An overall failure of care: Coroner slams child welfare agency after violent death of toddler

Warning: This story refers to violent child abuse.

• Leith Hutchison shaken to death by his father.
• Toddler’s femur had been broken weeks before and suspected abuse reported.
• Child welfare agency response “flawed” and “inadequate”.
• Coroner finds “overall failure of care”.
• Oranga Tamariki admits “we didn’t get it right”.

Leith Hutchison was 15 months old when he was violently shaken to death by his father.

Weeks earlier, the toddler sustained a broken femur while in the man’s care.

Coroner Louella Dunn held an inquest last year to ascertain the role of multiple agencies involved in the care and protection of Leith prior to his death - and whether that care and protection was adequate and appropriate.

In her findings, released today, she ruled a number of factors contributed to Leith’s death, including “a lack of direction and control of the investigation” by CYF - now Oranga Tamariki - and a “lack of leadership” that led to “inadequate responses and an overall failure of care”.

Leith Hutchison was shaken to death by his father. Photo / Facebook

Processes were “flawed” and an “error of judgement” was made when a “new” and inexperienced social worker was assigned to Leith’s case.

“I consider that Leith’s inquest has shown that CYFS need to be more robust and proactive to properly address suspected child abuse and to intervene in an appropriate and timely manner,” Coroner Dunn said.

She also recorded the total failure of multiple adults in Leith’s life to report bruising and other injuries - or witnessed him being abused.

Leith Allan Hutchison died on April 23, 2015.

His last days were spent on life support at Starship children’s hospital after he suffered a blunt force trauma to his head.

Following a police investigation, his father Dane Blake was charged with murder.

He later pleaded guilty to a reduced charge of manslaughter and was convicted and sentenced to five-and-a-half years imprisonment.

Read more here on Blake’s conviction and Leith’s tragic death.

The inquest was held so Coroner Dunn could look into the toddler’s entire life to see what went wrong and how she can protect other children from the same situation in future.

It spanned four days, during which Leith’s mother Kate Hutchison, other relatives, police, health professionals and social workers from OT gave exhaustive evidence about their involvement with the family.

Soon after Leith’s birth, Hutchison was referred to community mental health services and a psychiatrist for post-natal depression.

Leith Hutchison was 15 months old when he died. Photo / Supplied

In May 2014, staff at Grey Base Hospital reported “concerns of possible neglect” after Leith’s older brother needed treatment after swallowing turpentine.

Infant, Child, Adolescent Mental Health Service (iCAMHS) became involved and the family were discussed at the hospital’s At Risk multi-disciplinary meeting.

At the meeting, it emerged a Plunket nurse had also made a report of concern to OT.

The family were discussed at a further seven At Risk meetings between June and September 2014.

In July 2014, Leith and his brother were placed on the Vulnerable Infants List.

Earlier that month a Work and Income NZ family violence coordinator contacted community mental health, disclosing Hutchison was struggling and wanted to engage.

Winz referred Hutchison to Family Start and her GP.

Six days later, Hutchison was assaulted by her then-partner - while she was holding Leith.

The assault was raised at a family violence interagency response meeting, after which Leith was also referred to iCAMHS.

The West Coast District Health Board Violence Intervention Programme coordinator and Hutchison’s GP were also notified.

Over the next few months, the family had various and ongoing interactions with the agencies.

By December iCAMHS and Women’s Refuge remained involved but the At Risk team and OT had closed their cases.

In January 2015 Blake found out he was Leith’s father - the day after the boy turned 1.

Despite having no experience of caring for a child, he began taking Leith at weekends.

When Blake delivered Leith home on March 1 2015 he told Hutchison to keep an eye on his leg which was “sore”.

Several hours later Leith could not put pressure on the limb and Hutchison took him to hospital.

Paediatrician Dr John Garrett diagnosed an undisplaced spiral fracture to Leith’s left femur - an injury resulting from a twisting force on the bone.

Given Leith’s age, Garrett lodged a report of concern with OT.

Kate Hutchison holds on to her favourite photo and jumpsuit of her son Leith. Photo / Greymouth Star

A Multi-Agency Safety Planning meeting (Masp) was held the next day. Garrett, OT social workers and health board staff attended.

Police usually attended but were not present that day.

