A coroner investigating the horrific death of three-year-old Moko Rangitoheriri has repeated a call for all children to be compulsorily monitored by government agencies until the age of five.
Moko died in 2012 after spending two months with Tania Shailer and David Haerewa in Taupo.
His mother Nicola Dally-Paki was caring for Moko's brother at Starship hospital when Moko was killed.
His injuries included lacerations and haemorrhage deep within his abdomen which caused his bowel to rupture.
Faecal matter leaked into his abdomen, causing septic shock.
In findings released today Coroner Wallace Bain repeated a finding from another infant’s death – that of Nia Glassie who died in 2008.
He recommended all children should be registered with government agencies and health providers to allow monitoring to occur.
"That monitoring to include scheduled and unscheduled visits to the homes where young children are living so that the monitoring will ensure that they are kept safe and then provided with the necessities of life," he said.
"That has to apply with even more force today."
Had the recommendation been in place for Nia or Moko there would’ve been a better chance of Moko’s situation being identified and removed, Coroner Bain found.
If social organisations had monitored they would’ve found Shailer "in distress with depression and mental issues and assaulting Moko, another caregiver recently released from jail with a history of domestic violence…."
He noted a number of "red flags" including the old Child Youth and Family not visiting the toddler.
In a statement a spokeswoman Glynis Sandland for the new ministry for Vulnerable Children Oranga Tamariki said compulsory monitoring "suggests a multi-agency approach is required and that is something for the government to consider."