• A coroner’s inquest into the deaths of six Northland young people, including Martin Loeffen-Romagnoli, has revealed systemic failures.
• Hamuera Ellis-Erihe, 16, of Raumanga died in 2018. He loved dancing, rapping and singing.
• Summer Mills-Metcalf, 14, of Kaipara, died in 2018. She was described as a happy, smiling girl who enjoyed pulling pranks on family members.
• Ataria Heta, 16, of Moerewa died in 2020. She was a stand-out kapa haka performer with a kind nature.
• Maaia Reremoana Marshall, 13, of Kaitāia died in 2018 after being under the care of Oranga Tamariki.
• James Patira Murray, 12, of Ruakākā died in 2018. He loved rugby and was a Northland representative.

WARNING: This article discusses suicide and may be upsetting to some readers.

In the days leading up to his death, troubled teen Martin Loeffen-Romagnoli was happy. He was singing and on the way home from hockey practice when he told his mother he had decided to fly.

She thought the 15-year-old meant he wanted to be a pilot — but now believes he was telling her his plans. He was found dead the next morning.

“Losing my son has broken me, I died with him,” Veronica Romagnoli told an inquest being held in Whangārei into the deaths of six young people aged 12-16.

The coroner’s inquest, now in its third week before Coroner Tania Tetitaha, is seeking solutions to impediments to suicide prevention.

Hamuera Ellis-Erihe, Summer Mills-Metcalf, Maaia Marshall, Ataria Heta, James Patira Murray and Martin all died by suspected suicide and multiple agencies have given evidence of their involvement with the children.

Oranga Tamariki had involvement in Maaia, James and Martin, exposing flaws in record-keeping, unshared information and disengagement.

Intertangled service relationships, repeated reports of concern, behavioural issues and bullying have been raised in Martin’s case.

His mother, who gave her evidence earlier in the hearing, said Martin was a handsome talented hockey player.

“He was a friendly lovable boy but he always pushed the boundaries very far.”

At a young age, she knew “something was different” and Martin was identified as being on the spectrum.

“He wanted friends but his social skills were unorthodox and made it hard for him. He always wanted to learn how things worked. It was difficult for him to understand people’s emotions.”

Born in Chile, Loeffen-Romagnoli grew up in Tauranga but by the age of 5 had five reports of concern lodged with then-child protection service Child, Youth and Family (CYF).

By 2016, Martin was living in Northland but his living situation was strained with his behaviour consistently an issue.

He was eventually sent to boarding school — something the principal told the inquest was a bad idea.

Martin’s mother said things escalated quickly while at the boarding house where her son was constantly bullied and beaten up.

She said his belongings were taken and he would send her photos of bruises he received.

On one occasion he was beaten up by four boys while lying in bed and retaliated with a cricket bat. He was immediately suspended.

She said she called multiple meetings with the school and boarding house and even went to the police, but nothing was done.

“Mum, there’s no point. Why am I getting punished? If I’m good I get punished, if I’m bad, I get punished. I went to the police, I did a statement I’m still in trouble, I’m still a piece of s***,” her son told her one day.

The family pulled him out of boarding school and things began to come right at his new school.

In the days leading up to his death, he was happy and she thought he had turned a corner as they drove home from practice.

“Mum, I’ve decided to fly,” he said and she thought he was planning for a career as a pilot.

Martin went to bed happy and told his mother he loved her.

He was found dead the next morning on August 15, 2018.

The 15-year-old's mother called multiple meetings with the school her son was being bullied at. Photo / 123rf

Reports of concern - but no action taken

The extensive history of engagement with Oranga Tamariki officials was presented at the hearing by regional practice advisor Selina Taniora and revealed several flaws.

On some occasions, reports of concern had been filed within 10 days of each other but no action was implemented and his file was closed.

While living in Tauranga, Martin had at least four agencies assigned, two that offered the same service, to which Coroner Tetitaha asked “Is it a danger to have so many agencies working at the same time?”.

Taniora said she would not have expected to see two agencies offering the same service involved and said “There is that risk of too many cars up the driveway”.

While Martin was in Northland more reports of concern were lodged with no action taken and Coroner Tetitaha said the file was difficult to assess as the recording was poor.

Taniora told the court the difference in resourcing between Auckland and Northland was poor and local offices had to rely on other community providers.

In the Far North, Taniora said there were just five social workers while Whangārei had between 18-22 alongside a relatively small youth justice team.

“That is inadequate to the population.

“The workforce has to rely heavily on local relationships and the goodwill of kaimahi across the children’s sector to meet the needs of tamariki. In terms of caseloads, unmanageable is the nicer way to put it,” she said.

Staffing at Oranga Tamariki sites in Northland was highlighted at the inquest. Photo / RNZ

Taniora said social workers in Northland are managing at least 20 to 25 children — responding to those already on the books, new cases walking through the door and youth justice.

“The volume of work in Te Tai Tokerau for those responding to family harm and mental health is at risk to the number of social workers that are able to adequately respond and is really unbalanced. There are not enough social workers to respond to the level that whānau need.

“You have to work extra hard because we don’t have resources or staffing to respond to mahi that comes through the door.”

School counsellors, helplines - Not up to the job

Romagnoli told the court she no longer trusted the system and made a recommendation for schools to have one counsellor for every 150 students.

“School counsellors are not up to the job ... It’s a scary thought that we think or are led to believe that there is support at schools.”

Romagnoli also believed services such as 1737, a number her son dialled three times in the weeks before he died, did not work.

“The helpline clearly didn’t help, because he’s dead.”

Romagnoli, who works for St John, has noticed in her work that the age of those attempting suicide was getting younger and crisis teams were severely understaffed.

“The greatest support for mental health patients would be in the community.”

She commended Coroner Tetitaha for the opportunity to speak at the inquest and hoped any change would be a step forward.

The coroner is expected to release her decision on the six youth deaths in early 2025 but already indicated there will be a finding all of the rangatahi died by suicide.

SUICIDE AND DEPRESSION

Where to get help:
• Lifeline: Call 0800 543 354 or text 4357 (HELP) (available 24/7)
• Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: Call 0800 376 633 or text 234
• What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
• Depression helpline: Call 0800 111 757 or text 4202 (available 24/7)
• Helpline: Need to talk? Call or text 1737
• Aoake te Rā (Bereaved by Suicide Service): Call 0800 000 053
If it is an emergency and you feel like you or someone else is at risk, call 111

Shannon Pitman is a Whangārei based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.