The coroner who investigated the death of Moko Rangitoheriri says all children should be registered from birth and monitored until the age of 5.
However, the Minister for Children has poured cold water on the idea.
The compulsory monitoring of children, by midwives or Plunket, was the number one recommendation of coroner Wallace Bain in his findings into the 2015 death of Moko.
The 3-year-old was subjected to horrific abuse at the hands of his carers, Tania Shailer and David Haerewa, who were jailed for 17 years after admitting his manslaughter.
Compulsory checks on children was the same recommendation Bain made after the inquest of Nia Glassie, who also died at the hands of her carers in 2007.
"Had that recommendation been in place, and for example midwives and Plunket were empowered to check on children and enter homes (subject to safety considerations) and properly funded to do so, Nia Glassie and Moko would probably still be alive today," Bain wrote.
"The court asks one simple question. If there is no record of the existence of a child under 5, then how can all children under 5 be properly checked to be safe in their environment?"
Ninety-four children have been killed between 2007 and 2015 and Bain urged the Government to focus on the issue by sending his report to Prime Minister Jacinda Ardern and the Minister for Children, Tracey Martin.
The Ministry for Children is undergoing a five-year transformation and Bain echoed the comments of the Children's Commissioner, Judge Andrew Becroft, who gave evidence at the inquest.
"We have a once-in-a-lifetime opportunity in Aotearoa New Zealand to build a world-leading care and protection. We will never get this chance again.
"As a country, we must. This shameful abuse against our children has to stop."
But Children's Minister Tracey Martin said although she understood where Bain was coming from, "I don't think [compulsory monitoring is] something that most New Zealanders would be comfortable with".
"My initial conversations with colleagues reflect a similar view. While every child's death is a tragedy and there are far too many, thankfully they are still rare. Most families are loving families," she said.
Bain's findings also pinpoint specific failings by government departments, individuals and social welfare agencies, which missed numerous "red flags" in the care of Moko and his siblings.
A "red flag" was described by the coroner as an opportunity to intervene, which might have saved Moko.
These included "Reports of Concern" social workers from Starship Hospital made to Child Youth and Family (now the Ministry for Children) but not reported to police, or investigated.
Moko's brother was in Starship Hospital with an infected leg and their mother, Nicola Dally-Paki, had nowhere for Moko or his sister to live.
She was escaping a violent relationship and was sneaking her children into the hospital at night so they had somewhere safe to sleep.
"It was not hard for the court to conclude that with the lack of support, whanau difficulties and financial resources, Dally-Paki, really had an inability to provide a safe and stable environment for her children," wrote Bain.
"That is a clear red flag from the time that they were at Starship before they were placed with the caregivers and moved to Taupo. It was missed, yet there to be seen."
This lack of accommodation led Dally-Paki to turn to her friend Tania Shailer, who lived in Taupo, for help. Two months later, Moko was dead.
It's a decision Dally-Paki regrets every day.
"I accept that I, as a victim of domestic violence, made mistakes, my children and I live with those mistakes every day," Dally-Paki told the inquest.
"Perhaps if I had been judged less harshly, Moko would be in my arms today."
Other "red flags" were missed in Taupo, including reports of concern from a kindergarten teacher and a request for "urgent attention" for Shailer because of her depression.
Shailer was struggling to cope with her own children - aged 7, 5, 4 and 2 - before taking in Moko and his sister.
She cancelled counselling sessions, another red flag, with Family Start counsellors who were also unaware Moko was living with her.
A Taupo GP also referred Shailer to a psychiatrist who identified borderline personality disorder, self-harm tendencies, mood swings and sleep deprivation.
Shailer was also getting help from a Family Start programme from Rural Education Activities Programme (Reap). Two workers visited her home 10 days before Moko's death but did not see him.
"Again another red flag," wrote Bain. "They should have asked to see him because Shailer was again stating she was struggling to cope with his behaviour."
The Maori Women's Refuge and CYF should have been providing services, but Bain wrote neither knew that Haerewa, who had a criminal history of family violence, was living in the house.
