Police and Oranga Tamariki routinely rejected evidence of child abuse without getting input from health professionals, says the doctor who treated murdered 5-year-old Malachi Subecz.

In some of these cases, the children had reappeared in hospital months later with fatal injuries.

Dr Patrick Kelly was the on-call paediatrician at Starship children’s hospital when Malachi was admitted on November 1, 2021.

Kelly is a national expert in child protection and has given evidence in high-profile trials, including the 2007 murder of Nia Glassie.

Kelly told a coronial inquest in Auckland today that it was immediately clear that Malachi’s injuries were not consistent with the caregiver Michaela Barriball’s claims that he had fallen. He was bruised, grazed, burned and malnourished.

“To be frank, he showed evidence of a sustained period of cruelty … and arguably torture, up to his death,” he said.

The inquest in Auckland had earlier heard that photographs of Malachi with what appeared to be bruising had been supplied to Oranga Tamariki by a family member months before he died.

The photographs were reviewed by Oranga Tamariki social workers, who concluded there were no specific care or protection concerns - without an assessment by a doctor.

“It is of fundamental importance that the coroner appreciates that this behaviour by Oranga Tamariki was not an anomaly,” Kelly said.

“I would go so far as to say it was business as usual. There is a similar, embedded, business as usual culture in police. If those practices continue, other cases like Malachi will continue.”

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Kelly reviewed the same photographs in court today and said the combination of bruises were “unusual” and more likely to be deliberate than accidental.

Two months after Malachi’s death, Kelly dealt with an almost identical case, in which a young girl whose mother was in jail was admitted to hospital with severe injuries and later died.

A police officer had earlier seen the child with two black eyes and bruising on their neck but accepted the caregivers’ explanation that they were accidental.

Decisions to close a report of concern were “arbitrary and widely variable”, and often made by police or child protection with little or no training in injury interpretation, Kelly said.

Malachi Subecz before his death in Tauranga in December 2021. His caregiver Michaela Barriball later pleaded guilty to murdering the 5-year-old. Photo / Supplied by Megan Cotter

The coroner has heard evidence that staff at the Tauranga daycare which Malachi attended noticed injuries on him and were concerned enough to take photographs, but did not make a report of concern to Oranga Tamariki.

In response, a major inquiry into Malachi’s death by Dame Karen Poutasi recommended that Government introduce mandatory reporting of child abuse. That is also a key focus of the coronial inquest.

“I have no confidence at all that mandatory reporting in Malachi’s situation would have made any difference to the outcome,” Kelly said.

“The reason why I lack that confidence is that even if the daycare centre had made a report of concern with photos to Oranga Tamariki, the chances are no better than 50/50 that Oranga Tamariki would have gone to see the child.

“If they had gone to see the child, the chances are no greater than 50/50 that they would have sought a health professional about what the injuries meant.”

Between October 2021 and June 2022, 16 children were admitted to Starship with serious head trauma from abuse and six of them died.

“Malachi was only one of the 16,” Kelly said.

“My question to both Oranga Tamariki and Dame Karen Poutasi - why do we seek to learn from what happened to Malachi and not the others?”

Kelly said he was not blaming police officers or social workers, who were constrained by resourcing within their own departments and particularly within the health system.

Health NZ - Te Whatu Ora had not prioritised the prevention of child abuse, despite the scale of the problem.

There were no dedicated resources for child abuse assessments, and demands for dedicated clinics had not been met. Starship was the only dedicated, multi-disciplined facility in the country.

When acute assessments of injuries were sought by Oranga Tamariki or police, they had to be “squeezed” into a paediatrician’s busy workload or join the queue at a busy emergency department.

Despite violence intervention (VIP) training being mandatory, very few Health NZ doctors completed it. Similar training for GPs was almost entirely voluntary.

Kelly said greater collaboration was required between police, Oranga Tamariki and the health sector.

Law changes in 2019 which allowed greater information-sharing between the agencies was the “greatest advance in child protection in 30 years”, he said. But in practice, information-sharing was still patchy.

It had led to a “one-way traffic” system in which health workers shared information with Oranga Tamariki but received nothing back.

Oranga Tamariki was a “black box”, he said.

His “simple solution” was that every time police or Oranga Tamariki received an allegation of visible, physical injuries, that photo should be shared with a health professional and an assessment should be done as quickly as possible.

That process had to involve comprehensive, two-way information sharing between health, Oranga Tamariki and police.

He said that Health NZ should also join the Child Protection Protocol (CPP), a formal agreement between Oranga Tamariki and NZ Police.

Michaela Barriball was sentenced to life imprisonment with a minimum non-parole period of 17 years for murdering Malachi Subecz. Photo / Andrew Warner

Isaac Davison is a senior reporter who covers Auckland issues. He joined the Herald in 2008 and has previously covered the environment, politics, social issues, and healthcare.