A coroner's inquest into the death of three-year-old Moko Rangitoheriri has heard his case was so horrific it made Nia Glassie's tragic death look like "kindergarten" in comparison.
Moko died on August 10, 2015 following weeks of abuse and neglect at the hands of carers Tania Shailer and David Haerewa. The pair was convicted of manslaughter and each sentenced to 17 years behind bars.
- Moko's mother speaks about his horrific death
- Opinion: Moko's death is murder by torture
- Moko's death raises debate over child abuse prevention
Now, a three-day hearing is underway in Rotorua, in an attempt to find ways other tragedies could be averted.
In 2011, Coroner Wallace Bain held the inquest into the brutal death of three-year-old Nia Glassie - a death which shocked the country at the time.
On Wednesday morning, during the opening session of Moko's inquest, he talked of Nia's suffering.
Nia died from brain injuries after being beaten and kicked, swung on a clothes line and put in a tumble dryer set to hot.
"We thought then, nothing could get as bad," he says.
"It seems what happened to her was kindergarten compared to [Moko]."
Over the course of several weeks, Moko was kicked, thrown, dropped, bitten and stomped on.
After Moko's final - and fatal - abuse, Shailer called an ambulance and said Moko had fallen from a wood pile. But when paramedics arrived, it was obvious the story didn't match Moko's injuries.
Moko died in hospital from injuries suffered during prolonged abuse and torture.
Warning signs not picked up on
Detective Inspector Lewis Warner, who has been in the New Zealand Police for 34 years, was put in charge of Operation Corsa - the investigation into Moko's death.
He testified at the inquest that Shailer had mental health problems and appeared to be in a very bad place around the time of Moko's death, sending multiple text messages to friends mentioning her depression.
Witnesses at the hearing said there were multiple social organisations involved with the family, and at least 10 individuals.
At the beginning of July, Moko's sister told Trina Marama - from the Māori Women's refuge - that Shailer was hitting Moko. But Shailer denied it.
Three weeks before Moko's death, Shailer attended a second counselling session with Family Works. She discussed her low tolerance levels and mental health issues. The counsellor was not aware she was caring for two extra children, Moko and his sister.
Five days before Moko's death, Shailer went to her third counselling session at Family Works. She said she was caring for two extra children. She told the counsellor she was struggling to cope, and said Moko had bruises from banging his head against a wall.
The counsellor says her face changed as she spoke of Moko - she would look stressed, angry or tense. However, she did not disclose harming him.
Ms Marama later changed her story to police and stated that she never confronted Shailer about it. No "report of concern" was ever completed by Ms Marama.
The inquest is being held in two parts, and eight witnesses are being called. The second part will take place later in the year.