Investigation: How social workers missed the 12 danger signs in the life and death of Isaiah Neil, who was left in a hot car while his carers smoked synthetic drugs
At just eight months old, Isaiah Neil was probably New Zealand's youngest victim of synthetic drug addiction.
Heat stroke was the official cause of his death, but it was synthetic drugs that turned his carers into "zombies", which killed him.
His mother and grandmother were so keen to smoke a $40 bag of black market "synnies" they left Isaiah to sleep in the car.
It was around 12.30pm on a sunny November day in Ruatoki, in the eastern Bay of Plenty.
They got stoned, then slept. Isaiah was strapped in his car seat, doors and windows closed.
The average temperature outside was 20C, but according to experts, would have climbed to 45C inside the car within an hour.
Three hours passed before Isaiah's father found him "limp, unresponsive and hot" but no one called 111.
He was put into a cot, his parents went back to sleep.
At 6.36pm - three hours later - an ambulance was finally called, but the paramedics arrived to find him dead.
His parents, Shane Neil and Lacey Te Whetu, as well as maternal grandmother Donna Parangi, were convicted of manslaughter.
"Any death of a very young child is tragic," said Justice Graham Lang in sentencing the trio.
"It is even more tragic when the death is completely needless and is caused by repeated failures by parents and those entrusted with his care."
Read more:
• Hot car death: The father of baby Isaiah Neil says home detention for manslaughter was too light
There is no doubt where the criminal culpability falls - in the home where Isaiah should have been safe.
But there were also repeated failures by Child Youth & Family when concerns were raised about the dysfunctional household.
Isaiah, or his older siblings, came to the attention of CYF 12 times in the three years before his death, according to interviews, court transcripts, police documents and social worker case notes obtained by the Weekend Herald.
There were 10 official "Reports of Concern" dating back to November 2012, three specifically concerning synthetic drugs, in the months before Isaiah was left in the car with fatal consequences.
Four complaints were laid by Shane Neil, Isaiah's father.
Currently serving 10 months' home detention after admitting the manslaughter charge, Neil isn't seeking sympathy, or to shift the blame for his son's death.
"I have to accept the responsibility of failing Isaiah," Neil told the Weekend Herald this week.
"If I was going to have any sort of peace, even just a little bit, I had to plead guilty."
But even so, the 31-year-old does feel his concerns about the Te Whetu household were brushed aside.
His relationship with Te Whetu was volatile, marred by fighting and domestic violence against each other.
Neil would move out whenever they split up and it was during these breaks he would call CYF.
The "reports of concern" are consistent: concerns about the children being exposed to violence in the house, as well as Te Whetu's escalating addiction to synthetic cannabis.
However, his behaviour did not bolster his credibility with social workers.
Evidence from court suggests Neil was not a supportive father, with Justice Lang saying he "played virtually no part in the upbringing of the children".
After the first complaint, Neil called back a week later to retract the allegations made "maliciously" because the couple had split up again.
He had been admitted to a psychiatric unit for care and was now feeling better, according to the case notes.
A year later, a second complaint was found to be unsubstantiated, when it emerged Neil had slapped Te Whetu.
He pleaded guilty to assault, which allowed Lacey to later obtain temporary protection and parenting orders from the Family Court against him.
This meant Neil was unable to have unsupervised access with the children, although the couple were still in an on-again, off-again relationship.
The children looked healthy, the house clean and tidy. Staff from kohanga reo and Plunket thought Te Whetu was a good mum.
Case closed.
"I advised I have no concerns for the children in the care of the mother," the social worker wrote on the file.
This pattern repeats across hundreds of pages of case notes.
Whenever they split up, Neil would ring CYF to report his concerns about the household - especially Te Whetu's drug habit.
Each time, Te Whetu - and her mother - would deny the allegations and turn the tables by telling the social workers about Neil's previous violence and mental health problems.
Neil was unable to shake the perception that he was the problem; that he was only calling CYF out of spite each time they broke up.
"The social worker wouldn't accept any of the information I passed on," Neil says.
"She said without evidence, it was just my word against Lacey's . . . but they weren't made up stories. They were true."
So he tried to get proof.
