The Coroner who investigated the death of Moko Rangitoheriri says all children should be registered from birth and monitored until the age of 5.

The compulsory monitoring of children, by midwives or Plunket, was the number one recommendation of Coroner Wallace Bain in his findings into the 2015 death of Moko.

The three-year-old was subjected to horrific abuse at the hands of his carers, Tania Shailer and David Haerewa, who were jailed for 17 years after admitting his manslaughter.

Compulsory checks on children was the same recommendation Bain made following the inquest of Nia Glassie, who also died at the hands of her carers in 2007.

"Had that recommendation been in place, and for example midwives and Plunket were empowered to check on children and enter homes (subject to safety considerations) and properly funded to do so, Nia Glassie and Moko would probably still be alive today," Bain wrote.

"The Court asks one simple question. If there is no record of the existence of a child under 5, then how can all children under 5 be properly checked to be safe in their environment?"

There have been 94 children killed between 2007 and 2015 and Coroner Bain urged the Government to focus on the issue by sending his report to Prime Minister Jacinda Ardern and the Minister for Children, Tracey Martin.

The Ministry for Children is undergoing a five-year transformation and Bain echoed the comments of the Children's Commissioner, Judge Andrew Becroft, who gave evidence at the inquest.

Coroner Dr Wallace Bain says compulsory checks on children under 5 might have saved Moko. (Photo / Getty Images)

"We have a once-in-a-lifetime opportunity in Aotearoa New Zealand to build a world-leading care and protection ... we will never get this chance again.

"As a country, we must. This shameful abuse against our children has to stop."

Judge Andrew Becroft, the Children's Commissioner, gives evidence at Moko's inquest. (Photo / Alan Gibson)

Bain's findings also pinpoints specific failings by government departments, individuals and social welfare agencies which missed numerous "red flags" in the care of Moko and his siblings.

A "red flag" was described by the Coroner as opportunity to intervene which might have saved Moko.

These included "Reports of Concern" social workers from Starship Hospital made to Child Youth and Family (now the Ministry for Children) but these were not reported to police, or investigated.

Moko's brother was in Starship Hospital with an infected leg and their mother, Nicola Dally-Paki, had nowhere for Moko or his sister to live.

She was escaping from a violent relationship and was sneaking her children in the hospital at night so they had somewhere safe to sleep.

"It was not hard for the Court to conclude that with the lack of support, whanau difficulties and financial resources the mother, Dally-Paki, really had an inability to provide a safe and stable environment for her children," wrote Bain.

"That is a clear red flag from the time that they were at Starship before they were placed with the caregivers and moved to Taupo. It was missed, yet there to be seen."

Nicola Dally-Paki, mother of Moko Rangitoheriri, gives evidence at the inquest. (Photo / Alan Gibson)

It was this lack of accommodation which led Dally-Paki to turn to her friend Tania Shailer, who lived in Taupo, for help. Two months later, Moko was dead.

It's a decision Dally-Paki regrets every day.

"I accept that I, as a victim of domestic violence, made mistakes, my children and I live with those mistakes every day," Dally-Paki told the inquest.

"Perhaps if I had been judged less harshly, Moko would be in my arms today."

Other "red flags" were missed in Taupo, including reports of concern from a kindergarten teacher and a request for "urgent attention" for Shailer because of her depression.

Shailer was struggling to cope with her own four children - aged 7, 5, 4 and 2 - before taking in Moko and his sister.

She cancelled counselling sessions, another red flag, with Family Start counsellors who were also unaware Moko was living with her.

A Taupo GP also referred Shailer to a psychiatrist who identified borderline personality disorder, self-harm tendencies, mood swings and sleep deprivation.

Shailer was also getting help from a Family Start programme from Rural Education Activities Programme (REAP). Two workers visited her home 10 days before Moko's death but did not see him.

"Again another red flag," wrote Bain. "They should have asked to see him because Shailer was again stating she was struggling to cope with his behaviour."

While the Maori Women's Refuge and CYF should have been providing services, Bain wrote neither knew that Haerewa, who had a criminal history of family violence, was living in the house.

"Again, a red flag. It highlighted that no one is visiting the house to actually see the children and that should have been patently clear from the reports of concern at Starship Hospital and all the other matters mentioned."

Finally, there was another "Report of Concern" filed on 30 July 2015 - ironically by Shailer who was concerned about the children going back into Dally-Paki's care.

Under CYF policy, Moko and his sister should have been seen by CYF staff.

"That did not happen. It is clear from the evidence, and the post mortem report, that Moko could have been saved if he had been visited at the house within seven days," wrote Bain.

"It was accepted that this should have happened."

Arama Ngapo-Lipscombe, the lawyer representing Nicola Dally-Paki, said findings of the Coroner highlighted the incompetence of CYF, including senior staff, in ignoring departmental policy.

"I would expect as a result of the Coroners findings and the clear incompetence of the Ministry that they will be issuing an apology to Ms Dally-Paki."

Despite the numerous red flags, Bain said it was a major concern that Moko was not visited by any organisation.

If Moko had been seen - and given medical treatment - even several hours before his death, Bain said the pathologist report was clear the toddler could have been saved.

If there were compulsory checks on children until they reached 5, when they attend school, Bain said there would have been a better chance of his survival.

In a statement released to media, the Ministry for Children made no mention of the "red flags" that were missed.

The recommendation of compulsory monitoring would need to be a multi-agency approach and something for the Government to consider.

"We feel deep sympathy for everyone who loved this little boy. The particular circumstances affected everyone. The tragedy was Moko died after repeated abuse and throughout this no one heard his voice."

A spokesman for the Prime Minister referred the Herald to the office of the Minister for Children, Tracey Martin.

At the time of publication, she was yet to respond.

If you're in danger now:

• Phone the police on 111 or ask neighbours of friends to ring for you.
• Run outside and head for where there are other people.
• Scream for help so that your neighbours can hear you.
• Take the children with you.
• Don't stop to get anything else.
• If you are being abused, remember it's not your fault. Violence is never okay

Where to go for help or more information:

• Women's Refuge: Free national crisis line operates 24/7 - 0800 refuge or 0800 733 843
• Shine, free national helpline 9am- 11pm every day - 0508 744 633 
• It's Not Ok: Information line 0800 456 450 
• Shakti: Providing specialist cultural services for African, Asian and middle eastern women and their children. Crisis line 24/7 0800 742 584
• Ministry of Justice 
• National Network of Stopping Violence
• White Ribbon: Aiming to eliminate men's violence towards women, focusing this year on sexual violence and the issue of consent.

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