Photo: Kim Baker-Wilson/RNZ
Three years after Tauranga teenager Maddie Hall took her own life her parents are left with one unanswered question - what if?
What if Maddie had been given all the support she needed as soon as she went to Tauranga Hospital after trying to take her life in May 2020?
What if Maddie had received the comprehensive psychotherapy her clinicians agreed would be most beneficial?
What if Maddie's early life was not upended by sexual trauma?
What if more could have been done to save her life? What if the mental health system was better?
Maddie died on 31 March 2023 at the age of 16.
Almost three years earlier in May 2020 she was found trying to take her life. It would later emerge she had earlier tried to kill herself in November 2019.
In findings made public on Tuesday following a 2024 inquest, coroner Marcus Elliott found Maddie died by suicide but there was "no aspect of the medical care which can be said to have 'clearly linked to the factors that contributed' to Maddie's death".
As a result, he had no power to make any comments or recommendations about Maddie's death.
The Canterbury Suicide Postvention Working Group - a collection of agencies including health, education and care authorities that monitor and respond to suicides in the region - sought to suppress details of the coroner's report and Maddie's name.
The group submitted that four other young women had died by suspected suicide since Maddie's death in circumstances that amounted to a "cluster" with links through direct peer connection, shared social networks or online
interactions.
The group also said a cohort of 44 other people in Canterbury connected to the "cluster" was at elevated risk of suicide contagion.
"These connections reflect an overlapping peer ecosystem in which distress, grief and identification with each other's experience have been continually reinforced," the group said.
The group was concerned about the "significant online and social media risk component associated with this case, particularly the unregulated dissemination and glamorisation of suicide related content on platforms such as TikTok and Instagram."
Maddie's parents, RNZ and Stuff opposed suppression.
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