"Yes," was the final answer of Lew Warner.
The first witness at the inquest of Moko Rangitoheriri, the detective inspector outlined in detail the police investigation into the little boy's death.
The homicide inquiry started on August 10, 2015 when Tania Shailer called 111; Moko had fallen from a woodpile and hurt himself.
"It became apparent that the explanation given did not match Moko's injuries," said Warner.
Shailer and her partner, David Haerewa, were jailed in June 2016 for 17 years with a minimum non-parole period of nine years after pleading guilty to manslaughter.
Warner took the Coroner, Dr Wallace Bain, step-by-step through the circumstances leading up to Moko's suffering.
There was the volatile relationship between his parents, the mental health history of his killers, as well as the professional agencies involved with both families.
Child Youth and Family, the Auckland DHB, the Maori Women's Welfare Refuge, the Waipahihi Kindergarten, Family Works, as well as the Rural Education Activities Programme.
Arama Ngapo-Lipscombe, the lawyer representing Moko's mother, listed them all and asked Warner a question.
"Would you accept that is a rather extensive list of individuals and organisations that were involved with baby Moko prior to his death?"
In a quiet voice, Warner said: "Yes".
The same question is one Coroner Wallace Bain hopes to address in his findings.
"Had the parents, the child or the caregivers come to the attention of any child welfare and/or educational agencies, and if so, what were the circumstances of that attention?"
Moko's older brother had several long admissions to Starship Hospital with a serious leg infection between October 2014 and September 2015.
As a result, their mother Nicola Dally-Paki was interviewed by an ADHB social worker which identified concerns around her violent relationship with the boys' father Karauna Rangitoheriri.
She was referred to Shine, an organisation which provides specialist support for family violence.
While in hospital, there were two "Reports of Concern" made to Child Youth and Family in February and May 2015.
While there were no explicit concerns for safety, the reports included fears about family violence, stress, the children moving back and forward from Tokoroa and the lack of money.
CYF did not tell the police, said Warner.
While a senior Auckland DHB social worker Leshaun Perumal said there were concerns that CYF did not appear to have investigated the first "report of concern" in February, so the second was made in May.
"It became clear during this admission that the paucity of social, whanau and financial resources impacted Ms Dally-Paki's ability to provide a safe and stable environment for her children."
Moko and his sister were staying with different family and friends while their brother was in Starship Hospital.
But for one period of around three weeks, they were all sleeping in the hospital.
Dally-Paki was unable to secure a room at Ronald McDonald House, which provides emergency accommodation for families with children at Starship.
Concerns had been raised about the family's gang links, but her decision to move from Tokoroa also meant Dally-Paki was ineligible for a room - Ronald McDonald House is generally for families who live outside of Auckland.
She was placed on a waiting list for social housing and kept sleeping in the hospital.
On June 12, Dally-Paki took Moko and his sister to live with Tania Shailer in Taupo.
On June 8, the head teacher at the kindergarten sent a "report of concern" to Family Works regarding Tania Shailer.
Family Works is a not-for-profit organisation which provides counselling and social work services.
The kindergarten requested "urgent attention" for Shailer because of her depression and social needs.
Shailer was looking after four children aged 7, 5, 4 and 2, before taking in Moko and his sister a few days later.
She had her first counselling session on July 1, but cancelled the next appointment a fortnight later.
During this time Shailer texted friends to say she was struggling with depression and having "ugly moments" with the two extra children.
She referred to Moko as a "motherf***er" and a "c***". She also complained her mental health medication was not working,
On July 22, Shailer attended a second counselling session with Family Works.
She discussed her low tolerance levels, depression and racing thoughts. Family Works was unaware Moko and his sister were also in the house.
On July 23, a Taupo GP referred Shailer to a psychiatrist in Rotorua with concerns about her mental health.
Specifically, a borderline personality disorder, self-harm tendencies, mood swings and sleep deprivation.
Only July 29, Shailer went to Child Youth and Family to lay a "report of concern" because of her concerns around the children returning to the care of Dally-Paki.
Shailer was also getting help from the Family Start programme, an intensive home visiting service delivered in Taupo by the Rural Education Activities Programme.
Two workers visited the home on July 31, although they did not see Moko who was in one of the bedrooms for time out.
