Coroner criticises OT after baby’s shaking death

A coroner has criticised Oranga Tamariki's failure to intervene "in an appropriate and timely manner" in the care of a 15-month-old boy, who was later shaken to death by his father.

Leith Allan Hutchison died at Auckland Starship Hospital in April 2015, due to a brain injury he suffered after being shaken by his father, Dane Blake.

Blake pleaded guilty to manslaughter in 2017 and was jailed for five-and-a-half years, but was released less than two years into his sentence in January 2019.

On Wednesday, Coroner Louella Dunn's findings into Leith's death were publicly released.

A coronial inquest held in the Greymouth District Court in October 2022 heard there had been warning signs that Leith was being abused or neglected.

Leith's mother, Kate Hutchison, lived in Cobden on the West Coast with Leith and her eldest son, Isaac. She had initially thought her partner Romi Blown was Leith's father, but a DNA test in 2014 confirmed his biological father was Blake, with whom Hutchison had a brief sexual relationship in 2013.

Coroner Dunn heard Leith was predominantly in Hutchison's care, but stayed with Blake on weekends and sometimes on weekdays.

A large part of the coronial inquest centred on the involvement of Child, Youth and Family (CYFS), now known as Oranga Tamariki (OT), with the family.

The first concern of possible neglect came in May 2014 when Isaac, then two-and-a-half years old, was admitted to Grey Base Hospital after swallowing turpentine. Two months later, Isaac and Leith were placed on CYFS' "vulnerable infants list".

In December 2014, the Family Court requested CYFS file a report in relation to Leith and Isaac due to concerns about alcohol and drug use in the home, and the exposure of the children to family violence.

In January 2015, Leith started spending time in Blake's care.

In March 2015, Leith broke his femur while in Blake's care. Blake told a doctor and social worker he had been playing with Leith on the floor and accidentally rolled onto his leg. The doctor lodged a report with CYFS.

Blake was later interviewed by police and gave a different explanation of how the injury occurred, saying he had grabbed Leith to prevent him from rolling off the bed.

Various other injuries on Leith were observed by a number of people in early 2015, including bruises above his eye, on his chin and his cheek.

Blake's half-sister, Grace Besant, told the coroner on one occasion while she was visiting Leith, Blake was feeding him breakfast. Leith was crying and Blake became angry and smacked him across the face.

In April 2015, a nurse visited Blake's uncle at his home for an unrelated reason. While there she noticed a baby boy in another man's care - it was later established that this was Blake with Leith.

The nurse told Blake that he needed to take Leith to the doctor because he was clearly unwell. The baby was congested, had a snotty nose, was pale and had red eyes from crying. Blake did not react or make any response to the nurse's advice.

He took Leith to the doctor three days later where he was diagnosed with a viral infection and possible mild bronchitis.

A post-mortem done after Leith's death found he had multiple bruises on his face, upper body, left buttock and right thigh. The inner surface of his upper lip was torn, a type of injury that can be caused by a blow to the mouth. He had traumatic head injuries, including bleeding on the surface of the brain and damage to part of the nerves in the brain.

For eight months after Leith's death, Blake denied any knowledge of how or why Leith suffered fatal injuries. He was initially charged with murder but later accepted a manslaughter plea bargain.

Coroner Dunn identified several failures in the lead up to Leith's death. One was that CYFS had allocated a new social worker with limited experience to Leith's case after he was admitted to hospital with a broken femur.

"The allocation of responsibility to a new and inexperienced social worker is concerning given Leith's vulnerability, the seriousness of injury and the history of care and protection concerns CYFS had documented for Leith and Isaac," said the coroner.

Another failure was that CYFS placed too much reliance on a doctor's opinion that Blake's explanation for how the femur fracture happened was plausible without any further investigation of Leith's home situation or Blake's parenting ability.

It took hours for Leith's parents to seek medical treatment for his leg injury, Blake gave conflicting explanations as to how the injury occurred, Leith had already been noted as a "vulnerable infant" by CYFS, and the police had been involved - all aspects the coroner said should have pointed to the fact that further investigation by CYFS was needed.

The coroner said the ongoing monitoring by CYFS after Leith was discharged from hospital - and Blake continued to have unsupervised care of the boy - was inadequate.

"While CYFS shared information with other agencies there was a lack of direction and control of the investigation. Poor record keeping and a lack of leadership led to inadequate responses and an overall failure of care."

Coroner Dunn made numerous recommendations including that suitable experienced social workers be allocated to files that involve injury or harm to young and vulnerable children, that information should be better shared between all the agencies involved in the care and protection of a child, and that care plans put in place after a discharge from hospital must be properly monitored by CYFS (now OT) to prevent further harm to the child.

"It was evident as a result of the investigation into Leith's death that other persons observed bruising and/or harm to Leith (and in some cases witnessed abuse), however did not report their concerns to either the police or CYFS. I urge anyone who knows or suspects a child to have been abused or is subject to abuse to report this promptly to either OT or the police," the coroner said.

Leith "deserved more" from OT

Responding to the coronial findings, Nicolette Dickson, chief social worker and deputy chief executive professional practice at OT, acknowledged CYFS "did not get things right in this case".

"Since being established as a new ministry in 2017, Oranga Tamariki has made ongoing and sustained efforts to improve child protection practices," she said.

"In the last nine years, there have also been significant changes to legislation and the way that we work with our partners aimed at strengthening children's safety and wellbeing."

These included having an agreed protocol with clear roles set out for both OT and police when dealing with suspected child abuse, ongoing meetings with healthcare agencies on how to best work together in such cases and updated guidance on how OT must engage with other organisations and agencies to develop a clear safety plan when a child is a victim of suspected harm.

"We have strengthened our oversight, support and training for new social workers. In 2022, chief executive Chappie Te Kani issued a directive that only social workers with more than 12 months experience as a registered and practising social worker should have the responsibility for completing initial assessments," said Dickson.

"I want to acknowledge Leith Hutchison who deserved more from our agency. I wish to extend my sincere thoughts to Leith's whānau and to every person who loved him."

If you believe a child is in immediate danger call police on 111. If you think a child you know could be at risk of harm from abuse or neglect contact Oranga Tamariki on 0508 326 459 or email contact@ot.govt.nz Click here to learn more about identifying signs of abuse.

This story was first published by Stuff.