Murdered Rotorua toddler Nia Glassie slipped through the net of protective agencies to suffer horrific abuse undetected, says a coroner investigating her case.
Nia was killed in 2007 by her mother's partner, Wiremu Curtis, who spun her on clothes lines, stuck her in a clothes dryer and threw her on her head in mock wrestling moves.
An inquest by Rotorua coroner Wallace Bain is looking at how state and community monitoring systems failed to protect the 3-year-old, and has discussed monitoring all new parents.
The inquest, held in Rotorua yesterday, heard how Nia's older brother had had his skull fractured in similar abuse by a former partner of their mother 14 years beforehand.
Neighbours had reported abuse at Nia's house involving other children just months before she moved in.
And Nia's kohanga reo staff had smelled cannabis and urine in her hair during the weeks she was being abused.
But the 3-year-old had no records in police or Child, Youth and Family systems until she was admitted to hospital with fatal injuries.
Mr Bain questioned whether reporting suspected abuse should become mandatory.
The inquest also discussed having all new parents receive periodic monitoring and legislating guidelines for early childhood centres and health providers to report abuse.
"Unless there's some reason to come to an agency, do they slip through the net?" he asked Child, Youth and Family acting chief social worker Kelly Andersen.
Ms Andersen replied that many health providers and other institutions had guidelines to report abuse, but there was nothing to say this would necessarily happen.
Nia's mother, Lisa Kuka, in jail for manslaughter for failing to protect Nia from violence and for failing to get medical help, appeared at the inquest.
She detailed her history of moving from town to town, having a string of relationships, and working late hours to give her children opportunities.
She had trusted her 17-year-old partner to take care of her children, and even when she saw him perform wrestling moves on her daughters she thought it was just "playfighting", she said.
Royal Australasian College of Physicians paediatrics chairman Johan Morreau said hers was a story of poverty.
About 15 per cent of children were in similar at risk households and an early detection system with house visits needed to be put in place to find those children and protect them, Dr Morreau said.
He had seen increasing numbers of children with post-traumatic disorder and behavioural issues because their parents were not coping.
"New Zealand has a huge amount of work to do. This country has to actually decide that children matter," Dr Morreau said.
Kuka should have received extensive support after her older son was abused in 1993, he said.
"This mum didn't develop the instinct she needed to after the first episode. We failed her by taking a limited view of that previous abuse. That was a key window of opportunity."
Detective Senior Sergeant Mark Loper told the inquest he frequently saw similar abuse.
It was a national problem that needed to be addressed by focusing attention on children under 5, Mr Loper said.
Children's Commissioner John Angus said there was a balance between respecting the privacy of families and making sure children were protected, and Nia's case might be reason to put more emphasis on protection.
Coroner considers support Nia missed
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