The story of James Whakaruru, who was beaten to death by his stepfather, will be told at an international child abuse conference in South Africa next week.
Four-year-old James died in April last year, in Hawkes Bay, after being pummelled by his stepfather, Benny Haerewa.
Commissioner for Children advocate Trish Grant will tell the annual international child abuse conference, in Durban, how New Zealand's system failed James.
Ms Grant said it was a dire warning of how child abuse could be hard to detect if state agencies failed to communicate. The international message was that the onus was on governments to provide care and protection for children.
In James' case, many indicators were never put together, she said. "It's that picture of risk, that whole jigsaw puzzle put together."
James died after one or more assaults from Haerewa, who had already been convicted of assaulting the boy.
The report found agencies worked without reference to each other, and ended their involvement assuming other parts of the system would protect James.
His mother, Te Rangi Whakaruru, had attempted suicide 10 days before his birth, when she was aged 15, but her midwife did not tell Plunket. After nine unsuccessful attempts to make contact, Plunket gave up without advising the listed GP or anyone else.
James was admitted to hospital several times before Haerewa was arrested and convicted, but released on bail. Police did not tell Child, Youth and Family Services that Haerewa was associating with the family in breach of bail conditions.
CYFS failed to investigate the case or refer James for a family group conference.
Later, after James was taken to hospital with further injuries, doctors did not check his medical records, or alert CYFS. Probation officers did not check on Haerewa after his release, even though he failed to report regularly.
James died shortly after being taken to hospital with severe internal injuries.
- NZPA
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