The suffocation of a baby by her sleeping drunken mother in the back seat of a parked car has left a state agency criticising family members for not getting her help.
As a coronial inquest was yesterday opened into the death of 2-year-old Tahi Elvis Edwards in January last year, Child, Youth and Family released the summary of an internal investigation over the case.
Tahi's mother, 30-year-old Ngaire Kura Tukiwaho, admitted sleeping on him following a day of heavy drinking and was sent to jail in May.
The family was well known to CYF, which had previously taken into its custody two children which the boy's father had with another woman, but in its report the agency found there were no gaps in its policy or procedure.
Instead, CYF cited a "pattern of substance abuse across the generations".
It also pointed to no family member or professional seeking intervention for Tukiwaho's drinking or care of her child.
CYF was not notified of any concerns over the baby - nor that Tukiwaho had given birth to Tahi in late 2010. She had already been advised of safe sleeping practices after she lost a 1-month-old son, Hoani Benino, to cot death three years earlier.
But despite the advice, Tukiwaho drank excessively at least once or twice a week throughout her pregnancy with Tahi.
"Police have learned that when there was money, there was alcohol," Rotorua Detective Constable Christopher Kerekere told yesterday's inquest.
On the eve of Tahi's death, Tukiwaho drank continuously for about 12 hours, while intermittently breast-feeding Tahi.
After Tukiwaho and her partner returned to their home some time after 11pm, and the baby was put to bed, a fight broke out and she was struck in the face.
She could not recall what the argument was over, but she told police: "I must have got lippy as he punched me in my left cheek."
She put Tahi back in his pram and returned to her sister's house around midnight.
Other people she did not know were there, so she decided to sleep in a car, first leaving the baby in his pram outside, and then taking him into the back seat. It was later found Tahi died as a result of probable accidental asphyxia associated with an unsafe sleeping environment.
When police spoke to Tukiwaho, she acknowledged she knew about the sleeping risks.
"Police learned that on a sobriety scale of one to 10, with 10 being heavily intoxicated, Tukiwaho put herself at an eight or nine," Mr Kerekere said.
After Tahi's death, two of his siblings were taken into the care of Tukiwaho's family, as was a third child she gave birth to later that year.
When Social Development Minister Paula Bennett learned of the case in May, she ordered CYF to investigate, saying there were too many unanswered questions around the family.
She sparked controversy after commenting on the possibility of state-ordered sterilisation in an on-air discussion with talkback host Michael Laws. Ms Bennett declined to comment on the case last night.