The mother acknowledged she had slapped M as the child's crying made her angry, and the clinic sought assistance from CYF - the second agency to which M was referred.
CYF arranged counselling with the Anger Change Trust - the third agency - and for M to be cared for by a caregiver. The mother saw the counsellor on 16 occasions. It was arranged for her parenting skills to be assessed by Plunket, the fourth agency, and Family Start, the fifth agency.
This was when the Plunket nurse said the mother's parenting skills were almost nil. A Place of Safety warrant was sought - unsuccessfully - by CYF from the Waitakere
Family Court, the sixth agency.
The mother later said that at the time she had taken M with her to South Auckland to avoid CYF but the police had caught up with her and as the alternative was seven years in jail, she had handed M back, who was then placed with a non-whanau caregiver - the seventh agency.
In April 2002 an interim custody order was granted for both M and her older sibling. M remained with her non-whanau caregiver and the sibling was placed with another caregiver.
In June a barrister was appointed for both children - the eighth agency - and in 2003 the (CYF) custody order was made permanent.
After a meeting with the parents a Plunket nurse wrote that the mother had a lot of issues from her past and a lot of anger towards baby M: "I believe M is at risk from her mother. I believe (the mother) will need extensive counselling and support before she has the competence to deal appropriately for these children and any other children she may have."
M remained with the non-family caregiver for nearly four years - from March 2002 until December 2005. Some thought was given to making this arrangement permanent.
Papers showed the mother indicated she would want M back and there was debate among the professionals about whether a placement for M with whanau would be preferable for cultural and identity purposes. M's counsel opposed this.
In mid-2005, M's parents put forward the names of two whanau members as permanent caregivers for their daughter. They were CYF approved department caregivers and the child's transition to them was completed in December 2005. M stayed with them till December 2008.
Access for her parents was arranged under the supervision of IOSIS Family Solutions, the ninth agency, in Manurewa but was sporadic and the relationship between the mother and the caregivers was at times "volatile".
In a developmental history from last year the mother says they would not give her access unless she "brought bread, milk, food or weed".
By early 2007, the mother had separated from the father, was living in Massey and receiving support from a Family Start worker at the Waipareira Trust. Records also showed that from early 2007 the CYF social worker was working to return M to her mother's care. In July 2007, the mother applied to Waitakere Family Court for the CYF custody order to be discharged and an update from a psychologist - the 10th agency - was sought.
By late 2008 M's whanau caregiver had announced he was moving to Australia and could not take M.
The placement of M back with her mother began on an overnight basis and M spent Christmas with her mother who had just given birth to her fifth child. M did not return to her previous caregivers.
In June 2009 M went for counselling with the 11th agency and disclosed sexual abuse while with her whanau caregivers.
CYF was advised but did not follow up on that letter until further letters in August and September. An evidential interview was carried out in December by the Puawatahi (the 12th agency), an agency of the Auckland Central Police, attached to the Auckland District Health Board, and later the whanau caregiver was arrested and charged with unlawful sexual connection and indecent assault. The charges have since been dropped.
In February last year, M was treated at hospital - the 13th agency - for a laceration to her hand which her mother said was the result of a fall.
At the end of April, M had a swollen cheek and hand and a friend of the mother told police last year the mother had said those injuries had happened when she "lost it."
In May a review was put before the court and a social worker noted
M was showing "very challenging behaviour" at home which had increased now police were investigating the allegations of sexual abuse against her last caregiver.
Also in May the mother wrote to the Prime Minister expressing concern M had been abused while in care arranged by CYF. The Minister of Social Development, Paula Bennett, responded outlining assistance CYF had undertaken to supply.
On May 23, a public health nurse - the 14th agency - visited the home after receiving a referral from the school - the 15th agency - through the Home Care for Kids Service - the 16th agency. Concerned after talking to the mother, the nurse contacted CYF seeking support for the family. CYF did not respond and in June the school made a referral directly to Marinoto Child and Family Services - the 17th agency.
In July, Marinoto advised the school and CYF it had declined the school's referral. CYF arranged for M to be seen by Auckland Specialist Services - the 18th agency.
On August 9, after seeing M, the psychologist from Auckland Specialist Services recorded that M's behaviour, such as putting dish washing liquid into the baby's bottle, posed risks.
On August 30, M set fire to a mattress in the garage.
On September 2, the school advised CYF that M had a swollen face and had said she had had a fork stuck in her cheek. An emergency meeting was arranged at Marinoto. Marinoto found M was not suffering from psychosis or disassociation: "Her behaviours are directly related to the extreme trauma that she has suffered at the hands of her previous CYF-Whanau caregivers." Oversight of M at home was arranged through Senate Nursing - the 19th agency.
On September 9, she was seen by a public health nurse at school as her teacher was concerned about an infected foot. She was admitted to Waitakere Hospital's Rangatira Ward, the 20th agency - for an infected blister - which was not considered suspicious, then transferred to Starship - the 21st agency - for suspected cellulitis. She was operated on and discharged. On September 17 a nurse from Home Care For Kids - the 22nd agency - visited. CYF noted no issues were identified and M was discharged from the follow-up service.
On September 29 M was examined by a doctor for the alleged sexual abuse but nothing was found. The next day her mother took her to her local doctor - the 23rd agency - where the doctor felt some "coercion" by the mother.
In October M attended counselling sessions at Marinoto and on October 27 a professionals meeting found she no longer seemed to be in crisis. A further meeting was set for November 24.
On November 9, the mother told the counsellor M alleged the father had assaulted her. The counsellor asked the mother to bring M in; the mother did not. Marinoto had planned a school observation but was told M was absent with a stomach complaint. The observation was rescheduled for the November 11 but they were advised the mother had claimed M was at a tangi.
Also that day, the home was inspected by Housing NZ - the 24th agency - and as all the children were home the inspector notified the Improving School Attendance Programme - the 25th agency.
Between November 10 and 15, the mother inflicted severe violence on M. She told the police she was angry at M's behaviour and allegations against the father.
The violence included use of hands, fists, broom handle and a table leg. M's grandmother called the police on the November 15 and M was found in a wardrobe. The mother had written words on M's body which are blanked out in the report, but from court we know they included "skank" "incest" and "mental f***er."