In May 2015, a few months after Isaiah was born, Neil used a cellphone to film the "bucket bong" Te Whetu used to smoke the synthetic drugs.
"I have notified CYF previously about the cannabis but they have done nothing about it," Neil said, according to the case file.
Te Whetu was spending hundreds of dollars on synthetic drugs, says Neil, instead of on food and rent.
When Te Whetu discovered the video, she went into a rage.
She punched, kicked and scratched Neil, as well as threatening him with a large knife, before damaging the windscreen wipers and side mirrors on his car.
When Neil reported the attack to the police, Te Whetu slashed his tyres in the car park in front of the station.
This time, the incident was referred to CYF by the police, as well as Neil.
Te Whetu said she was not coping with looking after the children, says Neil, and was frequently threatening to hurt herself.
"She makes me worry about the kids when she says these sorts of things," Neil told CYF.
It was the second time CYF had been told about Te Whetu's deteriorating state of mind. The previous year, social workers had visited the home after a phone call from Neil.
Te Whetu had locked herself in the bathroom and threatened to kill herself.
At the sentencing hearing Justice Lang said fragile mental health had affected Te Whetu for some time, and she had smoked synthetic cannabis daily to "escape from the pressures of your everyday world".
"It is clear that the consumption of drugs has had a huge effect on your life. Your family had in fact become concerned about your ability to care for the children," said Justice Lang, referring to the final report of concern.
In August 2015, just three months before Isaiah died, Kylie Te Whetu visited her family in Ruatoki.
She found her sister Lacey and mother Donna Parangi "stoned" unconscious and described them as "zombies", according to court documents released to the Weekend Herald.
"Mum was lying in the room and she was just lying there and she couldn't get up," Kylie Te Whetu told the court. "Lacey was in the other room, she couldn't get up either."
She took the two older children back home to Auckland, but Isaiah was left in the care of his mother.
About a month later, Te Whetu wanted her children back but Kylie Te Whetu didn't want to return them.
CYFS documents show the police called Kylie, who told the officer about Te Whetu's addiction to synthetic cannabis. Police reported the matter to social workers.
But she had no legal right to keep the children with her, so they went back to Ruatoki.
Three months later, Isaiah was dead.
In the days after his death, CYF - now called the Ministry for Vulnerable Children, Oranga Tamariki - reviewed its involvement with the family.
"Better practice on Child, Youth & Family's part may not have prevented Isaiah's death," said a spokeswoman, "but the social work practice could have been better."
The response has angered Neil's family, who also made two reports of concern.
"Our stance on that is 'What's the point of your organisation?'" says one relative, who asked for anonymity.
"Your job is to save kids, particularly those in imminent danger. And you didn't do your job. Sorry, that's not good enough."
The family is also frustrated that Oranga Tamariki has not released the full review into Isaiah's death to them.
"If they don't feel they're at fault, they could just tell us what we didn't do right. I'd love to know what more we could have done."
In one lengthy email to CYF in September 2013, a notification from the relative compared the unsafe home environment to one of New Zealand's worst cases of child abuse.
"The ineffective parenting or caregiving, the immaturity of the caregivers, drugs, alcohol and violence, turning a blind eye and creating a culture of silence . . . I am afraid these children will become another victim of our inability to act," she wrote.
"If they are not the next Nia Glassie, then they will be."
Neil was "no saint", say his family But they believe CYF focused on his faults and did not recognise Te Whetu's.
"Every time he called CYF, Lacey and Donna would turn it back around on him," a family member says. "And CYF took it at face value, they didn't dig into what Shane was actually saying. He became a convenient scapegoat.
"The social worker looked at each incident in isolation. Deal with it, next one, deal with it, next one.
"She didn't step back, string it all together and think: 'There's something seriously wrong with this situation'."
It's a criticism acknowledged in a bullet point summary of the CYF review of Isaiah's death, released to the Weekend Herald under the Official Information Act.
The social work practice could have been improved in the following areas:
*More robust information gathering to form an accurate picture of family dynamics and functioning in response to reports of concern.
*Better understanding of cumulative harm and assessing new information in the context of previous family history.
*Improved assessment of the parenting capacity in light of the issues raised.
