In his findings on the death of toddler Nia Glassie, the Rotorua coroner, Wallace Bain, does not hide his sense of shock. "In my 19 years of conducting inquests ... I have never had to endure such horrendous evidence which led to the death of this little girl in horrific circumstances," he says.

It is, therefore, hardly surprising that he recommends strong medicine to tackle the country's appalling child abuse problem. Some of this can be criticised because of the extent of state intrusion into the lives of families. Yet it is difficult to dismiss out of hand, if only because of the scope of the problem in areas such as Rotorua.

Perhaps the saddest aspect of the Nia Glassie case is that her plight never came to the attention of the police or Child, Youth and Family. Dr Bain suggests checks to remedy this. He wants all children to be registered compulsorily with government agencies, health providers and other voluntary agencies at birth, and to be monitored compulsorily until they reach 5.

This would include spot checks of their homes. The state, the coroner says, should also have the power to override the decisions of parents who want to opt out of services.

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On the latter point, Dr Bain is undoubtedly right. The interests of the child must always be uppermost. The extent of the state intrusion that he prescribes does, however, raise a set of problems.

The coroner suggests that intervention and monitoring would concentrate on parents in single-parent homes where the family have previously come to the attention of authorities, where a mother works full time and others care for the children, and where domestic or child violence has been identified. Yet that would not remove the need for Child, Youth and Family to exercise considerable discretion.

Spot checks, in particular would soon become highly unpopular if it was seen to be heavy-handed with parents who were doing their very best for their children. Such checks were certainly not part of the "good old days" of the Plunket nurse, to which Dr Bain refers.

They seem a step too far. And if all the coroner's proposals were adopted, Child, Youth and Family would need far greater financing and resourcing. It is possible he has not considered fully just how much extra would be required for a system that demanded both spot and scheduled visits.

Dr Bain is on far firmer ground in wanting legislation to enable the compulsory sharing of information between government agencies, health providers and others. This, indeed, was highlighted in the Government's recent Green Paper for Vulnerable Children.

So obvious is it, particularly given the number of children falling through the cracks, it is remarkable that, privacy concerns notwithstanding, it has not already been enacted.

The coroner also identifies the importance of community involvement, another widely agreed step to curb child abuse. He wants the Government to ensure witnesses to abuse report it immediately, with significant penalties for failing to do so.

Happily, this is already covered to a large degree in the Crime Amendment Bill. It would see family members or flatmates facing 10 years' jail if they do nothing to stop abuse in the house where they live, even if they did not inflict it.

That aside, the Government is hardly acting urgently. Its Green Paper merely reaffirms the well-established importance of early intervention and effective parent support. Nothing will flow from it for at least a year.

Dr Bain has been alerted to the need for a far more direct response by the circumstances of Nia Glassie's death. His findings should compel the Government to act with far greater pace and purpose to protect the country's most vulnerable children.