Just before rising from the judge's bench, Coroner Wallace Bain paused.

"To Moko's mum at the back of the court, our sympathies to you again.

"I hope this is...I know you've lost your little boy but as a result of this inquest I hope it will help other little children being lost."

The closing remarks were a touch of humanity after three days of dark, sometimes detached evidence, as lawyers and professionals analysed the life and death of Moko Rangitoheriri from every angle.

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The wider ills of society, the dysfunctional home Moko lived in, the horrendous list of injuries which killed him, and the many missed opportunities to save the 3-year-old.

Listening to all the depressing details, was Nicola Dally-Paki.

She sat in the Rotorua District Court, smartly dressed, with dignity as her life was laid bare for the world to see.

On hearing the gentle words from the coroner, Dally-Paki smiled sadly, nodded and mouthed "thank you".

For while the hearing was about a little boy, the evidence was about two young mothers.

Nicola Dally-Paki and Tania Shailer, one of Moko's killers, were struggling to cope. But the warning signs were either "missed, misinterpreted, or minimised", in the words of Judge Andrew Becroft, the Children's Commissioner.

And Moko suffered the consequences.

Moko's mum

Nicola Dally-Paki gives evidence at the inquest. Photo/Alan Gibson.
Nicola Dally-Paki gives evidence at the inquest. Photo/Alan Gibson.

Nicola Dally-Paki was just 19 when she married Karauna Rangitoheriri.

Just one year later, in 2009, the patched Black Power member was convicted of assaulting her.

Two more convictions followed in 2013 and 2014, as well numerous police callouts for family violence.

They had three children together, the youngest being Moko, until Dally-Paki decided to leave the violent relationship.

During this time, their eldest son - whose name is suppressed - had several long admissions in Starship Hospital with complications from a serious leg infection.

Struggling financially on the benefit, Dally-Paki was travelling back and forth between Tokoroa and Auckland to be with her sick son, while Moko and his sister stayed with relatives or friends.

She applied for a room at Ronald McDonald House, which provides emergency accommodation for families with children at Starship, but was declined.

Concerns had been raised about the family's gang links, but her decision to move from Tokoroa also meant Dally-Paki was ineligible for a room; Ronald McDonald House is generally for families who live outside Auckland.

She was placed on a waiting list for social housing and for a three-week stretch, a desperate Dally-Paki was sneaking Moko and his sister into Starship Hospital to sleep on the ward with their brother.

However, a number of agencies were aware of the dire situation.

Social workers at the Auckland District Health Board referred Dally-Paki to Shine, which provides specialist support for family violence.

The DHB also made two "Reports of Concern" to Child Youth and Family [now known as the Ministry for Vulnerable Children Oranga Tamariki] in February and May 2015.

While there were no explicit concerns for safety, the reports included fears about family violence, stress, the children moving back and forward from Tokoroa and the lack of money.

"It became clear during this admission that the paucity of social, whanau and financial resources impacted Ms Dally-Paki's ability to provide a safe and stable environment for her children," said senior DHB social worker Leshaun Perumal.

CYF did not tell the police, or follow up on the reports of concern.

This was a missed opportunity, said Judge Becroft.

Judge Andrew Becroft, Children's Commissioner, gives evidence at the inquest. Photo/Alan Gibson.
Judge Andrew Becroft, Children's Commissioner, gives evidence at the inquest. Photo/Alan Gibson.

"It seems fair to say that if Oranga Tamariki and/or Starship Hospital had taken a different or more proactive approach to the issue of finding safe care for Moko and his sister in Auckland," said the Children's Commissioner, "the situation for Moko could have been very different."

He suggested either, or both, agencies could have convened hui-a-whanau or a meeting for family to come together and be told about the needs of the children.

They can then make their own plan to solve the problems, with support from the agencies, as needed.

If serious risk to the children is identified at the hui-a-whanau, then Oranga Tamariki can step in.

Instead, Moko and his sister went to live with Tania Shailer in Taupo.

It's a decision Dally-Paki regrets every day.

"I accept that I, as a victim of domestic violence, made mistakes, my children and I live with those mistakes every day," Dally-Paki told the inquest.

"Perhaps if I had been judged less harshly, Moko would be in my arms today."

Moko's killer

Tania Shailer and David William Haerewa were sentenced to 17 years in prison. Photo/Rotorua Daily Post.
Tania Shailer and David William Haerewa were sentenced to 17 years in prison. Photo/Rotorua Daily Post.

Dally-Paki trusted Tania Shailer; they had been friends for 15 years.

Shailer was also a trained early childhood teacher, so Dally-Paki thought her children were in good hands.

But like Dally-Paki, Shailer was struggling to cope.

She had four children of her own - aged 7, 5, 4 and 2 - to take care of and was battling worsening depression.

While ultimate responsibility for Moko's death lay with Shailer and her partner David Haerewa, Judge Becroft pointed out "considerable responsibility" for the agencies working with her.

They were the Maori Women's Refuge, Family Works and REAP, which held the contract for the Family Start home visit service, as well as Child Youth & Family.

While Shailer was skilful in hiding what was happening in her home, Judge Becroft said she dropped a number of worrying comments which properly skilled professionals should have picked up on.

These "red flags" included her statements about her depression worsening and struggling with two extra children, as well as coping with Moko's behaviour.

Despite some professionals actually visiting the house, they did not query why Moko was spending long amounts of time in his room or ask to see him.

Everyone involved in working with children - not just Oranga Tamariki staff - needed to be properly trained so they can pick up on the danger signs, said Judge Becroft.

"All of the community agencies involved knew the household was under stress and that Tania Shailer had mental health problems and a history of family violence," said Judge Becroft.

"Sadly, none of them thought to check on Moko's wellbeing."

'Whanau, hapu, iwi'

Merepeka Raukawa-Tait giving evidence at the inquest. Photo/Alan Gibson.
Merepeka Raukawa-Tait giving evidence at the inquest. Photo/Alan Gibson.

The inquest also examined the creation of Oranga Tamariki, the 'culture change' of police, and child poverty.

"They live in struggle street every day. That's reality for so many of our families," said Merepeka Raukawa-Tait, best known as the former chief executive of Women's Refuge.

"Tempers get frayed and the biff and the boot comes out...it's a tragedy but it's happening."

She urged greater funding for NGOs who had a greater chance of success of connecting with dysfunctional families than any government agency.

"They are the ones people will talk to. Who talks to them about a way forward, who tells them 'this is not your destiny...you are not meant to be living on your knees'...we don't talk to our families like that."

If there was one point everyone at the inquest agreed on, it was Oranga Tamariki alone cannot keep children safe.

"It is the family responsibility. And if we are Maori then it's whanau, hapu and iwi," said Raukawa-Tait.

"Don't internalise everything. There is no shame in saying 'I'm not coping'...don't hide and hope it's going to get better. Put your hand up and try to get help."