Babies Chris and Cru Kahui died of head injuries at Starship Hospital in 2006. Two years later, in the High Court at Auckland, Mr Kahui was acquitted of their murders. The inquest held into the death of the twins finished in June last year. Citing Victor Hugo's Les Miserables and the Victorian author Charles Dickens, Mr Evans said child abuse was a "centuries-old" problem.
He said there was no single strategy to solve the complex issues involved.
Mr Evans heard from child protection experts at the inquest that sat over 20 days at the Auckland District Court.
One of those was paediatrician and the clinical director of the child abuse centre at Starship Hospital, Dr Patrick Kelly. He told the inquest there were systemic weaknesses in information gathering.
He said health and education authorities should have a statutory responsibility for the safety of children. Those working in the health sector should form the "front line" because few children are known to CYF at the time their abuse is first recognised, he said.
"In contrast all children born in New Zealand are known to a health practitioner."
In his finding, Mr Evans said even with the best care, some cases could not be prevented. But he said that was not the case with the Kahui twins.
"The lethal abuse that occurred in this case could have been anticipated and protective steps taken, had the existence of the earlier injuries been known."
However, CYF was only alerted to the case once the twins were admitted to hospital with fatal injuries on June 13, 2006.
"The fact that the twins were being nurtured in an unsafe environment and were at risk of further injury also remained unknown to authorities," Mr Evans said.
New Zealand has the highest rate of deaths from accidents or injuries in children under 19 years. The rate of maltreatment of children under 15 is the fifth highest among the 26 OECD countries.
There were 124,291 "care and protection notifications" to CYF during the 2009/10 year.
