By CATHERINE MASTERS
When James Whakaruru turned up in hospital with his penis cut so badly that he needed an emergency circumcision, the urologist believed he "had been up to no good."
Despite different versions of how the injury had happened - the 3-year-old had been bitten by a dog, said mother Te Rangi, and hit by another child with a stick - it was decided "nothing sinister had occurred."
Within two years, James' dead body lay in a post-mortem room, black and blue on the outside and mangled on the inside from repeated vicious beatings doled out by his mother's boyfriend, Ben Haerewa.
Who knows the feelings the urologist now has, knowing the circumstances of the little boy's brutal life?
What is known is that he was just one of an enormous number of people involved in James' life who were ineffective in stopping or even recognising the abuse.
All sides of James' family were well-known to social workers.
The Whakaruru family had had six interactions on care and protection and youth justice issues since 1965.
The Haerewa family had had eight such notifications, and James' natural father's family had had 13.
Young James was on a road to hell on Earth before he was even born.
Just days before his birth, Te Rangi slit her wrists. She was just 15 and she survived, but over the next five years her small and lovely son with the warm brown eyes was beaten, stomped, hit and bludgeoned by her boyfriend until he finally died, a miserable, lonely and agonisingly painful death.
Unprotected by his mother, James nursed his bruises and confusion, probably bewildered at what he had done to deserve the anger and neglect.
The Commissioner for Children's report into his life and death can only delve into what is known. What other horror he suffered in the small central North Island towns where his mother and boyfriend lived will remain untold.
People knew what was happening to James but even if they cared, no one really helped.
Everyone failed him, from his whanau and doctors - and there were many - to his social workers, the police, Plunket and neighbours.
Everyone just assumed someone else would do something.
When Te Rangi became pregnant with James, her age and vulnerability indicated a need for additional help and support.
Her suicide attempt 10 days before the birth was because she had split up with his father and had nowhere to live.
At her age, she should have been the subject of a notification to social workers. There was none.
The writing was on the wall and James never stood a chance.
There were misunderstandings between the professionals involved in his birth on June 13, 1994.
A general practitioner and midwife assisted, but they had different understandings of their roles.
A health social worker was briefly involved but closed the case without assessment. The midwife was not formally told about the suicide attempt and in turn she never told Plunket.
She did mention emotional and social difficulties but she also said - wrongly - that health social workers were still involved.
Plunket saw James and Te Rangi just three times, quitting after nine unsuccessful attempts to make contact.
They did not advise the listed GP or any other service or agency.
"The pattern then began to emerge, although hidden from view, of James being taken to see different GPs, after-hours clinics and hospital-based health professionals," says the report.
When James was about one, Te Rangi sealed his fate. She began her relationship with Ben Haerewa.
By the age of 18 months, James had been to GPs for facial injuries, and when he was just over 2 he was admitted to hospital with serious injuries from a domestic assault.
Before this, on December 27, 1995, Te Rangi was assaulted by Haerewa and the police attended, but no formal complaint was made and she was never taken to Women's Refuge or Victim Support.
It just got worse for James.
On July 18 the next year, Haerewa hit James so hard he knocked him out.
Hospital records show there was bruising to the child's forehead and jaw, to the side of his neck, the back of his head, the tops of his feet, his left upper arm, both shins, the left side of his rib cage and left thigh, as well as grazing to the back of his head and his forehead.
Haerewa was charged with injuring with intent. On July 23 he was granted bail and told to keep away from James. Social workers were told by police and James' case was assessed as urgent.
Te Rangi's grandparents were told by social workers to seek an interim custody order to keep him safe. The grandparents told them Haerewa was "dangerous and violent."
When Te Rangi wanted to get James back from her mother, the grandmother's solicitor contacted social workers and was told the department was "not taking legal action at this stage."
Social workers say they believed Haerewa was in police custody.
James, meanwhile, was being shunted between his mother and her parents.
An informal agreement was reached under which James would live with his grandmother.
