Agencies should have picked up on a series of red flags before 5-year-old autistic schoolboy Leon Jayet-Cole was brutally killed in the care of a violent drug addict step-father, according to a damning coroner's report released today.
A lack of detailed analysis of earlier reported bruises and "injuries", "naive" social workers, and a lack of communication between Child, Youth and Family (CYFS), police, and Canterbury District Health Board (CDHB), all contributed to a lack of interventions that would have saved the boy's life, Coroner Brigitte Windley has found.
Jayet-Cole was rushed to hospital after suffering a serious head injury at his Christchurch home on May 27, 2015, and died in hospital soon after.
A post-mortem examination revealed he had suffered 44 injuries, including severe blunt force head trauma, a broken jaw, spinal bleeding and retinal haemorrhaging.
Stepfather James Stedman Roberts – a regular user of drugs, including heroin and cannabis who had married Jayet-Cole's mother Emma Roberts, who is now called Emere Jayet - was charged with his murder.
A murder trial was set down to begin at the High Court in Christchurch in October 2016 but he died in July that year.
An inquest into Jayet-Cole's death was heard in 2018 and 2019.
Today, Coroner Windley released her 118-page findings which finds all three agencies failed to identify that "James [Roberts] posed a serious risk to the [Leon and another child's] safety".
"I find that prior to his death Leon was exposed to an escalating risk of violence by James [Roberts] that CYFS, Police and the CDHB should have collectively identified (having regard to the scope of their respective mandates) but did not," Coroner Windley concluded.
"Had that risk been identified, that may have led to agency intervention.
"It is impossible to say whether identification of the risk of violence would definitely have led to the type and scale of interventions that would have prevented Leon's death ... but any intervention would plainly have reduced the likelihood of Leon being killed."
Jayet-Cole's father Michael Cole feels let down by the agencies, especially Oranga Tamariki (formerly CYFS) which he describes as being "extremely broken".
He believes there has been a lack of accountability and compassion shown by the agencies throughout the coronial process.
"They were always trying to wriggle or wrangle themselves around a corner – it was never to front up and face it," he said.
"I don't think anything the [coroner] can recommend is enough to change anything. Because you're telling people to do their job [and] what you're telling them should just be common sense."
During the inquest, social workers accepted there had been three earlier incidents, dating back to January 2013, where children at the Lambeth Crescent house in Redwood had been reported with bruising but CYFS had failed to investigate further.
After Roberts arrived in the household after starting a relationship with Jayet, both Jayet-Cole and another child suffered a number of injuries between April 2012 and May 2015, often involving bruising to the left side of their heads.
"With the benefit of hindsight, we didn't have a critical eye on the situation," an Oranga Tamariki spokeswoman said.
"There were situations to step back and consider the role Roberts played in family. [I] don't believe we took those opportunities when we could have.
"James Roberts was regarded as part of the solution, not the problem."
The boy's earlier injuries, explained as accidental or unexplained, along with a police check on Roberts, "should've raised a red flag for us at that time", the spokeswoman said.
Detective Sergeant Christopher Power, who was second-in-charge of Operation Lambeth, told the inquest that police, CYF and the CDHB all had part of the family picture but no one agency had a complete, overall view.
And, with hindsight, he accepted that police inquiries into reports of Roberts' earlier behaviour could have been handled better.
Roberts had an "inherent predilection" towards anger, violence and bullying, Power said, which was triggered by drug use or when angered at being challenged.
Emere Jayet originally stood by her husband but later told the inquest that she now blames her ex-partner.
"I now accept that James killed Leon," she said.
Coroner Windley concluded that the systems and processes agencies have for identifying and responding to child safety concerns were "broadly adequate" but were "not utilised or optimised as they should have been".
In Jayet-Cole's case, the failure of the agencies to identify the risk of violence from Roberts came after "transactional rather than cumulative" assessments which "lacked critical analysis and rigour".
