In his findings on the death of toddler Nia Glassie, the Rotorua coroner, Wallace Bain, does not hide his sense of shock. "In my 19 years of conducting inquests ... I have never had to endure such horrendous evidence which led to the death of this little girl in horrific circumstances," he says.
It is, therefore, hardly surprising that he recommends strong medicine to tackle the country's appalling child abuse problem. Some of this can be criticised because of the extent of state intrusion into the lives of families. Yet it is difficult to dismiss out of hand, if only because of the scope of the problem in areas such as Rotorua.
Perhaps the saddest aspect of the Nia Glassie case is that her plight never came to the attention of the police or Child, Youth and Family. Dr Bain suggests checks to remedy this. He wants all children to be registered compulsorily with government agencies, health providers and other voluntary agencies at birth, and to be monitored compulsorily until they reach 5.
This would include spot checks of their homes. The state, the coroner says, should also have the power to override the decisions of parents who want to opt out of services.
On the latter point, Dr Bain is undoubtedly right. The interests of the child must always be uppermost. The extent of the state intrusion that he prescribes does, however, raise a set of problems.