Inquest into youth suicides finds exposure to family violence

Mon 23 May 2016

Coroner Carla na Nagara has released findings from a joint inquest into the suicides of four 15 year old girls between July 2013 and August ...

Coroner Carla na Nagara has released findings from a joint inquest into the suicides of four 15 year old girls between July 2013 and August 2014 in the Hawke's Bay suburb of Flaxmere.

Coroner Nagara said a striking feature of the cases was that all had been exposed to domestic violence. She said the girls had been experiencing a number of significant stressors, including parental separation, difficult relationships with step-parents, difficult or non-existent relationships with a biological parent, lack of parental control, high levels of responsibility for younger siblings, domestic violence and abuse, alcohol and drug use and online bullying.

In the report, the Coroner said that "... it is acknowledged that the Police and CYF generally appear to have worked consistently within their legislative mandate, and, in respect of CYF, with programs and processes or templates that were operative and available at the relevant times." She also said it would be too simple to suggest that any one factor resulted in the deaths. However, Coroner Nagara said "... the legislative mandate of CYF and Police lacks the responsiveness or flexibility to effectively support children and young people living in circumstances similar to those being considered here."

The Coroner expressed concern that the focus within the current system remains on children's physical safety and not on the psychological and emotional well-being of children exposed to violence. Specific to suicide, responses to suicide risk are only triggered when a child makes express statements of feeling suicidal. While concerns regarding the girls' well-being were known to a number of agencies and individuals, the focus on discrete events meant these were not acted on.

In discussing possible recommendations in the report, the Coroner said "What seems to me to be vital to the success of any such initiative is ensuring that all agencies in a position to see that young people exposed to numerous risk factors are struggling ... are able to alert other agencies to any concerns so that action can be initiated and coordinated."

The Coroner's recommendations include:

  • A coordinator be funded by Hawke's Bay DHB to set up a multi-agency platform for the reporting and coordination of response to young people at significant risk of suicide
  • The DHB set up a whānau wellbeing facility in Flaxmere for families and young people for drop-in support
  • The Minister of Justice review the Care of Children Act 2004 to consider the automatic appointment of a "lawyer for child" in cases where there are allegations of family violence and that judges have the power to direct counselling for children exposed to childhood trauma including domestic violence.

It has been suggested that the Hawke's Bay Regional Children's Team, which is to be implemented under the Children's Action Plan, may address the recommendation for a coordinator.

A team is to be set up to discuss the coroner's recommendations, involving the District Health Board's population health service, mental health service, the Hawke's Bay community and other key agencies.

The findings apply to all communities; as the Coroner pointed out "it would be wrong to consider the findings irrelevant to other communities with similar levels of social deprivation and disadvantage."


A report by the Suicide Mortality Review Committee (May 2016), Ngā Rāhui Hau Kura: Suicide Mortality Review Committee Feasibility Study 2014–15 includes looking at suicides by rangatahi Māori. The report states:

"Coronial reports and other narratives contained within the CYMRC [Child and Youth Mortality Review Committee] database suggest family violence was prevalent in the lives of some of the rangatahi. Forty-two (n=42/194, 21.6%) of the rangatahi had either been exposed to family violence as tamariki, most commonly as a witness to domestic violence in their whānau, or had been in a violent relationship later in their short lives (Table 4.10). Thirty-one (n=31/42, 73.8%) of these 42 rangatahi were male, accounting for almost a quarter (n=31/125, 24.8%) of all rangatahi males. Because family violence can often go unreported, these numbers are most likely an undercount."

In terms of sexual abuse, the report states:

"Coronial reports and other narrative contained within the CYMRC database identified that 27 (n=27/194, 13.9%) of the rangatahi Māori subgroup had disclosed sexual abuse at some point in their lives68 (Table 4.11). The disclosure rate was two to three times greater among females than among males in the rangatahi Māori subgroup. These numbers are likely to be an undercount."

The time-limited Suicide Mortality Review Committee (SuMRC) was established in May 2014 under the auspices of the Health Quality & Safety Commission, in order to "trial a suicide mortality review mechanism to improve knowledge of contributing factors and patterns of suicidal behaviour in New Zealand, and to better identify key intervention points for suicide prevention." The SuMRC recommended the Government "funds the SuMRC on a long-term basis in order for the SuMRC to have an impact in reducing suicide."

Update: A suicide prevention plan has been developed and presented to the Hastings District Council for approval. It was developed by an inter-agency group led by a suicide prevention coordinator, following recommendations from the coronial report. 

Children's exposure to intimate partner violence

Jan Logie MP has blogged about the need to address intimate partner violence as part of the Child, Youth and Family review and in family law, by integrating "an evidenced based approach to domestic violence into the heart of our child protection services."

The need for work on "vulnerable children" to include addressing children's exposure to intimate partner violence and other forms of family violence has been discussed in Parliament.  

Two NZFVC issues papers provide research and information about children's exposure to intimate partner violence:

The CDC (US) recently released a technical package to support agencies and communities to understand and address adverse childhood experiences, including exposure and experience of violence, abuse and neglect.

Suicide and exposure to violence

Research has shown that exposure to family violence can be a risk factor for youth suicide. See the following studies for more information about youth suicide and family violence in New Zealand:

  • Beautrais, A. L., (2001). Child and young adolescent suicide in New Zealand. Australian and New Zealand Journal of Psychiatry.  35(5): 647-653. DOI: 10.1046/j.1440-1614.2001.00944.x
  • Clark, T. C., Robinson, E., Crengle, S., et al. (2011). Risk and protective factors for suicide attempt among indigenous Māori youth in New Zealand: The role of family connection. Journal de la Santé Autochton. March: 18-31. Available online
  • Fleming, T. M., Merry, S. N., Robinson, E. M., Denny, S.J. & Watson, P. D. (2007). Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Australian and New Zealand Journal of Psychiatry, 41: 213-221. Available online
  • Clark, T.C., Robinson, E., Crengle, S., Grant, S., Galbreath, R.A. & Sykora, J. (2009). Youth’07: The Health and Wellbeing of Secondary School Students in New Zealand. Findings on Young People and Violence. Auckland: The University of Auckland. Available online
  • Fergusson, D. M., Woodward, L. J., Horwood, L. J. (2000). Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychological Medicine. 30: 23-39. Abstract available online

The following studies provide a broad overview of issues:

  • Beautrais, A. L., Collings, S. C. D., Ehrhardt, P., et al. (2005). Suicide prevention: A review of evidence of risk and protective factors, and points of effective intervention. Wellington, New Zealand: Ministry of Health. Available online
  • Gluckman, P. D., et al. (Ed.). (2011). Improving the transition: Reducing social and psychological morbidity during adolescence. Auckland, New Zealand: Office of the Prime Minister's Science Advisory Committee. (See Chapters 14: Families and children: a focus on parental separation, domestic violence and child maltreatment & 16: Youth suicide).  Available online

Related media


Flaxmere up for major community award, Bay Buzz, 16.12.2022

Suicide prevention plan to be presented to Hastings District Council, Hawke's Bay Today, 19.07.2018

Family violence stats reversed in Flaxmere project, Hawke's Bay Today. 19.05.2018

Lawyers for abused children impractical, Radio NZ, 14.05.2016

Police defend suicide response after strong criticism from coroner, Stuff, 12.05.2016

CYF overhaul should help stop Flaxmere tragedies, Radio NZ, 12.05.2016

Bullying a factor in teens' deaths, Hawke's Bay Today, 12.05.2016

Coroner makes finding on sudden deaths of four teens, Hawke's Bay Today, 11.05.2016

Coroner finds links between Flaxmere teen suicides, Newstalk ZB, 11.05.2016

Inquest into suicides of four Flaxmere girls finds all were exposed to family violence, Stuff, 11.05.2016

Teens who took their own lives were done a 'grave disservice', says coroner, Stuff, 11.05.2016

Family violence in four Flaxmere suicides, Radio NZ, 11.05.2016

Domestic violence a contributor in all four Flaxmere suicide cases, The Dominion Post, 11.05.2016

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