The coroner said agencies tended to accept explanations from Roberts and Emere Jayet "when there was a clear basis for scepticism", reflecting a "cognitively biased mindset" that Jayet-Cole and another child in the house were accident prone.
"It also reflected a significant degree of credulity and naivety, especially on the part of social workers," the coroner said.
Coroner Windley said it was telling that prior to Jayet-Cole's death, it did not occur to anyone that Roberts, who had a violent history, was making ongoing and serious threats and was present on every occasion that Jayet-Cole was hurt, that he "might've had a hand in the string of injuries which preceded Leon's death".
The coroner said it is difficult, in those circumstances, to make recommendations to prevent further deaths in similar circumstances.
Oranga Tamariki, she noted, has already improved its practice standards across a range of relevant areas since Jayet-Cole's death.
Although the coroner hoped that "lessons from this case are clear", she said policy improvements alone would probably not have prevented the boy's death.
"The problem was not that there were inadequate systems to deal with identified family violence, but rather that the risk of violence in this case went undetected until Leon was killed," Coroner Windley said.
"To be blunt, the individuals applying the relevant policies, across all three agencies, failed to undertake the depth of analysis needed in respect of what I accept was a complex and challenging family situation."
Police also come in for criticism. The coroner said they should've taken a "much closer interest" in the first injury incident involving a child at the household back January 2013.
The coroner made six recommendations, designed to improve information gathering, risk assessments, and analysis for staff responding to the risk of violence that threatens the safety of children.
Oranga Tamariki today accepted it was "clear there were missed opportunities to identify the danger that James Roberts presented, and he was seen as a support to the family, rather than a threat".
"The coroner's report made it clear there was an accumulation of evidence across agencies that should have raised the level of concern about the children's safety," deputy chief executive children and families south, Alison McDonald said.
"We have accepted the coroner's findings, and will carefully consider them alongside other Government agencies mentioned in the report."
Canterbury DHB said it will now "fully consider" all of the coroner's recommendations.
"We accept that our systems and processes in place at the time of our interactions with the family could have been better utilised, and we remain committed to enhancing clinical information-sharing between other public sector organisations," said Dr Richard French, acting chief medical officer.
Police said they accept the initial findings and are now reviewing the final report to identify any areas for improvement.
"Child abuse is unacceptable and police is committed to working with our partners including Oranga Tamariki and DHBs to prevent, identify, and investigate harm," a spokeswoman said.
"This includes the work of our child protection teams which are based in every policing district, who are guided by the child protection protocol, the joint police and Oranga Tamariki response to dealing with reports of child abuse."
A TRAGIC TIMELINE OF RED FLAGS –
April 12, 2012: Leon taken to hospital by ambulance with a badly lacerated tongue. Emma and James Roberts say he'd fallen off a chair. After Leon's death, police find it had been deliberately inflicted.
September 2012: Respite carer says Emma had slapped another child in the household across the head. Police and CYFS tipped off.
January 2013: Another child taken to hospital with facial injuries and bruising. Authorities told he'd been spinning excitedly at home, fell, and hit the TV.
January 21-24, 2013: Leon's father Michael Cole receives threatening text messages and phone call from James Roberts. Report made to police but no further action taken.
July 2014: Other child hospitalised with "unwitnessed" head injury at home.
September 2014: School rings police after spotting forehead bruises on another child and are not convinced by Emma's explanation.
April 7, 2015: Children found home alone at Lambeth Crescent.
April 8, 2015: Police warn James Roberts after he threatened a Ministry of Social Development investigator.
May 5, 2015: Neighbour phones police saying James Roberts had appeared on her front lawn and threatened her with a knife. Police called to the house three times that day.
May 21, 2015: Leon arrives at school with "concussion-like symptoms/vomiting". Photos taken by teachers and Emma contacted to pick him up.
May 27, 2015: Leon rushed to hospital with serious head injuries and dies the next day.