"Again, a red flag. It highlighted that no one is visiting the house to actually see the children and that should have been patently clear from the reports of concern at Starship Hospital and all the other matters mentioned."
Finally, another "Report of Concern" was filed on July 30, 2015, ironically by Shailer who was concerned about the children going back into Dally-Paki's care.
Under CYF policy, Moko and his sister should have been seen by CYF staff.
"That did not happen. It is clear from the evidence, and the post-mortem report, that Moko could have been saved if he had been visited at the house within seven days," wrote Bain.
"It was accepted that this should have happened."
Arama Ngapo-Lipscombe, the lawyer representing Dally-Paki, said findings of the coroner highlighted the incompetence of CYF, including senior staff, in ignoring departmental policy.
"I would expect as a result of the coroner's findings and the clear incompetence of the ministry that they will be issuing an apology to Ms Dally-Paki."
Despite the numerous red flags, Bain said it was a major concern that Moko was not visited by any organisation.
If Moko had been seen - and given medical treatment - even several hours before his death, Bain said the pathologist report was clear the toddler could have been saved.
If there were compulsory checks on children until they reached 5, when they attend school, Bain said there would have been a better chance of his survival.
Any organisation looking at the welfare of a child, if they had gone into the home where Moko was being 'cared for', they would have found a caregiver, Shailer, in distress with depression and mental issues and assaulting Moko, another caregiver recently released from prison with a history of domestic violence and seen injuries to Moko that would have raised alarms.
In terms of tackling the wider issue of child abuse, Bain pointed to reducing poverty as crucial and was glad to see Ardern taking responsibility for lifting children out of poverty.
In a statement to media, the Ministry for Children made no mention of the "red flags" that were missed.
The recommendation of compulsory monitoring would need to be a multi-agency approach and something for the Government to consider.
"We feel deep sympathy for everyone who loved this little boy. The particular circumstances affected everyone. The tragedy was Moko died after repeated abuse and throughout this no one heard his voice."
A spokesman for the Prime Minister referred the Herald to the office of the Minister for Children, Tracey Martin.
The Minister's reponse is below:
This was a hideous crime. What happened to Moko is shameful. Unfortunately all we can do now is remember him; and do better. We have to continue the system improvements under way with Oranga Tamariki. Part of that is agencies working better together; part of that is what OT is doing – especially around raising social work standards, and getting more and better caregivers. And we have to do a lot better as a society. As adults and neighbours and friends and whanau, we have to look out for kids and we have to speak up for them. I think the inquest has done us a service. I want to acknowledge Coroner Bain and all of those who appeared. It's positive that he found that a lot of improvements have been made over the past few years, and he made a couple of practical suggestions that could make a difference. Improving the care standards for social workers so that there is really good, consistent practice, is really important and something Oranga Tamariki has already begun to roll out. As for the recommendation for compulsory monitoring of children, I can understand where he's coming from, but I don't think it's something that most New Zealanders would be comfortable with. My initial conversations with colleagues reflect a similar view. While every child's death is a tragedy and there are far too many, thankfully they are still rare. Most families are loving families.
If you're in danger now:
• Phone the police on 111 or ask neighbours or friends to ring for you.
• Run outside and head for where there are other people.
• Scream for help so that your neighbours can hear you.
• Take the children with you.
• Don't stop to get anything else.
• If you are being abused, remember it's not your fault. Violence is never okay
Where to go for help or more information:
• Women's Refuge: Free national crisis line operates 24/7 - 0800 refuge or 0800 733 843
• Shine, free national helpline 9am- 11pm every day - 0508 744 633
• It's Not Ok: Information line 0800 456 450
• Shakti: Providing specialist cultural services for African, Asian and middle eastern women and their children. Crisis line 24/7 0800 742 584
• Ministry of Justice
• National Network of Stopping Violence
• White Ribbon: Aiming to eliminate men's violence towards women, focusing this year on sexual violence and the issue of consent.
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