WARNING: This story contains details of violence against young children, which some readers may find distressing.

Seven years ago, a 16-week-old baby girl died in Wellington after being killed by her father, who was subsequently convicted and jailed for her manslaughter.

Now a coroner is considering what, if any, changes are needed to ensure further tragedies are prevented.

In November 2018, baby Manuia* and her parents, whose names are suppressed, were living in a converted garage and led a transient life. Her parents’ relationship was marred by alcohol, drugs, and unemployment.

The evening before she died, Manuia was taken to the hospital after she had been crying all day. She was diagnosed with reflux, given a prescription, and sent home.

The following day, the baby’s mother repeatedly tried to check on her daughter, but the father wouldn’t let her into the sleepout.

That evening, the father brought his daughter into the house, unresponsive. Paramedics were called but were unable to revive her.

A post-mortem subsequently revealed she had died of cardio-respiratory failure, secondary to traumatic brain injury, with multiple rib fractures that were both new and old.

Clinical experts agreed that the injury that led to her death occurred on the afternoon she died, but it’s unclear how the injuries were inflicted.

Her father was subsequently jailed for five years and four months for his daughter’s manslaughter, as well as five charges of assaulting his partner and a charge of assaulting a child.

Coroner reopens the inquest

Once the criminal proceedings were concluded, the coroner reopened an inquiry, asking the various agencies to file reports about their involvement in the case.

These were subsequently reviewed by two experts, Senior Sergeant Sharon Price and social worker Jonelle McNeill, to decide if the agencies’ responses were satisfactory.

Based on all the evidence, Coroner Ian Telford issued draft findings.

This week, an inquest in the Wellington District Court is considering those findings, before representatives from the police and Oranga Tamariki.

This morning, Coroner Telford began by giving the baby girl the pseudonym Manuia, a Samoan word that means blessing, and held a minute’s silence to mark her death.

Senior counsel assisting the coroner Jennifer Wademan told the hearing the inquest would consider whether there was any need to refine the recommendations made by the expert witnesses, how the recommendations are being implemented, and, finally, what, if any, lessons could be learned from Manuia’s tragic death to prevent further deaths.

Since Manuia’s death, the Family Violence Act has also come into force, enabling agencies to share information, although this has been with varying degrees of success.

The inquest heard there have been changes, including the introduction of a programme in 2018 called ,, to understand the wider dynamics of family harm, the patterns of harm, and the adverse circumstances in which they occur.

Inspector Allies Edge told the hearing the programme’s introduction had coincided with a transformation in the police, moving from a paper-based system to a technological one.

One of the coroner’s recommendations is that if all the areas within a district used the same reporting mechanisms, the response to families like Manuia’s, who regularly moved around a district, would be seamless.

The inquest heard about Family Safety Systems (FSS), a computer system where agencies like the police, Oranga Tamariki, Corrections, and Women’s Refuge upload, collate and share information about family violence callouts.

But the inquiry heard it only operates in two of the four areas in the Wellington district.

Coroner Ian Telford is holding an inquest into the girl's death. Photo / NZME

The court also heard within the Wellington district that two different models exist to deal with reports of family violence - Whāngaia Ngā Pā Harakeke and the Family Violence Interagency Response (FVIARS).

But the inquest also heard the intention of the Wellington district is to have a unified FSS and to have a multi-agency operating model that ensures information sharing not only in the area, but across the wider district.

Inspector Edge was unable to give a timeframe for when this would happen.

McNeill said while the signalled changes were welcomed, she worried about the impact on unborn children and suggested interim measures could be put in place.

But he also pointed out other initiatives, like an early intervention and information sharing for at-risk kids, between the police and the Ministry of Education. It had been rolled out to 99 schools in the district, and there were further plans to extend it into the early childhood sector.

We can’t be everything to everybody

The inquiry also heard police receive fewer than half of domestic violence callouts, either because they are not reported or are reported to another agency, who don’t regularly report them.

This raised the question about whether the police were the right agency to own the overriding multi-agency system response.

Inspector Natasha Allan told the court the police needed to look at what their core role was, because there was only so much resource, and “we can’t be everything to everybody”.

Summarising the situation, Wademan told the inquest it was a series of threads.

“It’s ensuring we have the training for recruits, ensuring that the family harm supervisors are getting the reports with the information in them that are going to the multi-agencies.

“It’s not a singular step that is going to address this. It’s a multi-layer practice.”

The inquest is set to continue for the rest of the week.

*Manuia is not the baby’s real name. It is a pseudonym given to her by the coroner.

FAMILY VIOLENCE

How to get help:
If you're in danger now:
• Phone the police on 111 or ask neighbours or friends to ring for you.
• Run outside and head for where there are other people. Scream for help so your neighbours can hear you.
• Take the children with you. Don't stop to get anything else.
• If you are being abused, remember it's not your fault. Violence is never okay.
Where to go for help or more information:
• Women's Refuge: Crisis line - 0800 REFUGE or 0800 733 843 (available 24/7)
• Shine: Helpline - 0508 744 633 (available 24/7)
• It's Not Ok: Family violence information line - 0800 456 450
• Shakti: Specialist services for African, Asian and Middle Eastern women and children.
• Crisis line - 0800 742 584 (available 24/7)
• Ministry of Justice: For information on family violence
• Te Kupenga Whakaoti Mahi Patunga: National Network of Family Violence Services
• White Ribbon: Aiming to eliminate men's violence towards women.
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Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.