Coroner Ian Telford found Watene Kainga died of Sudi – sudden unexpected death in infancy – after he had been placed in an “unsafe sleep environment” on a couch.
However, in the findings, released on Tuesday, nearly six years after the Napier boy’s death, the coroner said the 8-month-old was at high risk throughout his short life and there had been “pervasive deficits” in Oranga Tamariki’s social work practice and supervision of the family.
The inquest report details a background where his family was in emergency housing for almost all his life, with the parents trespassed or evicted from several motels and their relationship described as “volatile and permeated by family violence”.
The report lists the agencies with whom the family was involved, including Oranga Tamariki, the police, the Eastern District Family Harm Team, maternity services, Work and Income, the family violence prevention agency Dove Hawke’s Bay and the social agency Te Kupenga Hauora - Ahuriri.
Watene was born on March 24, 2018, and a court-appointed assessor found 14 incidents or circumstances that should have been logged by Oranga Tamariki as official “reports of concern” in the following months.
However, by the time of his death on December 22, 2018, Oranga Tamariki had recorded only two reports of concern: one filed just before Watene’s birth, and a second in March 2018, when a motel owner saw the baby’s father hitting his mother while she was holding another child.
“I find that Oranga Tamariki staff incorrectly handled concerns reported to them, and this significantly and negatively impacted how Watene’s case was managed,” Coroner Telford said in his report.
He said the assessor found Oranga Tamariki’s practice standards, frameworks and practice, were “fit for purpose”, particularly for guidance to identify, assess and respond to Sudi risk factors.
“However, it is apparent that on this occasion, those practice frameworks did not materially inform practice in the field at the critical times.
“It seems likely that if the relevant assessment and planning standards and tools had been applied in Watene’s case, different plans and decisions would have been made by statutory social workers in conjunction with whānau,” the coroner said.
“Crucially there was seemingly no overview of all facets of risk, and by any assessment, Watene was at high risk throughout his short life.”
Watene was seen playing happily with another baby the day before he died and was in the care of extended family members that night while his mother was out socialising.
He was placed on a folded blanket on a couch, with a small pillow on top of it, and was seen with his head on the pillow drinking from a bottle, which he was holding with both hands.
About 3am on December 22, a relative got up and found Watene rolled over with his head facing down in the corner of the couch, and he was “really cold” to the touch.
Shortly afterwards, partygoers from a nearby property heard a woman yelling about a baby not breathing and followed her back to the house, where an ambulance was called.
Watene’s mother arrived home about this time and with another relative started mouth-to-mouth resuscitation.
He was declared dead nine minutes after the ambulance arrived.
The coroner found Watene’s cause of death was sudden unexpected death in infancy (SUDI), with multiple risk factors but from natural causes.
“I find that the unsafe sleep environment was the most obvious and imminent risk factor established by this inquiry.
“However, other Sudi risk factors and vulnerabilities existed, including young age, growth retardation [of unknown genesis], maternal smoking and lung infection.
“Put simply, it is not possible to know with any degree of certainty which of these co-existing risk factors led to Watene’s death.”
Coroner Telford found Oranga Tamariki staff incorrectly handled concerns reported to them, “and this significantly and negatively impacted how Watene’s case was managed”.
The coroner also repeated the “key message” for parents and caregivers in the hope more deaths in similar circumstances could be prevented.
“For every sleep, babies up to one year of age should be put to sleep on their backs, in their own sleeping space [a firm, flat and level surface with no pillow], with their face clear.”
Oranga Tamariki’s Chief Social Worker, Nicolette Dickson, said the agency agreed with the coroner that the social work practice and supervision in Watene’s case was “not of the standard that we would expect”.
“Oranga Tamariki did not do enough to act on concerns reported to us about Watene’s safety and wellbeing during the time we were involved with him and his whānau,” she said.
Dickson said that since Watene’s death, Oranga Tamariki had made “substantial changes” to its practice, including the introduction of a new approach “focusing on mana enhancing support for children and whānau who come to our attention”.
“We have also strengthened our existing practice standards through the development of a new framework, models and tools to ensure social workers are always able to apply best practice.
“In 2024, we introduced a supervision model aimed at encouraging social workers to be more reflective in their practice and strengthen critical reasoning and professional decision-making,” she said.
“I would like once again to acknowledge Watene Tamahana Rezik Flawless Iraia Kainga.
“He should have received far better support from our agency. I wish to extend my sincere sympathy to everyone who loved him.”
Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.
