Malachi Subecz. Photo: Supplied
In one phone call on 21 June, 2021, Megan found out her aunt Jasmine Cotter had gone to prison on drugs charges and that no-one in the family knew who had her son.
After learning that a Tauranga woman called Michaela Barriball had custody of him, Megan was even more worried.
Barriball's mother was her aunt's co-accused.
"The moment I found out who she was and her relation to Jasmine's co-offender, I knew something wasn't right. I didn't know what was happening, but it didn't add up. It didn't sound right."
Fearing that Malachi could be used as leverage to control his mother in prison, Megan started making calls from her home in the Wellington region.
Sitting side-by-side with her father, the softly spoken young mum describes her increasingly desperate efforts to get someone in authority to check on Malachi.
"I rang the prison to ask them for advice, I phoned OT [Oranga Tamariki], Jasmine's criminal lawyer, her family court lawyer, the lawyer for the child."
She even went to her local police station but was told by the receptionist it was "a civil matter".
Megan contacted Malachi's daycare centre asking them to keep an eye on the little boy.
At one point she obtained a photograph of Malachi from Barriball under the pretext of checking the results of recent eye surgery.
It appeared to show bruising on the child so she sent it to Oranga Tamariki, but the social workers who reviewed it did not agree and no action was taken.
She eventually found a lawyer who helped her apply for custody of Malachi.
The Family Court hearing was originally scheduled for 1 November but deferred because Barriball claimed to have Covid-19 symptoms.
The next day, Megan was called by Oranga Tamariki with the devastating news that Malachi was in Starship Hospital with a traumatic brain injury.
He died 10 days later on November 12 having been beaten, starved and scalded in the months before Barriball finally inflicted the fatal injuries in the sleepout they shared at the back of her father's house.
All the details have been laid bare in the subsequent High Court murder trial and the reams of reports on the case.
Megan's father, Shane, called the Office of the Chief Ombudsman while Malachi was still on life support, asking for an urgent independent investigation.
Just that day, the ombudsman had been granted the power to investigate notifications.
Judge Peter Boshier's report in October 2022 found Oranga Tamariki acted unreasonably and wrongly in its response to the reports of concern and did not put Malachi's welfare at the centre of its decision-making.
Corrections, police, Education, Health, the Ministry of Social Development and Oranga Tamariki all carried out internal inquiries and commissioned an independent cross agency review by Dame Karen Poutasi.
In December 2022 she made 14 recommendations to close what she called "five critical gaps", including mandatory reporting, vetting of carers for children of sole parents going to prison, improved information sharing and better monitoring of child protection in preschools.
"The system is broken," Shane says.
Shane says his family is determined that Malachi's death will result in real change. Photo: Supplied
He holds a laminated photograph of Malachi, and a blue plush bear embroidered with Malachi's name and the dates of his birth and his death.
"The very young social worker who was given the case, me and Megan don't have any ill will against her. It wasn't her decision. Managers and supervisors are meant to oversee those decisions."
Megan said Malachi was not "an invisible child" as Dame Karen's report described him.
There were many chances to intervene.
"It wasn't just one report by one person, several people made reports.
"If Oranga Tamariki went to see him, laid eyes on him and spoke to him they would have seen what was happening, or at least hopefully they would have seen what was happening, and made their investigation from there."
No law on mandatory reporting of abuse
Organisations working with children must have child protection policies, training and guidelines - but there is no law requiring health workers, teachers or anyone else to report suspected abuse.
The staff at Malachi's childcare centre had photographed bruises, cuts and other injuries in the months leading up to his death - but did not report them after talking with Barriball.
However, some experts warn mandatory reporting could actually make children less safe by flooding the system with unnecessary reports and discouraging struggling families from asking for help.
Independent victim advocate Ruth Money, who is working with Malachi's family to push for change, rejects that argument.
"The counter factual of that is what happens when you don't report, which is you end up with abused and dead children.
"There's always 'But what if I'm wrong?'. But what if you're right? We have to learn from this."
Megan's young children still ask questions about Malachi from time to time, and she tries to answer them as best she can.
However, even adults struggle to understand how this tragedy happened.
"My daughter, it's affected her quite a bit because she worries about fires and other things. Because she now knows there are things in this world that can harm her."
Malachi was - and still is - deeply loved.
The busy little boy whose birth "saved his mother's life" in her words, was at the centre of a large family.
Megan, whose youngest child is the same age, describes him as "courageous".
"He had to explore everything, he had to know what everything was and how it worked.
"But he was very well behaved. If you asked him to do something, he would listen and just do it, he wasn't an argumentative child."
Megan and Shane's concern now is for all the other "Malachis" who are out there.
Meanwhile, the government is still considering whether to implement mandatory reporting.