Toddler killed after Oranga Tamariki gives judge ‘inadequate’ report on bail change

Oranga Tamariki knew about the man who killed the young child but did not inform the 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 had asked for was important and courts should be able to rely on the agency to provide full and accurate information.

Wide-ranging suppression orders continue to surround the death of a “caring and kind-hearted boy” whose favorite words were “thank you.” The suppression also extends to the subsequent death of a man in prison while he was in custody accused of murdering a 17-month-old baby.

The tragic facts of the case were set out in two Crown Court findings published on Tuesday and in a decision by the Human Rights Tribunal.

In 2015, a mother left her young son and daughter with her partner while she attended a hairdressing course.

In messages exchanged between the couple, he assured her that the children were fine.

When the mother got home at about 7:30 p.m., she didn’t check on the children, who were light sleepers, because she didn’t want to wake them. She and her partner were watching TV before going to bed.

The next morning, when she went to wake her son, she found him under the covers at the bottom of the bed. He was cold, limp, and unconscious. He had a mark on his lip and a little blood was running from his nose.

Her partner called an ambulance while she tried to resuscitate her son. Paramedics arrived and took over CPR but confirmed that her son was dead.

“I tripped over my skateboard and fell on him”

The man told police he was carrying the boy when they tripped over a skateboard outside and he fell on top of him, a statement he later repeated to his partner.

When police searched the property, the only skateboard they found was locked in the garage, covered in cobwebs. Police also found pills, prescription drugs, needles and drug paraphernalia in the garage.

The pathologist said it was unlikely that a fatal injury could have been sustained from the fall the man described, and dismissed claims the boy had been “a bit grumpy but got up and played normally after a while”.

“No. He was probably in a coma and limp when he got injured. He could have been mistaken for dead if you hadn’t been watching carefully.”

The pathologist explained that the boy was forcibly thrown or pushed against 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 into a ball shape.

The coroner said the boy was “unconscious, practically quadriplegic” as a result of his fatal injuries, and was unable to get into bed. He estimated he died within an hour.

Coroner Elliott ruled that the boy died in his bed on October 12, 2015, before his mother returned home.

He said the man had inflicted injuries to the boy’s head and face with six separate blows, but the fatal blow was a hyperflexion injury (excessive forward bending in a “nose to toe” direction) that caused damage to the brain stem and upper spinal cord and required the use of significant force.

The coroner could not say exactly how the man inflicted the injuries, but he was the only person who could have done so. However, that did not mean the man murdered the boy, he said.

Oranga Tamariki report is ‘incomplete’

According to the coroner’s report, the couple’s relationship began in August 2014, and in March 2015, the couple moved in with her children.

The woman was training to be a hairdresser, but because of the hours, daycare was out of the question and she considered a man an important support. She didn’t think her children were at risk.

In January 2015, a man allegedly broke into a property, attacking the owner with brass knuckles and ramming his vehicle with his own. In April, police arrested and charged him with the alleged offence, and he was subsequently remanded in custody.

Police had opposed his release on bail because he had 25 previous convictions, including six custodial sentences. His criminal history spanned 15 years and included convictions for assault with a weapon, kidnapping, intimidation, threatening behaviour, threats to kill, breaching protection orders and assaulting women by men.

On June 2, the man was sentenced to six weeks in prison but remained in custody because he had several other active charges.

He then applied for electronically monitored bail to live with a friend and her son. The judge noted Oranga Tamariki – then Child Youth and Family – had no safety or welfare concerns.

Bail was granted on June 16 on the condition that he have no unsupervised contact with children under the age of 16.

In August, the prison service asked Oranga Tamariki for more information about the man. The social worker replied that he had a violent nature and a long history of child abuse and aggression towards women. They believed his new partner was at high risk.

The man then applied to have his bond varied so he could move in with his new partner and her children. The District Court judge granted the variation after an Orangi Tamariki report prepared for the hearing said he had changed his lifestyle for the better and did not want to repeat the mistakes of his past. It concluded that the OT had no concerns about the man living at the address.

The bail was amended on October 2, on the condition that the man not use violence against his partner or her children, but there was nothing to prevent 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 “incomplete” because it did not include all the relevant information, including concerns raised with the Prison Service just two months previously.

He said the report “should conclude that Oranga Tamariki does not support the revocation of electronic bail for this man”.

Although Oranga Tamariki admitted the conclusion was flawed, the coroner was reluctant to criticise individuals, saying the deficiencies in the report were due to a lack of suitably qualified staff in the office.

In the future, if no one in the office has the skills, they should be given to someone else in OT. The agency says it has made a number of changes, including increasing the number of social workers in the region.

At the time, Oranga Tamariki’s chief social worker, Peter Whitcombe, said the agency accepted the coroner’s findings and agreed it could have done better.

Following a review in 2016, a number of changes were introduced.

Whitcombe said that over the past few years Oranga Tamariki has made a fundamental change to the way it operates. This included new information sharing regulations that came into effect 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 we can to protect these tamariki from harm.”

Four hospital visits

Between September and October, the boy’s mother took him to hospital four times because he couldn’t put weight on his left leg. It took weeks – and an admission to another hospital – before he was diagnosed with a spiral fracture of the tibia – where the long bone is torn in half by a twisting force or impact. It is known to happen accidentally in young children.

A human rights review tribunal examined aspects of the boy’s treatment in the period leading up to his death. Its report criticised the hospital, saying it had failed to consider the possibility of non-accidental injuries despite a number of warning signs.

It was found that the boy’s care for patients in the pediatrics, orthopedics and radiology departments was inadequate, and as a result the boy was wrongly discharged from hospital twice.

The coroner did not comment on Te Whatu Ora’s policies and procedures, given the changes introduced following the commissioner’s findings.

The coroner was also critical of the safety plan Oranga Tamariki had put in place for the mother when she left hospital, describing it as “unsatisfactory in a number of respects” and imposed on the mother when 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 specify who would look after the children while she attended the course.

The coroner said the man probably caused the boy’s leg injuries because he was left alone with him while his mother went out for the evening. The boy had a sore leg the next day.

However, the coroner was unable to determine what would have happened if the break had been discovered before the bail adjustment hearing.

Death of a man

The man was arrested three days after the boy’s death and charged with his murder.

Once in custody, the man was transferred between an at-risk unit and voluntary protective custody because he was concerned about his mental state and the possibility of gang retaliation for the boy’s death (his father was a high-ranking member of the Mongrel Mob).

The man’s father testified during the investigation that his son told him over the phone that he wanted to commit suicide and that prison guards ordered him to do so.

In his findings, Coroner Elliott said it was “more likely than not” that the father had not raised his concerns about his son’s suicidal thoughts with prison staff, saying there was no record of this on file. The coroner ruled that if prison officers had been informed they would have referred him to a high-risk unit.

He said police investigated the man’s claims about prison guards, speaking to all four of them. All denied the allegations, and police did not charge anyone with inciting suicide.

There is no surviving record of the man’s deed or any record of the prison guard’s comments.

The coroner ruled that the man died on November 22, 2015, and was self-inflicted.

– This story was originally published by New Zealand Herald.