A man responsible for the death of a young boy was on electronically monitored bail at the time - and had only just been given permission to be around children. 

Neither the man nor the boy can be named but Coroner Marcus Elliott has today found the variation to his bail condition should never have happened and was only granted after the judge stood the case down and sought feedback from Child Youth and Family about whether it was suitable for him to be around children. 

A CYF social worker then prepared a report stating the man had “changed his lifestyle for the better”, had made mistakes but didn’t want to repeat them, had had help with parenting and started a Stopping Violence course. As a result, the writer had “no concerns” about him moving in with his partner and her children. 

He was granted the variation on October 2, 2015 and allowed to move in. 

Ten days later the little boy was found unresponsive in his bed by his mother. She had been at work the night before, leaving him in the care of her partner who had a history of violence. The boy could not be revived and was pronounced dead shortly after, having suffered a fatal spinal cord injury caused by hyperflexion. 

The Coroner’s findings released today are part two of an inquest into the boy’s death. The first part determined the man, who later died in custody after he was charged with murder, had inflicted the fatal spinal injury. 

The second part looked into the roles various organisations played in the lead-up to October 12, 2015, including who inflicted older injuries the boy had suffered, the sharing of information between agencies and the decision to grant the man a bail variation so he could be alone with children. 

The findings detail how the child had sustained several injuries between September 2015 and his admission to hospital in early October 2015, a week before he died. 

Those injuries, including several fractures, a missing tooth, bruising on his hips, back and buttocks and black fingernails, were considered suspicious by police. 

Discussions between Oranga Tamariki, doctors and police occurred to ascertain if it was appropriate to return the boy to his mother’s care but they didn’t know at that stage that her partner had been helping with childcare while she worked. 

The child had sustained several injuries between September and October 2015, including bone fractures, bruising, damaged fingernails and a missing tooth. Photo / File 

A pathologist later described the injuries as “uncommon” and said the fractures would have taken extreme force to inflict. 

Dr Martin Sage said the presence of multiple bony injuries of various ages was “ominous”. While on their own they could be seen as accidental, their presence together with the fatal injury meant the possibility they were deliberately inflicted needed to be seriously considered. 

However, despite the man having unsupervised time with the child during that period, the required standard of proof could not be met by the Coroner to determine he had inflicted them. 

When the man was first released from custody earlier in the year he was bailed to a different address on the condition he didn’t have unsupervised access to children under the age of 16. This was varied however after a judge received the social worker’s report. 

Coroner Elliott said the deficiencies in the report “appeared to have been due to a lack of staff with appropriate expertise” at the site. 

It was accepted by Oranga Tamariki, formerly Child Youth and Family, and the report writer, that the report was wrong. 

“The report should have stated that Oranga Tamariki did not support [the man’s] EM bail being varied.” 

Coroner Elliott also found the agency did not provide all relevant information to the court. 

Despite the man having contact with the child before his bail was varied, the Coroner found it would have been difficult for Corrections and police to identify any breaches without witness information. 

The child had been to hospital four times by the time Child Youth and Family became involved, and a safety plan eventually set in place, which was never in writing, was “unsatisfactory”. 

A letter was also sent from prison by the child’s father, who raised concerns about the man. The coroner said this should have prompted an investigation by Child Youth and Family, and ignoring the concerns was unacceptable. 

Coroner Elliott said the mother was attempting to make a life for herself, which included working on her career and caring for her children. 

“She saw [the man] as an important support and did not wish to jeopardise this,” he said. “[The man], and no one else, was responsible for [the boy’s] death,” Coroner Elliott said. 

“[She] trusted [him] by leaving the children with him on 12 October 2015. 

“[He] violated that trust by inflicting the injuries that caused [the baby’s] death... [she] therefore deserves compassion, not condemnation.” 

Significant suppression orders have been put in place by the Coroner, therefore names and identifying particulars of individuals cannot be reported. 

Oranga Tamariki chief social worker Peter Whitcombe said the agency acknowledged the child’s whānau and their ongoing pain. 

“We accept the Coroner’s findings and acknowledge that parts of our practice and involvement with this whānau were not to the standard I would expect.” 

Changes were implemented following a review of practice by the CYF chief social worker in 2016. 

“Oranga Tamariki will have a focus on early engagement, in particular working with our partners to build an understanding of the needs, strengths and opportunities for safety and protection within the whānau, hapū, iwi and family group alongside this, over the past few years Oranga Tamariki has undertaken a fundamental shift in the way we practice. 

“We are always working on the importance of sharing information, this is essential when working with tamariki, whānau and partners to ensure that tamariki are safe.” 

New information sharing provisions came into force in 2019 to support consistent and proactive information 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.” 

Hazel Osborne is an Open Justice reporter for NZME and is based in Te Whanganui-a-Tara, Wellington. She joined the Open Justice team at the beginning of 2022, previously working in Whakatāne as a court and crime reporter in the Eastern Bay of Plenty.