CJ White was just 10-months-old when he was murdered by his meth-addicted father — a tragedy a Coroner says could have been prevented if police and Oranga Tamariki had acted on desperate warnings from his terrified family.
In a damning finding, Coroner Mary-Anne Borrowdale said a “suite” of agency failures exposed systemic shortcomings, with authorities dismissing repeated pleas and an “overwhelming fear” the baby was in danger.
Senior journalist Anna Leask reports.
CJ died on July 10, 2019 from unsurvivable head injuries inflicted the previous day by his father, David Grant Sinclair.
Sinclair denied intentionally hurting CJ.
The court also heard that alongside “very severe brain and skull injuries”, there was “extensive bruising” over CJ’s body and a broken bone in his foot.
At least some of these injuries predated the traumatic brain injuries.
Sinclair was sentenced to life in prison with a minimum non-parole period of 17 years.
“What happened to CJ needs to be heard and understood, especially by those who are empowered to address the kinds of acknowledged shortcomings that played a part in CJ’s death,” said Coroner Mary-Anne Borrowdale.
“Baby CJ was a happy and healthy infant who was much loved by his mother and his grandparents. In the weeks before his death, CJ’s mother Laura White had tried directly – and through various Government agencies – to have CJ returned to her care.
“She was deeply worried that CJ was unsafe in Mr Sinclair’s home. Her efforts were unsuccessful.”
Coroner Borrowdale said Oranga Tamariki had “properly ‘acknowledged and accepted’ a suite of failings in its response to CJ’s situation”.
“Oranga Tamariki failed to ‘connect the dots’ and to probe sufficiently to gain a proper appreciation of the risk that CJ was in,” she said.
She also criticised police who admitted “shortcomings” by officers dealing with CJ’s family and a “breakdown in inter-agency collaboration”.
“Certainly, aside from some very limited information-sharing over the telephone, there was no meaningful collaboration between police and Oranga Tamariki to protect CJ,” she said.
“Laura was bounced from agency to agency as she - increasingly desperately – tried to ensure that someone would act in CJ’s interests by removing him from his father’s home.
“Both agencies let Laura and CJ down.”
CJ was born on September 6, 2018. His parents were not in a relationship and both had other children.
White, who had faced her own struggles, returned to Hokitika to be near her supportive parents before CJ’s birth.
Before his death, CJ was “doing well”. He was a happy, healthy and “delightful” baby who was learning to crawl and saying his first words.
His maternal grandparents formed a strong bond with CJ and said White was “a good mother” and they had no concerns about her parenting.
The coroner’s report outlines a difficult relationship between White and Sinclair.
He was said to be “angry” when he found out White was pregnant with CJ and “punched the wall”.
After CJ’s birth, “tension grew” between the pair around who would care for him.
Sinclair wanted to increase time with CJ, despite White’s concerns about his drug use and associates.
After a number of tense months, White agreed CJ could be left alone with his father. She went and stayed with Sinclair at his home for a period to “see and confirm” that the man “was capable of properly caring for” the baby.
“Laura stayed a few nights and satisfied herself that Mr Sinclair had the skills and equipment to care for CJ. However, she also says that during the stay she saw Mr Sinclair using drugs,” said the Coroner.
“Laura says that she did not plan to leave CJ for more than a week, and that she had immediate misgivings about the arrangement as soon as she left Mr Sinclair’s house.”
White had to travel to Blenheim for her other children and stayed for 12 days. She said Sinclair messaged her regularly to report on “how well CJ was doing” with him.
While she was away, White’s father contacted Plunket to report concerns that Sinclair had sole custody of the baby, “notwithstanding that he was rumoured to be involved in drug-taking”.
Plunket relayed this information to Oranga Tamariki and staff “spoke of organising a visit to assess how CJ was doing”.
When White returned to Hokitika, she went to pick CJ up.
She told the coroner that Sinclair had “looked like he had been smoking meth” and refused to wake the baby and asked White to leave.
The next day she asked to see CJ and Sinclair refused, saying he had applied for custody and would be in touch once it was sorted.