Garrett said he considered Leith’s injury “may have been non-accidental” however the explanation Blake gave was “plausible”.

The parties agreed Blake was not to be left unsupervised with Leith in the hospital until OT advised otherwise.

After the Masp, Detective Senior Sergeant Kirsten Norton was notified about Leith’s injury. She decided to await further medical information and an update from OT before planning further police involvement.

On March 3, she requested Leith’s medical notes.

Given Leith’s vulnerability and the seriousness of his injury; the matter was subject to the Child Protection Protocol - a joint operating procedure between police and OT.

A social worker was assigned to Leith’s case.

Coroner Dunn heard the social worker - referred to as Ms C - was “a new social worker with limited experience” who had never met Leith or his family.

Following a second Masp meeting, Blake was permitted unsupervised contact with Leith while he was in hospital.

When the boy was discharged on March 6, OT removed all restrictions on Blake’s contact with his son.

Police investigated Leith’s broken femur and concluded there was insufficient evidence to prosecute Blake, and no further police action was required.

Blake had his first unsupervised visit with Leith on March 10.

Just 44 days later, Leith was dead.

On April 20 Leith went to stay with his father. He was put to bed by his uncle who checked in on him several times and said he was sleeping and appeared normal and healthy.

At 12.30am, Blake rushed into his uncle’s room saying that he needed to take Leith to hospital as his breathing was “not good”.

Soon after Leith arrived, staff at Grey Base Hospital made the call to transfer him urgently to Starship.

Hutchison travelled with her son and when they arrived in Auckland told her Leith had been “forcibly shaken”.

On April 23 at 5.40pm, Leith had his life support switched off.

Starship Children's Hospital in Auckland. Photo / File

A post-mortem examination was carried out and Leith’s extensive injuries were discovered.

He had multiple bruises on his face, torso, buttock and thigh. The pattern of the bruises to the face was noted as possibly caused by fingertip grip marks.

The inner surface of his upper lip was torn - possibly resulting from an impact or blow to the mouth.

He had traumatic head injuries - swelling and bleeding on his brain - and bleeding behind his eyes.

A Starship doctor told the Coroner the damage to Leith’s brain was so extensive that if he had survived his injuries, he would most likely have been profoundly disabled, and almost certainly blind in both eyes.

She found evidence of “at least one previous episode of head injury prior to death”.

“Head injuries were described as the direct cause of death... consistent with blunt force head injury,” Coroner Dunn said.

From at least March 2015, adults noticed bruises of varying severity on Leith’s face and body.

The marks were “obvious”.

Hutchison’s friend Breesha De Goldie described one above his eye as “the size of a 50c piece”.

Hutchison herself noticed injuries.

Her partner at the time, Lyall Delaney, noticed a bruise on Leith’s cheek when he returned from Blake’s. It was “yellow and about the size of a 10c piece”.

He said Blake explained Leith’s “legs went out and he fell onto his walker”.

Given Leith still had his cast on after his broken femur, Delaney could not imagine Leith pulling himself up and falling over something.

During a Sunday morning visit, Blake’s half-sister Grace Besant said she witnessed him smack Leith in the face. He was “angry” because the toddler was crying.

She told her mother Donna Blake and her aunt, Denise Blake.

In early April, another of Hutchison’s friends, Kerrinda Hill, saw a “greyish blue” bruise on Leith’s right.

“He believed she saw a pattern that it was only when Leith was with Dane that he sustained [a] bruise,” Coroner Dunn said.

Hill told the coroner Hutchison said Leith had “come home from Danes with bruises”.

Leith Hutchison.

Coroner Dunn addressed the repeated failure of people to report the injuries.

“There may be reasons I am unaware of as to why a report or notification was not made.

“It is well known that New Zealand has an appalling history of child abuse cases. This abuse frequently occurs by caregivers behind closed doors.

“I urge anyone who knows or suspects a child to have been abused or is subject to abuse to report this promptly.”

Coroner Dunn said the main objective of the inquest was to ascertain whether - after Leith’s femur was broken - the steps decided upon to ensure his safety were adequate and appropriate; and if they were properly implemented.

