When 11-week-old Azariah Levi died, he weighed around 3kg – about half what a baby of that age would typically weigh.

Now, a coroner has issued a warning to parents over the importance of regular Well-Child Tamariki Ora checks, and seeking help from medical professionals if there are concerns about feeding and weight gain.

Baby Azariah’s parents were monitoring his weight loss themselves in the days before his death – weighing him after feeds, and feeding him with a syringe.

But Coroner Ian Telford said, in findings released today, that while Ariana and Allan Levi were aware of concerns, and taking steps they believed would support his wellbeing, the case highlighted the “vital role” of regular assessment by “suitably trained health professionals”.

Parents saw weight was slowly dropping

According to the findings, Azariah was born at home in Matamata on August 27, 2023, without midwifery support, or any antenatal or postnatal care.

His mother told the coroner this was driven by “a deep mistrust of the health system”, which she attributed to perceived clinical errors during her previous pregnancies, and another child’s treatment in hospital.

She told the coroner that her pregnancy with Azariah was normal, his birth was without complications, and he breastfed normally.

However, on November 12, his parents noted he was “not his usual self” – crying more than usual and not settling although he was reportedly feeding normally.

The next day, Azariah’s feeding noticeably reduced, he was sleeping longer than usual, and his “cheeks were going flat”.

They started weighing him before and after every feed and “could see that his weight was slowly going down”.

They said they prioritised feeding him every hour to get his weight back, and gave him expressed milk with a syringe.

Coroner Ian Telford has released findings into the baby's death. Photo / Supplied

Around 6pm on November 15, however, they observed he was having difficulty breathing, with slower breathing than usual and “holding his breath for less than 10 seconds” and “his lips were going blue…”

They decided to take him to hospital, and began to get their other children ready. At 8pm, they tried to feed him again. He vomited a “clear yellow liquid”, and Azariah’s father said he then “held his breath for a long time which really worried us, his eyes rolled back, and I was really concerned, so we called an ambulance”.

The ambulance was phoned at 11.24pm, and the couple started resuscitation immediately, guided by the call handler.

Azariah was taken to Waikato Hospital but despite “extensive efforts of all those involved”, could not be revived.

A pathologist later concluded he died because of “failure to thrive”, with a metabolic disorder considered the most likely explanation.

Following Azariah’s death, hospital staff notified the police, raising a number of concerns, including that he had not received antenatal, postnatal, or Well-Child oversight, and appeared to be severely underweight.

Police investigated, which included interviews with Azariah’s parents, and scene photographs recorded a diary documenting feeding and nappy times, as well as a stethoscope on one of the beds.

The police noted that Azariah’s parents are members of a Christian church, and recovered an audio recording from November 2023, in “which a man speaks briefly about healing in religious terms”, offering a prayer of anointing for Azariah, referring to concerns about his weight loss.

Ultimately, the police determined that criminal liability could not be established.

While mindful of the “profound grief” experienced by Azariah’s parents, and not wishing to add to their distress, in Coroner Telford’s view, the baby’s death was preventable, and timely medical intervention would have likely “altered the course of events”.

Faltering growth, metabolic disorder

A paediatrician, Dr Soper, engaged by the coroner, found evidence of Azariah failing to grow as expected from shortly after his birth, despite his parents providing adequate nutrition.

Soper looked at photos from August 27 and 28, taken shortly after birth, that showed a baby, presumed to be Azariah, with rounded facial features, suggesting a normal birthweight and appearance.

But by September 2023, at approximately four-and-a-half weeks old, two photographs showed a noticeable prominence of the “bony landmarks” on Azariah’s face, and his features appeared less rounded, indicating early signs of “reduced subcutaneous fat or growth faltering”.

By November 11, photos showed markedly prominent “facial bony landmarks”, despite reports that he was “outgrowing” his clothing at this age.

By the time of his death, his weight was around 3kg, which “is about what a newborn weighs, even though an 11-week-old would normally weigh almost twice that”, according to the findings.

Soper advised that “faltering growth” is now the preferred term for “failure to thrive”, and signs of it may be subtle: a child may not gain enough weight, may grow more slowly, cry or sleep more than usual, struggle during feeds, or interact less than expected for their age.

Soper said children with faltering growth needed to be assessed by a paediatrician.

Soper advised that children’s growth should be regularly tracked by Well-Child Tamariki Ora check-ups and that parents should seek help promptly if any concerns arise in relation to weight or feeding.

Coroner Telford said that as Soper advised, the signs of faltering growth can be subtle and may be difficult for parents to recognise, “particularly when caring for a child on a day-to-day basis”.

“In Azariah’s case, objectively clear signs of faltering growth were evident for some time prior to his death,” he said.

Evidence from his parents also indicated that they held particular concerns about his feeding, weight, and appearance at least three days before he died.

“With the benefit of hindsight, it is apparent that these concerns warranted urgent medical assessment at the time they arose.”

In particular, emergency assistance should have been sought “as soon as Azariah first displayed breathing difficulties and cyanosis at around 6pm, as these signs represent a medical emergency”.

The parents’ “deep mistrust” had at least in part stemmed from what Ariana Levi believed were shortcomings in care given to one of Azariah’s siblings, which she thought had led to long-term health problems for that child.

The coroner said it was relevant that this sibling presented to Rotorua Hospital in 2017, at three months of age, with “a clinical presentation similar to that observed in Azariah prior to his death”.

The child suffered a sudden cardiovascular collapse requiring intubation and ventilation, was found to have severe metabolic acidosis, and was noted to be significantly underweight for their age.

The coroner said that while his inquiry had not examined those matters, it was “apparent that these experiences influenced their decisions” about Azariah’s care.

While acknowledging these situations could be emotionally complex, in circumstances where a baby does not appear to be feeding or growing as expected, “the child’s wellbeing must always remain the first consideration”.

It was important for all infants to attend regular Well-Child Tamariki Ora checks, and parents or caregivers ought to seek medical advice promptly when concerns arose about feeding, weight, or growth.

“Parents and caregivers should call 111 immediately if a young child is struggling to breathe, develops blue lips, has difficulty swallowing, experiences pauses in breathing, or shows sudden changes in behaviour.”

Parents were advised to enrol their child with a Well-Child Tamariki Ora service and attend routine check-ups.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.