They did not ask to see him, despite Shailer stating she was struggling to cope with his behaviour, as the visit was for her own children.
On August , Shailer had her third counselling session with Family Works. She advised she was struggling to cope with the behavior of Moko and his sister, referring to them as traumatised children.
Moko was bruised from banging his head against the wall, said Shailer.
When speaking about Moko, Shailer looked stressed, tense and angry or frustrated.
The concerned counsellor arranged an urgent follow-up appointment for August 7, but Shailer cancelled.
On August 10, Shailer dropped her children off at the Waipahihi Primary School and Kindergarten. She smelt of cannabis and staff noted her behaviour was out of character.
That same day, Shailer with a friend and received a phone call. Shailer was very quiet afterwards and asked to be driven to the chemist to get an Epi-Pen.
This was to calm Moko down, as Shailer claimed he was running into walls and fighting with his sister. Shailer said he fell down the stairs, too.
The friend said Shailer should have called her, as she would have taken them to hospital.
At 3pm, Shailer called 111 to say Moko had fallen off the woodpile.
He was pronounced dead at 10pm.
Neither organisation knew Haerewa - who has a history of family violence - was living in the house.
On July 1, Shailer took Moko's sister to a course organised by a Maori Women's Refuge social worker.
The course was for children who have witnessed domestic violence.
According to Warner's evidence, Moko's sister told the worker she and Shailer had been hitting Moko.
"Aunty Tania would punch Moko but she made sure to say that the punches didn't hurt," is how the police recorded the worker's description of her conversation with Moko's sister.
This was denied by the worker in giving evidence at the inquest, who said her original statement to police was either "inaccurately written or understood".
"If I saw any signs of abuse, I would have reported it."
Instead, the worker said Moko's sister said Shailer hit her - not Moko - to stop the siblings from fighting.
"I immediately asked her to demonstrate what she meant by punch and she folded the tips of fingers and pushed my shoulder."
The worker discussed this with her manager and it was agreed this was Shailer's way to discipline Moko's sister. No further action was taken.
On July 29, the worker went with Shailer to the Taupo CYF office.
This was to file a "report of concern" about Dally-Paki coming to pick up Moko and his sister.
Shailer was concerned about the children returning to a violent environment, said thw worker, and was also struggling with the extra children.
This was relayed to a CYF social worker, whose name is suppressed.
The worker was "100 per cent certain" Shailer told the CYF staff member that she was not coping.
This was denied by the CYF social worker, who said the conversation was about Shailer's concerns about Dally-Paki's ability to care for the children.
"During the entire conversation Ms Shailer did not raise any current in-house domestic or child care issues or showed signs of not being able to cope with two extra children in the home."
The CYF staff member spoke with a social worker at the Auckland DHB to check Shailer's story.
Notes of that conversation, taken by the DHB social worker, record the CYF social worker saying Shailer was "struggling to cope" with the extra children.
The "report of concern" was officially filed on July 30 and given an urgent status - this means Moko and his sister should have been visited by CYF within seven days.
However, this did not happen.
This was because the concern was about Dally-Paki, not Shailer with whom the children were living, said the three CYF staff members who gave evidence at the inquest.
At first, the most senior of the CYF staff initially denied Moko could have been saved if they had visited the house within the seven days, as required under the policy.
But under cross-examination, Arama Ngapo-Lipscombe went on to list Moko's horrific injuries, many likely inflicted on August 6.
Q: "That policy was put in place so that children would be sighted, so do you accept that had you followed the policy, you would have seen Moko before he was killed?"
A: "I accept that, if we'd seen Moko. We did not believe that we needed to sight Moko [or the other children] based on the information that we were given."
Q: "But you have a policy and you went against your Ministry's policy?"
A: "Yes".
Q: "And you were wrong?"
A: "Yes".
Now the facts leading up to Moko's death have been established, the inquest has been adjourned so expert witnesses to analyse the evidence and help Coroner Wallace Bain make recommendations.
These witnesses may include Children's Commissioner Judge Andrew Becroft, Dr Johan Morreau, Detective Inspector Mark Loper and Merepeka Raukawa-Tait, former Women's Refuge leader and ex-MP.
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