A recent coronial ruling into a cluster of youth suicides in Northland has highlighted deep and ongoing gaps in support systems for rangatahi at risk of self-harm, particularly Māori young people and their whānau.
Coroner Tania Tetitaha released findings this week from a joint inquiry into the deaths of six young people, aged between 12 and 16, who died by suicide between 2018 and 2020. The inquiry, named Roimata Aroha mō te Whakamomori Taitamariki – tears of love for youth lost to suicide – was gifted by a local kaumatua and reflects the profound sadness felt by whānau and communities.
In her findings, Coroner Tetitaha concluded that the rangatahi – all known to services at points in their lives – effectively “got lost in the system.” Families, school staff and multiple agencies, including health services, education, Oranga Tamariki and Police, were aware of their risk, but there was no single lead agency and no clear pathway for coordinated support.
“The evidence shows persistent barriers to rangatahi and whānau accessing suicide prevention resources in Te Tai Tokerau, and those barriers remain today,” the coroner wrote.
The former Director of New Zealands Suicide Prevention Office, Matthew Tukaki, has said the sector is grossly underfunded and also said the Government has lost its way:
“For too long, suicide prevention in this country has been grossly underfunded, and the consequences of that neglect are being felt by whānau every single day. “We continue to pour money into crisis response, but we fail to invest properly in prevention, early intervention, and community-led solutions that actually save lives.”“You cannot expect meaningful change when the sector is stretched thin, under-resourced, and asked to do more with less year after year. “The Government has lost its way when it comes to suicide prevention. There is no clear strategy, no urgency, and no meaningful partnership with communities most affected. “What we’re seeing is a disconnect between rhetoric and reality. Communities are crying out for support, but the policy settings are not matching the scale of the crisis.If we are serious about reducing suicide, especially among rangatahi Māori, then the Government must stop tinkering at the edges and start listening to those on the front line.”
Tukaki went further:
“Māori communities are carrying a disproportionate burden, yet kaupapa Māori responses remain chronically under-resourced. That is a failure of equity and of Te Tiriti obligations. “Whānau don’t need another report. They need properly funded, culturally grounded services that are there before a crisis hits, not after.”
Families told the inquiry that their rangatahi faced a complex mix of issues – including relationship discord, bullying, substance harm, and trauma – that were not adequately addressed within a fragmented system. Rather than receiving seamless support, young people and whānau were often left to navigate multiple agencies, each with different processes and little information sharing.
The coroner’s report found that schools are under-resourced to provide consistent counselling and frontline support, while specialist mental health services – including Te Roopu Kimiora, the government’s child and adolescent mental health service – were stretched beyond capacity at the time of the deaths. In Northland, clinicians were reported to be managing caseloads far above recommended levels, leaving young people with delayed or inconsistent care.
For Māori whānau in particular, the findings are a stark reminder that equitable access to culturally safe and locally responsive support remains elusive. National statistics show that Māori – and especially young Māori males – continue to be disproportionately affected by suicide, with rates higher than non-Māori despite efforts to reduce self-harm and increase prevention activity.
The coroner has made a series of recommendations aimed at strengthening the response to at-risk rangatahi in Northland. These include the development of a coordinated care pathway that is visible and accessible to rangatahi and their whānau from first contact through to ongoing support, and the allocation of a kaiārahi (mentor) for any young person identified at risk of suicide.
Coroner Tetitaha also identified the need for better data collection and agency collaboration to inform future policy and practice, and for expanded school-linked support roles so that mental health professionals are embedded in education settings where rangatahi already are.
Whānau of those who died have expressed mixed feelings. While the recommendations are welcomed, their grief underscores the urgency of action. One mother said the recommendations cannot bring back her child, but hopes they will help prevent similar tragedies for other families.
Mental health advocates have also called for rapid progress, saying that suicide prevention strategy and services need meaningful resourcing and culturally grounded implementation if lives are to be saved.
The coroner’s findings mark a pivotal moment – one that demands sustained, collaborative, and culturally responsive action to ensure that rangatahi Māori and all young people at risk are supported, heard, and cared for before it is too late.
Where to get help:
- Aoake Te Rā
- Need to Talk? Free call or text 1737 any time to speak to a trained counsellor, for any reason.
- Lifeline: 0800 543 354 or text HELP to 4357.
- Suicide Crisis Helpline: 0508 828 865 / 0508 TAUTOKO. This is a service for people who may be thinking about suicide, or those who are concerned about family or friends.
- Depression Helpline: 0800 111 757 or text 4202.
- Samaritans: 0800 726 666.
- Youthline: 0800 376 633 or text 234 or email talk@youthline.co.nz.
- What’s Up: 0800 WHATSUP / 0800 9428 787. This is free counselling for 5 to 19-year-olds.
- Asian Family Services: 0800 862 342 or text 832. Languages spoken: Mandarin, Cantonese, Korean, Vietnamese, Thai, Japanese, Hindi, Gujarati, Marathi, and English.
- Rural Support Trust Helpline: 0800 787 254.
- Healthline: 0800 611 116.
- Rainbow Youth: (09) 376 4155.
- OUTLine: 0800 688 5463.
If it is an emergency and you feel like you or someone else is at risk, call 111.
