He was released back into the home where he would die weeks later without a safety management plan.
The inquest into the death of a toddler continued today, exploring multiple systemic failings that led to the child being in the care of a man on varied bail for threatening speech.
The first part of the inquest found the man, the partner of the child's mother, was responsible for causing a fatal spinal cord injury that killed the toddler, who was found dead in his cot.
The man was found dead in his prison cell weeks after he was charged with the child's death.
Witnesses from the District Health Board gave evidence today in the Wellington District Court, with one senior pediatric staff member saying the changes since the child's death have been intensive.
Mandated and continually updated training in the space of assessing children thought to be victims of non-accidental injuries, child protection checklists, and an overhaul of guidelines are just a few of those changes.
A significant failure was the lack of a "multi-agency safety management plan" that was said to be needed for the child's discharge, as well as poor decision-making and communication between all agencies.
Hospital workers, Oranga Tamariki, and police should have met to formulate one to keep the child safe when he returned home. This was never completed.
A DHB witness said changes had been developed to mitigate and prevent a death like this from happening again.
"The most important thing is to identify that there might be a problem," he said.
"I'd like to think in a similar case we would now be far more alert and attentive to the possibility of NAI [non-accidental injury] in the first presentation.
"There's a heightened level of concern from the doctors and the nurses."
Other medical witnesses said they were told by the mother that the man didn't have unsupervised contact with the boy. If they had known he was looking after children they would have focused inquiries on him as a non-biological caregiver.
"[She] said her partner was never left unsupervised with the children and I took her at her word," a witness told the court this morning.
The court heard extensive x-rays and medical examinations were done on the boy while he was in hospital.
His follow-up appointment and the outcomes of those tests, which would show historical injuries, however, came days after his death.
Oranga Tamariki said it had also made changes since the death, and acknowledged staffing increases have occurred but there are still vacancies for social workers and employee retention is an ongoing struggle.
There are ongoing challenges for recruitment in the area, and sufficient staffing requests have been made to make sure the area is well serviced.
Changes have been made in the regional office since the death, as well as nationwide according to witness evidence today.
"[The boy] is at the forefront of our minds and has influenced us greatly," a witness from OT said.
"There is a number of safety nets in place now to ensure the processes and procedures are followed."
She said the child's tragic death was a key influence in procedural changes within the organisation.
Further changes may be highlighted by the decision when released by Coroner Marcus Elliott at a later date.
The inquest is set to finish tomorrow with the mother of the boy to give evidence.
