Warning: This story discusses suicide and mental health, and may upset some readers.
A teenager's suicide has highlighted the dangers of children being exposed to pornography and sexualised online interactions, a coroner has found.
The 16-year-old Marlborough girl took her own life after suffering long-term trauma from early exposure to pornography, online grooming by older men and exploitative sexual contact.
The teenager, whose identity is suppressed, died in 2023 after being hospitalised due to her mental health earlier that year.
At the age of nine or 10 she had accessed pornography online by accident, and had later done so again due to a compulsive curiosity to revisit such material.
As the young girl grew into adolescence, she progressed into online contact with adult males, and then in 2022 - aged 16 - had physical sexual contact with a much older man, aged about 50.
Her mother reported the matter to police, but officers could not take any action against the man as the girl was above the age of consent and said she consented to sexual contact.
Coroner Mary-Anne Borrowdale, in findings released on Tuesday, criticised the role of pornography in young people's lives and the lack of acute mental health services in the teen's home region.
The girl's "online ordeal is a lesson to us all", Borrowdale said.
" was from a very young age exposed to indecent adult sexual material online, and to contact with exploitative adult males, causing her enduring trauma.
" parents acted responsibly to try to limit her access to these harms. But, as many parents and caregivers know, the modern world operates largely online and legitimate, healthy online contact is necessary and encouraged.
"Regulation of a young person's online exposure can be very difficult and, as technologies continually evolve, preventative vigilance and effectiveness are hard to maintain."
The teenager had online interactions and sexual intercourse with the older man in the months before her death, and her psychiatrist believed the interactions were exploitative and traumatising, and left the girl struggling with her mental health.
The specialist told the coroner the sexualised online contact made the teenager feel special, but also filled her with remorse and guilt.
" experienced guilt, increased anxiety, increased tics, and increased suicidal thoughts each time she connected with adult pornographic or adult chat sites," the doctor said.
" death brings attention to the incredible concerns related to the inherent risk with online predators. These individuals are adept at being able to locate, identify and exploit vulnerable people.
"During the grooming process, victims gradually become less aware of cues which would normally alert a person danger. Actions that would usually be recognised as perverse, become normalised.
"Experienced predators can, eventually, con their victims into seeking inappropriate sexualised activity, so that they can then dismiss personal culpability and mislabel this as 'consensual'. From what we can ascertain, this is what happened to ."
Concerns over children's access to harmful online content
The girl's parents had taken steps to protect their daughter from online harm and the trauma she was suffering.
Her father first reached out to the region's Child and Adolescent Mental Health Services in 2020 over concerns she was accessing pornographic material, interacting with adult men online and had searched the internet about suicide.
She was accepted into the service and was assessed as being at low risk with counselling recommended.
In September 2021 her GP referred her again to mental health services, as she had suicidal thoughts, was sleeping poorly, felt like a bad person and struggling with her mental health.
She was prescribed antidepressants and a psychiatric review was scheduled.
In February 2022, the teen met with a mental health services psychologist and reported stressors, including tics and conflict at home.
During subsequent sessions the teen disclosed she had been groomed online by sexual predators.
She began seeing a psychiatrist in April 2022, and was diagnosed with post-traumatic stress disorder with associated anxiety.
The psychiatrist's opinion was the girl was traumatised from having accessed pornography online by accident some years earlier, and had developed a compulsion to revisit it.
The teenager disclosed she had sexualised interactions with adult males on social media platforms. She also reported hearing voices in her head, including one that encouraged her to kill herself.
" stated that she had never tried to do so and would not give in to the voice," Borrowdale said. "She was future-focused and making plans. She was attending college full-time and was engaged with hobbies and volunteer work."
In October 2022 the teenager reported decreased suicidality and no intention to take her own life, but an increase in anxiety and stress.
In December the teenager called the mental health services helpline and said she was very anxious after recently meeting an older man twice for sexual encounters.
Her mother found out and took the matter to the police, but no further action could be taken.
The teenager told her mother she had blocked the man online, however messages showed the pair continued to have contact in the months that followed.
Over Christmas 2022 the teenager accessed the mental health services crisis team as she was again suicidal.
