The Health Minister says he expects a District Health Board to review its policies in light of a report which found staff missed multiple opportunities to report the suspected abuse of a toddler before he died of further injuries.

The Health and Disability Commissioner Anthony Hill yesterday released a damning report into the care received by a 16-month-old boy who had a fractured leg which doctors suspected may have been non-accidental. Soon after he was discharged he died of other injuries.

In a statement provided to the Herald, Health Minister David Clark called the case distressing.

"Clearly in this case mistakes were made, with tragic results," he said, although he clarified he was not familiar with the details of the particular incident.

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"Domestic violence is sadly all too common in New Zealand and it's important our health professionals look out for signs of abuse, and respond appropriately. I'm sure they work hard to do just that," he said.

Clark said one of the strengths of the health system was the willingness and commitment of those involved to learn lessons when something went wrong.

"I expect the DHB will reflect on whether their policies and practice are up to date in light of this case."

The DHB involved cannot be identified for legal reasons.

Ministry of Health deputy director-general of population health and prevention Deborah Woodley and chief adviser of child and youth health Pat Tuohy said the case would be discussed at the next inter-agency meeting with police, health boards, the Paediatric Society and Oranga Tamariki.

"This sad case demonstrates that there is room for improvement and provides learnings for us all," they said in a statement.

"All children deserve to be safe and Government agencies have a responsibility to work together to ensure our children are protected."

While health care providers were well placed to identify issues early and get support for victims of abuse it was not always easy to do, they said.

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"People are not always going to disclose family violence. But it is extremely important for all staff to know how to ask effectively and safely about intimate partner violence and to assess for signs or symptoms of child abuse and neglect.

"We provide DHBs with a wide range of child protection guidelines. We will work closely with them to ensure the challenges around implementing these processes and policies are progressed."

Each year the Ministry of Health spent more than $3.5 million on implementing the Family Violence Assessment and Intervention Guideline: Child abuse and intimate partner violence which provides training in identifying and responding to instances of domestic abuse.

Speaking to the Herald yesterday, Children's Commissioner Andrew Becroft said it was a "profoundly concerning incident that experts in our office call dreadful and appalling".

"This is as bad a systems failures could possibly be imagined," he said.

Today he told Radio New Zealand he believed the health board involved should be identified although it would have to wait until any further action had been resolved.

Hill's report found the DHB failed to provide adequate care for the boy and recommended the organisation provide the family with a letter of apology.

When the 16-month-old began to avoid using his left leg, his mother took him to hospital for treatment.

Despite at least three doctors admitting they considered it was possible that the tibia fracture was non-accidental, it was not until the boy's fourth visit and transfer to another hospital that those concerns were noted and the appropriate agencies informed.

The second hospital recorded two black fingernails, two damaged fingernails, a missing left bottom incisor, bruises around the hips and chest, and a light pink discolouration over the right lower quadrant of the abdomen and alerted authorities.

Because of the number of unexplained injuries, the boy was referred to Oranga Tamariki and the police child protection team.

Oranga Tamariki were asked to prepare a safety plan before the boy could be discharged but he went home after police arrived and spoke to his mother.

He was later found dead with further injuries.