How then, on August 13, did police find Haerewa breaching bail conditions at Te Rangi's house - along with James?
Social workers were not told.
On October 17, 1996, Haerewa entered a guilty plea and on November 7 was sentenced to nine months in jail with conditions, which were never conveyed to the Department of Corrections.
Custody continued to be thrashed out between Te Rangi and her parents and in December a social worker recommended that no further action be taken because James was in the care of his grandmother and she would not allow him to be in an unsafe situation.
In 1997, Child, Youth and Family Services were asked by the Family Court for two reports into James' family life and his safety.
The first concluded that social workers would have strong reservations about his safety if he returned to his mother because she intended to resume her relationship with Haerewa on his release from jail. Given her dedication to Haerewa, she would have difficulty keeping James safe.
On February 11, James was back in the emergency department with a cut to the chin after a "fall from the back step."
Despite this being his second head injury, he does not appear to have been admitted and earlier files were apparently not looked at. Neither social workers nor police were advised.
His mother, meanwhile, turns out to have been living with Haerewa's parents.
The authors of the report believe she was caring for James there, while social workers had thought him to be with his grandmother.
Haerewa was released from jail on March 3, 1997, five months early.
James' counsel was worried and sought a temporary protection order for James against him. Social workers have no record of knowing about it.
The Family Court asked social workers to monitor James no less than once weekly but they did not.
They said that there were no care and protection concerns for James because his mother had ended her relationship with Haerewa.
Meanwhile, an "administration error" meant court-ordered conditions on Haerewa, such as a six-month supervision order, were not imposed.
The conditions had been aimed at reducing domestic violence and increasing parenting skills.
Haerewa did not report to the Probation Service. He began but did not complete an anger management course.
In April 1997, James was given back to his mother, and he, Te Rangi and Haerewa lived with Haerewa's parents in Hastings.
"The statutory agencies that had become involved in his life some 10 months earlier because of the abuse by Ben Haerewa were now completely absent and he had been returned to the custody of his mother who had not been able to protect him in the past," says the report.
In May, Haerewa finally completed his anger management course and the temporary protection order became final, but the Probation Service still did not know about it.
From June 1997 until May 1998 information about James dries up.
He apparently lived with his mother and Haerewa for a while at Porangahau, a small coastal town in southern Hawkes Bay.
On May 9, 1998 - back in Hastings - James returned to hospital with the tear in his penis.
There was no report to social workers or the police.
For almost a year after this, information on James is silent until the two weeks before his life slowly ebbed away.
On March 20 last year he was rushed to an after-hours surgery with a deep cut on his lip which was stitched. James was never taken back for the stitches to be removed.
Then, on April 4, he was back in the emergency room of the Hawkes Bay hospital.
He was not breathing and his heart failed. At 8.18 pm he was pronounced dead.
He had a distended abdomen, extensive bruising to his face, mouth, limbs, chest, abdomen, back and buttocks, lacerations on his right ear and lips and tearing marks on his throat. He was faecally incontinent.
An examination of the body found further evidence of bruising on the inner thighs and right scrotum and swelling of the right arm, which could have been a fracture.
He died from one "extremely prolonged or, more likely, several prolonged beatings."
Says the commissioner's report: "It is difficult to appreciate how, in a country with internationally acclaimed legislation focused on reducing child abuse and domestic violence ... any child can die in the circumstances that James did."
* The following poem was sent to the Commissioner for Children, Roger McClay, by James' paternal grandmother, Rebecca Campus, after the commissioner told her James was a hero because his story would prevent other children from dying, "because for me now he is a hero, too."
Keep our little heroes safe
Let our little heroes play, laugh and smile
Love our little heroes and let them feel no pain
Show them that we love them all
Show them that we really care
Cherish them all, our little heroes
Let them love and live the life they deserve
Watch them grow, help them grow
From little heroes that they are
Watch them smile a beautiful smile
Watch them jump, run and play
Watch them grow from our loving little heroes
To healthy young men and women
These heroes are our future.