An urgent review took place in January 2023 after the teen twice harmed herself.
The girl was having intense suicidal thoughts, but wanted to live for her family.
She was transferred to Princess Margaret Hospital in Christchurch, the only South Island hospital with an inpatient adolescent mental health unit, and discharged 11 days later.
She told her psychiatrist she wanted to stop interacting with adult men and pornography online, and knew that her parents prohibited it. She felt tremendous guilt, but also an addiction or compulsion to continue, and could not reconcile her opposing thoughts and emotions.
The following month she twice called the mental health services crisis helpline and reported suicidal thoughts she could not distract herself from.
In early February she went to the emergency department and reported the voices telling her to harm herself had returned.
The after-hours crisis team told her there was only an adult mental health ward inpatient bed available, or she could go home with safety measures in place and be followed up with by mental health services in the morning.
The teen wanted to go home and for her mother to sleep outside her bedroom door to keep her safe.
The pressure this safeguarding arrangement placed on her mother was extraordinary, Borrowdale said.
"It reflects poorly on the acute capacity within our mental health system that a severely mentally unwell teenager who wanted clinical assistance with suicidal urgings could not be given an adolescent inpatient bed anywhere in the South Island."
Princess Margaret Hospital in Christchurch. Photo: Google Maps
The next day, the teen told mental health services there was now a single male voice, giving clear instructions as to how she should kill herself.
Urgent arrangements were made to access an inpatient bed at Princess Margaret Hospital and she was readmitted the following day.
While in the hospital she was cooperative with staff and worked hard, but her tics and the harmful voices continued.
She admitted to accessing online adult chat sites when she had access to her personal laptop and it was agreed access would be removed.
After nearly a month she was given leave from hospital, with a plan to be discharged if all went well.
The week before her leave, she was described as being tranquil, functioning, pleasant and polite.
She showed insight into her illness and demonstrated coping skills. Her tics had diminished.
The teen spoke to her psychologist the following day and seemed ambivalent as
to whether she wanted to be on leave or back in hospital.
The girl was concerned about whether she had acquired enough coping strategies. She denied being suicidal and appeared future-focused.
The pair discussed the harm of her having continued online contact and strategies for managing distress.
Two days later, while at home alone after calling a suicide helpline and her psychologist, she took her own life.
An examination of the teen's devices found there had been repeated and escalating contact between the teen and an older male - including naked photos of him - in the months leading up to her death.
Borrowdale said the girl had external and internal symptoms of trauma and she had come to despair of her chances of "beating her demons", and impulsively seized the opportunity of being alone to end her life.
"Ultimately, wanted to be free of her illnesses, and believed that in death she would achieve that freedom."
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No failings in the teenager's treatment
The coroner found there were "no material failings" in the treatment and support the teenager received from her GP, psychologist or mental health services personnel.
All clinical specialists had been attentive and appropriately concerned for her, Borrowdale said.
"However, it is patently unsatisfactory that an acute inpatient bed in a therapeutic
adolescent mental health facility was not immediately available for , when her mental health was imperilled, and she was acutely suicidal.
" was not resistant to treatment. She was cooperative with clinicians, sought help and was eager to be well.
"But it is no good for coroners and suicide advocates to urge young people to seek help, when the support they receive may be limited to texts, calls, and video-links, instead of face-to-face clinical assessment and treatment in a safe environment."
There were no obvious signs of the internal distress the girl was suffering in the days after her discharge from hospital, and she appeared well and content even in the minutes before her death.
"No one is at fault in having failed to predict or to prevent death that day," Borrowdale said.
Health New Zealand Te Waipounamu mental health and addictions lead Vicki Dent said the organisation was sorry for what happened and extended its sincerest condolences to family and friends.
The child and adolescent mental health inpatient service was provided in Christchurch as a regional service for the entire South Island. The purpose-built facility allowed staff to provide specialist services for all South Island tamariki and rangatahi requiring such care and treatment.
It was normal practice for those requiring acute and urgent in-patient care to be referred to the regional facility.
Health NZ did not respond to the coroner when sent her comments for consultation.
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