As a result, the Ministry's office in Whakatane now has more comprehensive assessments, record keeping and supervision to make better decisions more quickly.
"My sympathies go out to all those who loved this little boy," said Tayelva Petley, the Bay of Plenty regional manager.
"His death was incredibly sad and traumatic, including for those who've been held to account."
She said the needs of vulnerable children was the central focus of the agency's ongoing transformation.
"Prevention and early intervention is now central to what the Ministry does," said Petley.
"We know that when we work with children and families at an earlier point, we can make a real difference."
She cautioned that the changes would not be an "instant solution", but would take four to five years to create a new care system "truly focused on our most vulnerable children and young people".
There are three parts of Oranga Tamariki, said Petley. The Ministry for Vulnerable Children, other government agencies like health and education, and the community.
"In many ways we are the smallest part. The community is the largest and everyone has a role to play."
However, the internal review by CYF might not be the final say on Isaiah's death.
The wider circumstances could be examined in detail at an inquest in front of Dr Wallace Bain, the Coroner for the Bay of Plenty.
Bain has previously held inquests for Nia Glassie and more recently Moko Rangitoheriri, a toddler beaten to death, to examine how the vulnerable children fell between the cracks.
A decision about a Coronial hearing for Isaiah will made after the criminal case is finished, said a spokesman for Bain.
This will be after the Court of Appeal has made a decision on Parangi's bid to have her conviction overturned.
Stopping another needless death is why Shane Neil agreed to speak publicly about his son's death for the first time.
It took him a long time to accept his guilt; now he feels guilty about serving home detention while Te Whetu and Parangi were sentenced to three years in prison.
As they knew Isaiah was in the car while they smoked synthetic drugs, Justice Lang ruled the mother and daughter were more culpable.
While Neil "failed miserably" by not calling 111 when he found Isaiah, Justice Lang said there was a "real issue" as to whether the baby could be saved at that time.
For that reason, the judge granted home detention.
"I feel lucky to not be in prison, I feel like it was a light sentence," says Neil.
"I do blame myself . . . I failed. The last two years have been like waking up from a bad dream every day. Except it's not a bad dream, it's reality."
24 November 2012:
Relative of Shane Neil calls CYF with concerns about Lacey Te Whetu. Told to call police if urgent, or call CYF back.
27 November 2012:
Report of Concern by Neil. Children being exposed to drugs and domestic violence. Later calls back to retract allegations. CASE CLOSED.
19 September 2013:
Report of Concern by Neil's sister. Long email about domestic violence, drugs and alcohol, poor parenting comparing family environment to Nia Glassie death. Social workers interview Te Whetu, Plunket nurse and midwife. CASE CLOSED.
18 December 2013.
Report of Concern by Neil. About Te Whetu's's discipline of children and use of synthetic cannabis. Social workers visit house and accept Te Whetu's explanations. Neil also charged with assault. CASE CLOSED.
19 December 2013:
Report of Concern by police. Relating to Neil's assault charge. He later pleaded guilty. CASE CLOSED
26 March 2014:
Report of Concern by police. Neil wanted to take daughter to Hamilton because of safety concerns about synthetic cannabis, Te Whetu wanted police to stop him. Police advise they could not intervene without parenting order. CASE CLOSED
27 March 2014:
Te Whetu obtains parenting and protection orders in Family Court against Neil on grounds of previous assault.
2 July 2014:
Report of Concern by relative of Neil. About children being exposed to violence and drug abuse. As there was no specific incidents raised, no further action. CASE CLOSED.
29 July 2014:
Report of Concern by Neil. Te Whetu had threatened to harm herself and alleged abandonment of children. CASE CLOSED.
26 May 2015:
Report of Concern by police. Te Whetu charged with wilful damage and common assault against Neil. Allegations of synthetic cannabis. CASE OPEN
4 July 2015:
Report of Concern by Neil. Same incident, repeats allegations about Te Whetu's synthetic cannabis use. CASE OPEN
31 August 2015:
Report of Concern by police. Kylie Te Whetu removes Isaiah's siblings from her sister because of synthetic cannabis. CASE OPEN.
2 November 2015:
Isaiah Neil dies after being left in a hot car.
Allegations - raised after former student’s suicide - relate to former Murupara teacher.