2020 amidst "possible contagion".

The inquiry's name was gifted by a local kaumatua, the late Te Ihi Tito, Roimata Aroha mō te Whakamomori Taitamariki - meaning tears of love for youth lost to suicide.

It had been a long wait for those families since the joint inquest was held in November last year.

On Thursday, Coroner Tetitaha released her findings and they were stark.

"There were impediments to vulnerable rangatahi and their whānau accessing suicide prevention resources within Te Tai Tokerau and those impediments remain to this day," she wrote.

During the four-week inquiry, the coroner heard evidence from the families, Ministry of Health, Te Whatu Ora/Health New Zealand, Oranga Tamariki, ACC, the Ministry of Education and the Police, as well as experts.

The five young people were aged between 12 and 16 when they died and coroner Tetitaha found whanau and external agencies were aware of their self-harm risk but there was no lead agency.

Tetitaha found they effectively got lost in the system.

"All were required to approach multiple agencies to address any suicidal behaviour arising from substance abuse, sexual and physical abuse,