By NAOMI LARKIN
James Whakaruru did not stand a chance from the moment his 15-year-old mother tried to commit suicide - just days before his birth - until five years later when his stepfather beat him to death.
Along the way he was subjected to other vicious beatings and came into contact with many welfare organisations, but no one did anything to stop the abuse.
James was let down by the Government and every agency that was supposed to care for and protect him, according to a damning report by the Office of the Commissioner for Children.
The commissioner, Roger McClay, warns that unless the report's recommendations are followed "it is inevitable that other children will die."
The 86-page report, released yesterday, details a series of failures by the health and welfare sectors, the Departments for Courts and Corrections, the Government, Plunket and the police to detect and address the ongoing abuse which resulted in the boy's death.
It outlines a pitiful life half-lived by a child who was not quite 5 when he was beaten to death by his mother's boyfriend, Ben Haerewa, in Hawkes Bay last April.
Haerewa, aged 21, was sentenced to 12 years' jail last September for the attack, in which he used a brass tack-hammer, a steel vacuum-cleaner pipe, a jug cord, his fists and kicks to kill James.
He had already served a jail sentence for assaulting James when the boy was 2.
The report recognises, but does not investigate, the role of James' whanau in his care and protection.
It says agencies did not communicate with each other and then ended their involvement with the child, assuming that other parts of the system would protect him.
It says some staff seemed unaware of the signs that James was at risk or did not appreciate their role in his safety.
Few, if any, attempts were made to use culturally appropriate services, such as Maori lawyers, or get help from his iwi.
James was seen by medical professionals 40 times. Those occasions included seven visits to the Hawkes Bay HealthCare Regional Hospital - four to the emergency department - 30 visits to four medical practices and three Plunket visits.
However, information was not exchanged; hospital staff did not follow their own child-abuse policy or get his file notes from previous visits; and Plunket did not tell Child, Youth and Family Services or James' GP about their problems maintaining contact with the child.
"Health professionals failed to carry out basic checks to ensure James' safety," the report says.
CYFS did not follow legal and policy requirements and failed to get information from other agencies. Its investigation was unplanned and not coordinated with police. There was no family group conference.
Police did not tell CYFS when Haerewa breached his bail conditions. He was found with James and his mother, Te Rangi Whakaruru, at her home.
The Department of Corrections did not report prison visits to Haerewa by James and his mother. It took no action when Haerewa breached parole or when he failed to report to a probation officer from May to September 1997.
The Department for Courts left the judge's sentencing notes off its report and did not tell the probation service that there was a protection order against Haerewa.
The report says Haerewa beat James to death but "the state did not protect him in the way that it should have during the five years of his life."
"The fabric of care and protection which should have clothed, covered and comforted him during his life proved to be a torn and badly manufactured piece of cloth."
Among the 60 recommendations are:
* The Minister of Social Services should set up a working party involving the agencies. It would monitor how the recommendations were adopted and report to the Commissioner for Children.
* Police should follow national family violence guidelines so children of abuse and domestic violence get maximum protection under the law.
* The Ministry of Health should develop a national child health strategy that includes a common database about health services provided to a child for all health professionals to use.
The report has been welcomed by all the agencies it criticises.
CYFS chief social worker Mike Doolan said the service would implement the report's findings to turn them into "real improvements in our practice."
Matt Robson, the Corrections and Courts Minister, said Corrections acknowledged the tragedy of James' death and was actively working with other statutory agencies to "close the gaps identified in the report."
Social Services Minister Steve Maharey said the Government had already taken action in line with a number of the recommendations.
"I am determined that we will learn the lessons from James' tragic death."
Anne Shaughnessy, of HealthCare Hawkes Bay, said the organisation "clearly played a key part in this situation and does clearly accept some responsibility."
James' paternal grandmother, Rebecca Campus, of Hastings, said she "wished something more was done."
Police negligence in child-abuse work
Child's road to a lonely, brutal death
The boy who everyone failed
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