“Further issues raised at the inquest included lack of police presence at the first Masp meeting… uncertainty as to who was the proper lead agency following the femur incident, ambiguity of various terms used by medical staff to explain the cause of the femur injury, the inexperience of CYFS social workers dealing with a potential case of serious child abuse and a lack of adequate leadership and appropriate responses to protect Leith,” she said.

In her 31-page report, Coroner Dunn outlined “failings by CYF around the care and protection of Leith”.

“While CYF shared information with other agencies, there was a lack of direction and control of the investigation,” she said.

“Poor record keeping and a lack of leadership led to inadequate responses and an overall failure of care.

“It was an error of judgment by CYF to assign this file (after the broken femur) to a new and inexperienced social worker. Oversight and guidance from her supervisors were scarce and it was apparent at the inquest that (she) felt out of her depth.

“The allocation of responsibility to a new and inexperienced social worker is concerning given Leith’s vulnerability, the seriousness of the injury and the history of care/protection concerns CYFS had documented for Leith and (his brother).

Leith's father was jailed after pleading guilty to manslaughter. Photo / File

Coroner Dunn said it was also apparent during the inquest that terms used by medical staff involved in Leith’s case led CYFS staff to become “tunnel-visioned in their response to Leith’s care”.

“Undue reliance was placed on the medical opinion given by Dr Garrett that the explanation given for the femur injury was plausible,” she said”

“That reliance led to a flawed process and an inadequate response by CYFS to ensure that Leith was kept safe and protected from those responsible for caring for him.

“I consider that Leith’s inquest has shown that CYFS need to be more robust and proactive to properly address suspected child abuse and to intervene in an appropriate and timely manner.”

The Coroner made multiple formal recommendations.

Perhaps the most important was that when OT assign a social worker to cases involving young and vulnerable children - particularly with a documented history of care and protection issues - they must have the “appropriate level” of experience to carry out care and protection obligations.

In cases where multiple agencies are involved in the protection of a child in a suspected abuse case, each must ensure they are “adequately participating and providing information to the joint care process”.

And, in a suspected abuse case, whatever care was agreed on for a child after discharge from a hospital, OT needed to properly provide “in a timely manner” and monitor “to ensure no further risk or harm to that child is prevented”.

OT Chief Social Worker Nicolette Dickson responded to the Coroner’s report.

“Leith Hutchison should have celebrated his 10th birthday this year. His death was a tragedy, and I would like to acknowledge the profound grief and loss felt by his whānau.

“Child, Youth and Family did not get things right in this case. Leith... deserved more from our agency.”

Nicolette Dickson. Photo / Supplied

Dickson outlined changes made since OT was reestablished in 2017 to “improve child protection practices”.

She said guidance on multi-agency safety planning was updated in 2023 and the CPP was “currently under review”.

“Consideration is being given to Health NZ - Te Whatu Ora joining,” Dickson said.

“We also have separate agreements with Health, which outline our ongoing working relationship,” she said.

“This includes meeting at national, regional and district levels to discuss issues and how best to work together when there are abuse or neglect concerns.”

Dickson said since Leith died, OT had strengthened its “oversight, support and training for new social workers”.

In 2022, a directive was issued that only social workers with more than 12 months’ experience “as a registered and practising social worker” should be responsible for completing initial assessments.

“Alongside this, leaders who oversee frontline work, such as supervisors, are now expected to ensure social workers are allocated cases appropriate to their level of expertise and capability.”

“Furthermore, social workers are required to participate in a range of learning modules and activities including... learning forums and online courses covering areas such as... information sharing, supervision, seeing and engaging tamariki, family violence, safety planning, the legal framework and collaborative work with partners.”

Are you worried about a child?

If there is a real risk that the child will be harmed, ring police on 111.

You can also contact your local police by clicking here.

If you are worried a tamaiti or rangatahi may be suffering from ill-treatment, abuse or neglect; or experiencing abuse but you’re not sure if you should be concerned, and want advice, reach out to Oranga Tamariki by phone 24 hours a day on 0508 326 459 or email contact@ot.govt.nz

Anna Leask is a Christchurch-based reporter who covers national crime and justice. She joined the Herald in 2008 and has worked as a journalist for 18 years with a particular focus on family violence, child abuse, sexual violence, homicides, mental health and youth crime. She writes, hosts and produces the award-winning podcast A Moment In Crime, released monthly on nzherald.co.nz