“In regards to seeing him in mean time, he ain’t going anywhere with anyone or leaving my sight again,” Sinclair told White in a message.
She did not have any further direct contact with him.
“Laura tried to enlist WINZ, Oranga Tamariki, the police, a lawyer, and the Family Court in her efforts… to regain custody of CJ.
“By the time CJ died, these efforts had not succeeded. In tragic timing, on 10 July 2019 – the day that CJ died – Laura’s lawyer advised application to the Family Court for a parenting order had been declined.”
The coroner’s report contains harrowing details of CJ’s death.
A post-mortem investigation found dozens of bruises, a large skull fracture and catastrophic brain injuries consistent with high-speed crash trauma.
Coroner Borrowdale explained the purpose of her inquiry was to establish “whether anything could have been done to prevent CJ’s death”.
“If there are lessons to be learned from this tragedy, we need to learn them and do our best to ensure that such a thing never happens again,” she said.
“In this case, this has really amounted to asking whether CJ could and should have been removed from his father’s house.”
She said it may be self-evident that the baby “would not have been in harm’s way if Laura had not left him with his father”, it was important to remember that she “could not then foresee that Mr Sinclair would refuse to return CJ to her or what he would do to him”.
“And – especially relevant to my inquiry – Laura tried very hard to get CJ back.
“Laura was aware that Mr Sinclair used methamphetamine and believed him to be dealing drugs from home. Laura was right,” the coroner said.
“She told her family this. She told Plunket; Family Start; Oranga Tamariki; the police; her lawyer; and the Family Court.
“Did any of those social and government agencies have a basis to remove CJ from his father’s home? Did they do all that could reasonably be expected of them to look after CJ’s interests? My views on those questions follow.”
The coroner said White and her family had some awareness of Sinclair’s use of “hard drugs” and “CJ’s maternal grandfather, described himself as having ‘an overwhelming fear that CJ was going to die’,” she said.
Coroner Borrowdale made lengthy findings about each agency involved in CJ’s case.
She was satisfied that Plunket “acted appropriately, and followed correct processes” and reported concerns properly to Oranga Tamariki.
“I am not persuaded that Plunket could have done more at that time, and Oranga Tamariki was the right agency to take forward the allegations of risk to CJ,” she said.
Coroner Borrowdale said aspects of OT’s response ”were specifically inadequate” - particularly when White and her parents “repeatedly voiced desperate concerns that CJ was at risk”.
She said it was “sobering” to have White’s father tell her “I don’t think we pushed… hard enough with Oranga Tamariki”.
“They pushed as hard as they knew how. But in practice, the proper child protection response should not depend on the agency being repeatedly urged to act,” the coroner said.
“Family had met their duty by registering their concerns with Oranga Tamariki, and it was then for the agency to act.
“There was then no attempted uplift of CJ. The inexperienced, under-supervised and incompletely trained junior social workers, who considered the reports of concern about CJ, did not consider him at risk, so they took no steps to alter his living situation.
“Of course, Oranga Tamariki needs to consider questions of plausibility and proportionality when deciding its response, but staff ought to be encouraged to listen to the information and instincts of whānau, friends, neighbours and community members who come to it and report grave concerns for a child.
“It is no small matter to screw up the courage to approach Oranga Tamariki, and it behoves the agency to take such reports extremely seriously.”
Coroner Borrowdale further slammed OT for the way staff treated White.
“I am troubled by the wariness that staff displayed in dealing with Laura’s concerns. Its records focus largely on Laura’s mental state, her housing situation, and her personal history,” she said.
“It was relevant for the social worker to ask Laura, ‘why she had left CJ with his father who she knew to be doing drugs?’ But to my mind, the question is redolent of a ‘you made your bed, now lie in it’ approach.
“It appears that Oranga Tamariki’s wariness of Laura infected its response.”
Coroner Borrowdale listed a number of other “significant shortcomings” in OT’s response to White and investigations of CJ’s safety and his father’s drug use.
She was also critical of CJ’s case being assigned to staff who were “junior and ill-equipped”.
