By Catherine Hutton, Open Justice reporter of 
Photo: RNZ / Samuel Rillstone
A man who killed a toddler had a violent history that Oranga Tamariki knew about, but failed to tell a District Court judge who allowed him to live with the boy and his mother.
Now, Coroner Marcus Elliott has criticised Oranga Tamariki saying the information the judge requested was important and courts should be able to rely on the agency to provide full and accurate information.
Wide-ranging suppression orders still surround the death of the "caring and kind-hearted little boy" whose favourite words were 'thank you'. Suppression also extends to the man's subsequent death in prison while he was on remand accused of the 17-month-old's murder.
The tragic facts of the case are laid out in two coronial findings released on Tuesday and a Human Rights Review Tribunal decision.
In 2015, the mother left her young son and daughter with her partner while she attended her hairdressing course.
In texts exchanged between the couple, he assured her the kids were okay.
When the mother arrived home around 7.30pm, she did not check on the children, who were light sleepers, as she did not want to wake them. She and her partner watched television before going to bed.
The next morning when she went to get her son up, she found him under his covers at the bottom of the bed. He was cold, floppy and unresponsive. There was a mark on his lip and some blood coming out of his nose.
Her partner called emergency services, while she tried to revive her son. Paramedics arrived and took over CPR, but confirmed he was dead.
'Tripped over a skateboard and fell on top of him'
The man told police he was carrying the boy when they tripped over the skateboard outside and he fell on top of him - a claim he later repeated to his partner.
When police searched the property, the only skateboard they found was inside a locked garage with cobwebs on it. Inside the garage police also found pills, prescription medication, needles and drug paraphernalia.
The pathologist said it was not possible to get the fatal injury from falling the way the man described and rejected the claim the boy was "a bit grumpy, then he got up and played normally".
"No. When this injury happened, he would have been probably limp and comatose. He might have been mistaken for being dead at that point unless you watched carefully."
The pathologist explained that the boy was forcibly thrown or pushed on to something and effectively curled into a ball. Or, he was sitting and was struck on the back of the head and neck from above and behind, with a smooth, flat, object, forcing him forward into the shape of a ball.
The coroner found the fatal injuries would have left the boy "unconscious and essentially tetraplegic" and unable to get into bed, estimating it took the boy up to an hour to die.
Coroner Elliott ruled the boy died in his bed on 12 October 2015, before his mother got home.
He concluded the man inflicted injuries to the boy's head and face, which involved up to six separate blows, but the fatal blow was a hyperflexion injury (excessive frontwards bending in the "nose to toes" direction) - resulting in damage to his brain stem and upper spinal cord - requiring a significant degree of force.
The coroner could not say exactly how the man inflicted the injuries, but he was the only person who could have inflicted them. However, this did not amount to a finding that the man had murdered the boy, he said.
Oranga Tamariki report 'deficient'
According to the coroner's reports, the couple's relationship began in August 2014, and they moved in together with her children in March 2015.
The woman was training to be a hairdresser, but, due to the course's hours, daycare was not an option and she regarded the man as an important support. She did not think her children were at risk.
In January 2015, the man allegedly broke into a property attacking the occupant with a pair of knuckle dusters and ramming the occupant's vehicle with his own. In April, police arrested and charged him for this alleged offending and he was remanded in custody.
Police opposed the man's bail on the grounds he had 25 previous convictions, including six terms of imprisonment. His extensive criminal history spanned 15 years and included convictions for assault with a weapon, kidnapping, intimidation, threatening behaviour, threatening to kill, breach of protection orders and male assaults female.
On 2 June, the man was sentenced to six weeks' jail, but remained in custody because he faced several other active charges.
Following that he applied for electronically monitored bail to stay with a friend and her son. The judge noted Oranga Tamariki - then Child Youth and Family - had no safety and welfare concerns.
Bail was granted on 16 June, on the condition he was not to have unsupervised access to children under the age of 16.
