Sara Chatwin: Mindworks psychologist on self-inflicted deaths of young people reveal flaws in the suicide prevention system

The self-inflicted deaths of six Northland young people reveals dangerous flaws in our suicide prevention system.

An inquiry by Northland Coroner Tania Tetitaha into the deaths calls for a single, coordinated system. 

The youths had worked with up to 17 agencies - that hadn't seemed to identify or follow up on their need for support. 

Mindworks psychologist Sara Chatwin told Andrew Dickens we don't need more thinking groups and documentation, but rather people who have the skills and willingness to deal with these issues. 

She says in New Zealand, we clearly have a huge problem that other countries are very aware of. 

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Episode Transcript

Speaker 1 (00:00):
So corner Tan Ti Haha says the system is broken
after probing the suicides of six young people, These young
people that she looked at age between twelve and seventeen. Now,
some of these children, some of these young people had
contact with up to seventeen agencies, and yet still fell
through the gaps and the coroner's messages blunt, streamline care

(00:23):
or this will keep happening. My work. Psychologist Sarah Chatwin
is with me this morning. Good morning to you, Sarah. Sorry, Sarah,
my mouse is not working. I'll use my finger. No,
that doesn't work either. Ah, there we go, got you on,
I got it. I've got a sticky mouse, So there
we go.

Speaker 2 (00:42):
Oh dear, we don't want one of those this early in.

Speaker 1 (00:44):
The morning, Sarah. How on earth does this happen? How
do so many children slip through cracks?

Speaker 2 (00:51):
That was a particularly hard rate, and you know, it's
hard to not be Yet another voice suggesting that the
needs of the and are not being met by an
enormous amount of services and groups that don't seem to
be interfacing, sharing information, you know, picking up on the need,

(01:12):
picking up on those kids who are presenting in a
way that must be you know somewhat clear in these situations.
So you know, it's just hard not to sound like
another person who says the continuity of care when dealing
with these kids going through these issues is just wow,

(01:32):
it ain't there, right, No.

Speaker 1 (01:34):
Well, with so many agencies seventeen some had contact with seventeen,
you have to wonder whether the left hand knows what
the right hand is doing, and whether the right hand
is actually just presuming and assuming that the left hand
is doing all the work and when it isn't happening.

Speaker 2 (01:49):
And even if that isn't the case, and it clearly
looks to be that because there is no continuity of care,
because the conversation, the transparency between agencies, I mean, it
just can't exist or in a form that's workable. You
think to yourself, wow, we can understand the coroner's suggestion,

(02:12):
you know, about providing a single coordinated care pathway. Yes,
that sounds tremendous. Then of course we go to the
fact of, okay, how do we do that? So we
have all these agencies up to seventeen and the kids
that were highlighted in this article were I think six,
you know, they had been through they had seen thirteen agencies,

(02:34):
seventeen agencies they had experienced, you know, a raft of situations, bullying,
domestic violence, you know, disconnection with far no family parents.
The symptoms were very very similar in most cases, and
they had been in front of these agencies, but for

(02:56):
whatever reason, whether it was the lack of transparency, agency
picked it up but didn't transmit to another agency when
they lost the child because clearly the child wasn't seeing
them all at the same time, there weren't any of
those markers, any of will, any people putting their hands
up and saying, hey, we are seeing this person now
and then and ongoing. So clearly something has to be

(03:20):
more focused with regard to this particular person, with regard
to that particular person. But it's just not happening being
identified or being followed through with.

Speaker 1 (03:31):
If they create a single coordinated care pathway, it's still
going to be the same people that start it, and
they've just been amalgamated into one unit.

Speaker 2 (03:39):
So well, I think the key is that that doesn't happen.
The key is that if you are providing a single
coordinative care pathway, you clearly have to change the people up.
You clearly have to put people in place that have,
you know, communication skills, the ability to be transparent, the
willingness to deal with these issues, not just have thinking

(04:02):
groups and focus groups and documentation that proves that we
have this problem. Oh yes, in New Zealand, we clearly
have this problem. We are being viewed by other countries
as a country with a huge problem with regard to
teen suicide rates. So I think you're right. It can't
be an amalgamation. A single pathway that the coroner suggests

(04:26):
cannot be just an amalgamation of what we're going on
with at the moment with the same people, because clearly
this isn't working, and the people who are in this system,
there may be some who don't work. So it has
to be changed up and looked at. This will take
time and this will take resources.

Speaker 1 (04:44):
All right, Sarah Chah, I thank you. Yes, attending a
meeting in a room is not actually helping a kid
in any way, shape or form. James Murray twelve, Maya
Marshall fourteen, Harmawara elis Araje seventeen, Marty Leffen, Romanoli fifteen,
Summer Mills, Mecca fifteen at Harbor you hit at sixteen
on behalf of those responsible. We're so sorry for your family.

Speaker 2 (05:07):
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