Four teenage girls who committed suicide within 13 months in the Hastings suburb of Flaxmere had all been exposed to family violence, an inquest has found.
In her findings, Coroner Carla na Nagara called for improved facilities for troubled young people and more involvement from government agencies.
"Flaxmere happened to be the community to suffer the suicides of four young people within a short space of time," Coroner na Nagara said.
"This has happened before in other communities and will continue to do so until steps are taken to put in place effective interventions for young people in distress."
The deaths occurred between July 2013 and August 2014, and all four girls were aged 15.
Ms na Nagara said the exposure to high levels of family violence - physical, verbal and emotional - had been a feature of each of the girls' lives at different times.
Ms na Nagara's report called for:
- a co-ordinator to set up a multi-agency, coordinated response to young people who are believed to be suicide risks
- a whānau well-being facility in Flaxmere to provide a place for families and young people to drop in to for support
- the automatic appointment of a lawyer to advocate for a child in cases involving allegations of family violence
- judges to be given the power to direct counselling for children exposed to family violence.
Hawke's Bay District Health Board agreed to set up a working party to review the recommendations.
The names of the girls are suppressed.
In one case, the girl was believed to have been the victim of a sexual assault and of family violence.
In a second case, the girl had attempted suicide twice before. She had posted on Facebook after the death of the first girl, who was a friend, that she too wanted to die.
This girl was also the victim of social media bullying on Facebook.
In the third case, the girl had a violent, alcoholic father. Her boyfriend was also violent and abusive towards her, and her relationship with her mother was also violent.
She was also the victim of sexual abuse at the age of 10.
In a fourth case, the girl had been beaten with a stick, and was affiliated at a young age with the Black Power gang.
In investigating the deaths, Coroner na Nagara held meetings with education and health agencies as well as police. She made extensive recommendations to government agencies.
She said violence and suicides would continue to happen until there were effective interventions for young people in distress.
The DHB's chief executive Kevin Snee said the board had already improved procedures to follow up with people at risk of suicide.
Ministry of Health director of mental health Anthony Duncan said the report made for tough reading, and the ministry would be working with the DHB to consider the recommendations.
Calls for a stronger approach to family violence
A Flaxmere campaigner against family violence said it wasn't just government agencies that needed to take on board the message of Coroner na Nagara.
Henare O'Keefe, who has led campaigns against violence in the suburb, agrees that government agencies in the area needed to do more to identify youth at risk of suicide and help them.
But he said families also needed to improve.
"A better approach from right across the board, not just agencies.
"A better approach from mums, dads, grandparents - it's a community mandate I would suggest."
Flaxmere councillor Jacobey Poulatin said family violence was an issue in her community and a zero tolerance approach was needed.
"We just let it go on far too much and let children, and our toddlers in some situations, succumb to the ramifications of that."