Police did not handle a 111 call reporting concerns about a 2-year-old girl's welfare in accordance with police policy, standard operating procedures and good practice, the Independent Police Conduct Authority has found.
Police found the child dead the next day.
On March 20, 2019, Niki Sturgess called 111 to report that she and her husband wanted help getting their great-grandchild, Nevaeh, out of a house in Maketu.
Nevaeh was at the house alone with her father, Aaron Izett, while her mother was in hospital.
Among other things, Sturgess reported that Izett was "off his brain" and had just attacked her and her husband.
The call taker advised Sturgess police did not have the power to intervene because she and her husband did not have custody of Nevaeh.
Police did not send anyone to conduct a welfare check at the house that evening.
After receiving further reports about Izett's behaviour the next day, police went to the address and found Nevaeh's deceased body weighed down by rocks in an estuary next to the house.
Izett was arrested shortly afterward, and later charged with Nevaeh's murder and several other violent offences. In November 2020, a jury found Izett guilty of Nevaeh's murder.
The authority completed its investigation into this incident in April 2020, but delayed reporting until the conclusion of Izett's trial.
The authority found that the call taker coded the 111 call incorrectly, gave incorrect advice regarding police powers and did not record vital information which may have affected the police response to this incident.
It found the dispatcher on duty did not check the police database for further information on Izett and a second dispatcher later checked the database and verbally advised the first dispatcher of the relevant information, but did not copy significant information into the 111 event.
The authority concluded that police responded appropriately to the information the call taker had recorded about the incident. However, had the relevant information been recorded and properly coded, police likely would have responded much earlier than they ultimately did.
"This is an extremely sad case," authority chairman Judge Colin Doherty said.
"While police processes were found wanting, due to uncertainty about the exact timing of Nevaeh's death, it is not possible to say whether police would have prevented her being harmed if they had gone to check on her shortly after Mrs Sturgess' call."
Police acknowledged and accepted the Independent Police Conduct Authority's findings.
"We let Nevaeh and her family down," Assistant Commissioner Tusha Penny said.
"Had the information from the 111 call been properly recorded and shared, police may have had an opportunity to intervene.
"We will never know whether we could have prevented this tragic outcome, and for this we are deeply sorry.
"Police come to work every day to keep our communities safe, but on this occasion, we could and should have done more.
"Police met with Nevaeh's family yesterday to apologise in person and discuss the police response to the authority's findings."
The call taker and dispatchers involved are receiving ongoing support and training to ensure they are better equipped to respond to future incidents.
The dispatchers also agreed to share their experience and lessons learned with others in the role.
Sturgess agreed with the findings of the IPCA and said while they accepted the police apology, she was of the opinion that her initial call "was the only time they could [have saved Navaeh]".
"I don't think it's a matter of [forgiveness], I just hope they're going to make improvements."
She said the IPCA findings would, in time, allow them to heal, and wanted to see police-wide retraining on call handling.
"They need to go back to the drawing board and make some improvements," she said.
Thinking back to the night of the call, she remembered the state of the house, Izett's state-of-mind, and being "distraught and concerned".
"What I really wanted was some physical help, somebody with us ... We needed somebody."
She had plans to take Nevaeh to see her mother in the hospital, "but that wasn't possible. He wasn't going to let us".
She did not know anyone in Maketū which was why she turned to the police.
"We could have tried harder for her," she said, of herself and the police.
When asked by NZME whether there would be any disciplinary action, a police media spokeswoman said they were not in a position to comment on employment matters due to the privacy of the employee.
She said an internal review was always conducted in response to a critical incident such as this, as it was important to reflect and identify areas to be improved, with training and tools necessary to support staff provided to staff.
With the permission of the family, this incident will be used as a training case study, she said.
She said the recent changes to their call centres, separating emergency and non-emergency calls was an important change.
International examples showed having a specialised workforce taking only emergency calls lead to better outcomes for both police and communities, she said.
The dispatchers involved in this event have agreed to share their experience and lessons learned with others in the role.