Four agencies admit failing the toddler in 2015. (File photo) Photo: RNZ / Angus Dreaver
The grandmother of a little boy left at the mercy of an angry man with a long history of violence says she wants her dead grandson's story to be heard and known.
"Our family have had to almost grieve in silence due to the stigma of having a child murdered and the many name suppressions," the woman told the last session of an inquest in Wellington on Friday.
Heavy suppressions apply to prevent the child and family being identified, which extend even to the witnesses from the four agencies that admit failing the toddler in 2015.
"We don't feel we have had a voice," the grandmother said, when Coroner Marcus Elliott invited whānau to speak to end the inquest.
"We have added the words murder and child abuse to our vocabulary, which we don't shy away from saying.
"We want a voice, we want to talk about what happened, we want people to know [the boy's] story."
New Zealanders should be "ashamed" at a child being killed every five weeks, and needed to understand, to learn and "stop this", she said.
Coroner Elliott said he had "compassion" for the mother and the horror of what she went through.
The mother said she would never get over the death of her son.
Authorities allowed the man to move in with his new partner and her children, when previously his bail had prevented that; and when the boy turned up at two hospitals with unexplained injuries, he was sent back to the home by Oranga Tamariki, police and the hospital without a proper safety plan - and within days was found dead of severe injuries.
The man, who had more than a dozen convictions for violence, and was forbidden from seeing his own children after years of emotional abuse of them, was charged with murder but found dead in custody some weeks later.
Oranga Tamariki (OT) - at that time Child, Youth and Family (CYFs) - witnesses repeatedly said the agency had improved its practices.
"There are much more robust systems," one said.
The boy's father raised the alarm with OT back in 2015. He told the inquest via his whānau: "I tried to help my baby, but no one believed me."
The inquest heard the boy's father knew the man well. He wrote several times to Oranga Tamariki that he was worried for his son's safety.
Two OT staff told the inquest that should have triggered a 'report of concern'.
Instead, a police officer advised "scepticism", and CYFs went on to tell a judge it had "no concerns" about the man shifting into the boy's home.
Its report contained nothing about his violent history. The social workers who worked on that crucial report never saw the father's letters.
The father was not told when his son was injured and hospitalised.
In his message to the inquest, he thanked those who tried to keep his son safe - adding "if you knew what was going on in his house, you may have done more for him".
"I struggle with the knowledge that I was not there to protect him when others were not," the man wrote.
He thanked his lawyer for fighting for years for the family.
The lawyer told the hearing the man believed "Oranga Tamariki didn't acknowledge complaints that he made because of who he was".
The father concluded: "Moe mai ra e peipi ... Sleep on my baby, go to your ancestors now, who will protect you as you should have been protected on this Earth."
'Incredibly sad'
Earlier, an OT staffer told the coroner she was struck by a number of missed opportunities to protect the boy, including not involving the whānau in more decision making and not appointing a key social worker with responsibility and accountability for the children.
"It left me feeling incredibly sad," the staffer said.
The agency's lawyer told the inquest that the CYFs' report to the judge, to vary the bail, was "clearly ... wrong", and should have stated there were concerns, not that there weren't.
The bail variation said the man was not to have unsupervised contact with his partner's children.
The mother admitted she left the children with him several times, when he was living elsewhere.
But she rejected the suggestions of two social workers in their evidence that they spelled out verbally the rules around contact, at the time the boy was being discharged from hospital.
On discharge, there should have been a written safety plan - but the agencies failed to do one.
"I was not privy to any risks or concerns about [the man] fullstop," the boy's mother said in her testimony.
"I was shocked when I saw the list of his criminal convictions."
She thought the authorities were focused only on whether she had hurt the boy, she said.
The mother admitted she told CYFs the boy was never left alone with the man, when in fact he had been.
The lack of a written safety plan became a major sticking point at the inquest, because the evidence from the mother conflicted with that of the CYFs witnesses.
A family member of the boy said a written plan would not have worked anyway.
"We would not have trusted that safety plan," because the mother would not have adhered to it, they claimed.
A police officer earlier told the inquest a safety plan would have been explained to the mother "at length". He also denied there was not a comprehensive plan - though later admitted to not having seen one.
The lawyer for police said if they had only known about the man's supervised and unsupervised contact with the children, they would have done more - and so would the hospital, when the boy was first seen about a month before he died.
The mother said she was "always upfront" that the man was her key support for childcare.
A lawyer for the mother said it was up to the Corrections Department - which is responsible for risk assessments - to give the judge details of the man's criminal history.
However, a lawyer for Corrections rejected this, saying it could not do this piecemeal when the judge had asked CYFs to report back.
The coroner asked for final submissions from the agencies by January.
His findings will include any lessons on how to improve state agencies' responses.
The grandmother finished the inquest, saying:
"We therefore don't ask, but we absolutely implore you ... I beg you ... to ensure the changes your agencies have made, and will be making, do actually exist, people are educated in them, they are adhered to, they are reviewed and rolled out nationally.
"It is critical that this stop.
"Ehara taku toa i te toa takitahi, engari he toa takitini." (Success is not the work of an individual, but the work of many).