In August, Corrections asked Oranga Tamariki for more information about the man. A social worker responded saying he had a violent nature and a long history of abuse towards children and being aggressive towards women. They considered his new partner was at high risk.
Subsequently the man applied to vary his bail, to live with his new partner and her children. The District Court judge granted the variation after Oranga Tamariki's report, prepared for the hearing, said the man had changed his lifestyle for the better and didn't want to repeat past mistakes. It concluded by saying OT had no concerns about the man living at the address.
Bail was varied on 2 October, on the condition the man was not to be violent to his partner or her children, but there was nothing preventing him from being alone with them.
Ten days later the boy was dead.
Coroner Elliott was critical of the agency's report, describing it as "deficient" in that it did not contain all relevant information, including the concerns expressed to Corrections only two months earlier.
He said the report "should have concluded that Oranga Tamariki did not support the man's electronic bail being varied".
While Oranga Tamariki accepted its conclusion was wrong, the coroner was reluctant to criticise individuals saying the report's deficiencies arose because of a lack of staff with appropriate expertise in the office.
In future, if no one in the office had the skills it should be allocated to someone else within OT. The agency says it has made a number of changes, including increasing the number of social workers in the region.
Oranga Tamariki's then-chief social worker, Peter Whitcombe, said the agency accepted the coroner's findings and agreed it could have done better.
A number of changes were implemented following a review in 2016.
Whitcombe said over the past few years Oranga Tamariki had undertaken a fundamental shift in the way it practised. This included new information-sharing provisions which came into force in 2019 to support consistent and proactive sharing across the sector,
"It is important that not only Oranga Tamariki, but all other agencies, whānau and communities work together to do everything in our power to keep these tamariki safe from harm."
Four trips to hospital
Between September and October the mother took the boy to hospital four times because he could not put weight on his left leg. It took weeks - and an admission to another hospital - before the boy was diagnosed with a spiral tibial fracture - where a long bone is torn in half by a twisting force or impact. It is known to occur accidentally in toddlers.
The Human Rights Review Tribunal investigated aspects of the boy's medical treatment provided in the period before his death. Its report criticised the hospital saying there was no consideration given to the possibility of a non-accidental injury, despite a number of warning signs.
It found the boy's journey through the Paediatric, Orthopaedic and Radiology teams was inadequate and included two inappropriate discharges from hospital.
The coroner made no comment about Te Whatu Ora's policies or processes given the changes it made following the commissioner's findings.
The coroner was also critical of the safety plan formulated by Oranga Tamariki for the mother when she left hospital. He described the plan as "unsatisfactory in many respects" and imposed on the mother in a situation where she was "disempowered, distressed and understandably distrustful".
The coroner said the mother had no say in the plan, it was not written down and did not make clear who would look after the children while she attended her course.
The coroner found it was possible the man caused the injuries to the boy's leg, having been left alone with him while the mother went out in the evening. The next day the boy had a sore leg.
But the coroner was unable to make any findings as to what would have happened if the fracture had been identified before the hearing to vary the man's bail.
The man's death
The man was arrested three days after the boy's death and charged with his murder.
Upon being placed in custody the man moved between the at-risk unit and voluntary protective custody, following his concerns about his mental state and possible gang retaliation over the boy's death, as his father was a senior Mongrel Mob member.
The man's father told the inquest his son told him over the phone he wanted to end his life and prison officers were telling him to do it.
In his findings Coroner Elliott found it was "more probable than not" the father did not pass on his concerns about his son's suicidal thoughts to Corrections staff saying there is no record on file that he did. If Corrections officers had been told they would have returned him to the at-risk unit, the coroner ruled.
He said police had investigated the man's claims about the prison officers, speaking to all four of them. All denied the allegation and police did not charge anyone with inciting suicide.
There was also no record of the man's file or any record of the prison officer's comments.
The coroner ruled the man's death on 22 November 2015 was self-inflicted.
- This story was originally published by the New Zealand Herald.