“Oranga Tamariki failed to ‘connect the dots’ and to probe sufficiently to gain a proper appreciation of the risk that CJ was in,” said Coroner Borrowdale.
“The agency accepts that and has made some changes. Its continued under-staffing in the West Coast area, however, leaves me unpersuaded that the resourcing constraints that led to the mishandling of CJ’s case are not a continued problem, and concerned that they may yet resurface in future child protection cases.
“Police have properly acknowledged shortcomings in responding to the concerns for CJ expressed. The police retrospective review rightly found that Laura’s concerns should have been treated urgently and escalated.
“Mr White also felt that he was not taken seriously on the two occasions, during a single day, when he entered the Hokitika station to report his worries for CJ. He was left in tears by the response of police.
“This is powerful evidence of the extreme helplessness he felt in trying to protect a child that he and his wife desperately loved. Mr White’s concerns – like his daughter’s - should have been handled with the utmost seriousness and sensitivity.”
Coroner Borrowdale said in the year leading up to CJ’s death, nine social and government agencies were involved with White and her children.
“Given the history of agency failure to protect CJ, it is striking to read,” she said.
“Police have acknowledged that they were ‘disconnected’ from Oranga Tamariki in this place, at this time, and have provided assurances of much stronger collaboration – supported by better, clearer processes – today.
“Both Oranga Tamariki and the Police have accepted making errors when apprised of the risks that Mr Sinclair posed to CJ.
“Oranga Tamariki found and acknowledged numerous faults… The review findings were succinctly captured as: Oranga Tamariki had an opportunity to intervene earlier. In summary, Oranga Tamariki accepted that its social workers had essentially dismissed the concerns of the maternal family.
“Both agencies let Laura and CJ down. I encourage police and Oranga Tamariki to commit heavily to making their current joint investigative approach a success.”
Coroner Borrowdale said in the time that has passed since CJ’s murder both OT and the police had made significant changes to their processes.
“We accept the coroner’s findings and acknowledge that aspects of our practice and involvement with CJ’s family fell short of the standard we would expect,” said OT chief social worker and deputy chief executive of professional practice, Nicolette Dickson.
“CJ White’s death was a tragedy, and I would like to acknowledge the profound grief his family and loved ones will continue to feel.”
Dickson said analysis of CJ’s case for the coroner “found gaps” in the agency’s handling of the concerns raised about him.
“That led to missed opportunities to intervene,” she said.
“We made changes to address these practice concerns.”
Tasman district commander Superintendent Tracey Thompson said police also accepted the coroner’s criticism.
“We accept that there were shortcomings by the New Zealand police, and, on behalf of the police, I do want to apologise to CJ and to CJ’s family and provide my sincerest condolences to them,” she told the Herald.
“Since this tragic incident, we have worked to identify what the gaps were, what were the opportunities that were missed - and to work towards this never happening again.”
Thompson said concerns raised about CJ should have been noted as a family harm issue immediately.
Had that been done, the concerns would have been “reviewed straight away”.
“Our family harm team would have looked at it, assessed it, and actioned what needed to be done, within a timely manner,” she said.
“We’ve been really committed and focused on ensuring that our staff - particularly those that are at the front counter and are the first points of call to people that come to the station - (have) training on understanding what constitutes family harm matters, that they’ve got information that we need to risk assess, analyse, and act on accordingly.
“People come to us because they need assistance and they want help, and we need to make sure that we provide that to them.”
Police Minister Mark Mitchell said CJ’s death was “a tragic event all round:.
“My heartfelt condolences go out to CJ’s family for their profound loss,” hge said.
“In this case, the Coronial findings showed there were some shortcomings by the police. Police as an organisation are constantly looking for improvement, and while I know a number of changes have been made already, it is my expectation that the police address all issues identified to ensure that everything is done to help prevent this from happening again.”
A spokesperson for Minister for Children and the Prevention of Family Violence Karen Chhour said “my office won’t be commenting” when asked about CJ’s case.
“In this case, the Coronial findings showed there were some shortcomings by the police.
Anna Leask is a senior journalist who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 19 years with a particular focus on family and gender-based violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz