WARNING: This article discusses suicide and may be upsetting to some readers.  Six rangatahi (youth) who never knew each other walked the same troubled path, marked by bullying, loneliness, abuse, and fractured relationships.  Despite being identified as high risk, each encountered fragmented services and poor information‑sharing that left them without a clear route to support.  Their deaths formed a tragic cluster that has revealed the deep cracks in Northland’s suicide prevention system, prompting Coroner Tania Tetitaha to call for a single, co‑ordinated care pathway that ensures continuity of support.  However, Te Whatu Ora has responded to the coroner’s recommendations by acknowledging the importance of collaboration but says it had no additional funding to create new roles or services.  Of the six rangatahi, Coroner Tetitaha said: “It was a privilege to learn about their lives from their whānau pani (bereaved family) including those who took time to attend the pre-hearing conferences and inquest in person and by audio visual link”.  “E ngā pare raukawa o te mate, haere haere atu rā - To our precious loved ones who are no longer with us, I farewell you all.”  The scale of the crisis in Te Tai Tokerau is nothing new.  In 2012 a youth suicide cluster was identified after 19 teens took their lives. In 2018, Northland again recorded the highest rate in the country at 19.8 deaths per 100,000 people.  By 2020, the toll had risen to 36, with the rate climbing to 20.8 per 100,000, again the highest in New Zealand.  The national average that year was 11.5.  By 2024, figures showed no significant change.  The six rangatahi identified in the most recent cluster were Hamuera Ellis‑Erihe, James Patira Murray, Summer Metcalfe, Martin Loeffen‑Romagnoli, Ataria Heta and Maaia Marshall.  In November 2024, several agencies working with the teens gave evidence at the coroner’s inquest, which sought to investigate the gaps in their care.  The findings revealed that possible contagion was occurring, as all six knew of someone who had committed suicide or was self-harming.  Associate Professor Clive Aspin, who conducts research for the coroner into youth suicide, identified the young people had several, if not all, risk factors present at their time of death.  These included bullying, depression, anti-social behaviour, socio-economic deprivation, family violence, abuse and substance abuse.  The inquiry found the youth were living with some, if not all, of the risk factors. Data / Roimata aroha mō te whakamomori taitamariki inquiry  Each of the six had previously expressed suicidal ideation or engaged in self-harm, which was known to whānau and external agencies but barriers obstructed access to suicide prevention resources.  Families and schools struggled with limited knowledge of available support, reluctance or inability to engage with services, and the complexity of navigating multiple agencies.  These systemic barriers, the coroner noted, have persisted for some time and remain unresolved.  Co-ordinated care pathway  Two organisations came to the forefront of the inquest.  Te Roopu Kimiora (TRK), which provides frontline mental health services to rangatahi, was criticised by several witnesses for its high thresholds and limited responsiveness.  Schools reported frustration that assessments were often conducted by telephone and that admission required meeting a severe threshold of mental health difficulties.  Many rangatahi struggling with distress did not qualify, leaving school counsellors to manage arrangements with little direct engagement from TRK.  Crystal Paikea leads a team of three delivering suicide postvention services to the North. Photo / Te Whatu Ora  Meanwhile, Te Whatu Ora’s suicide prevention team, led by Crystal Paikea, gave evidence her team of three did not have the resources to m...