The former CEO of Women's Refuge wants sweeping changes to the way social agencies deal with cases of child abuse.
Merepeka Raukawa-Tait was one of six expert witnesses to give evidence on Tuesday, the last day of the inquest into the death of three-year-old Moko Rangitoheriri.
His caregivers Tania Shailer and David Haerewa abused and neglected the Taupo toddler for two months before his death in August 2015. The pair were jailed for 17 years for Moko's manslaughter.
Earlier during the inquest it was revealed that there were six different social agencies and ten different people involved with Moko's family around the time of his death.
It was heard that Shailer was struggling to care for her own children as well as Moko and his sister.
It's alleged she raised her concerns during a meeting with a Child, Youth and Family worker 11 days before his death - something the worker has denied.
It was also previously heard Māori Women's refuge worker Trina Marama was told by another child that Tania Shailer had pushed her - however Ms Marama and her colleagues decided this was purely disciplinary and not abuse.
While giving evidence today former Women's Refuge CEO Merepeka Raukawa-Tait ran off a list of 10 recommendations.
That included ensuring family support is available as soon as possible, more funding for preventative services, support and Māori providers for Māori families.
"We tend to deal with the aftermath, instead of saying what can we do prior," she says.
"I question whether we should be putting money at the front end, work with the families - unless we get in early nothing substantial will change."
She went on to say nothing much has changed in the 10 years since the fatal child abuse of Rotorua three-year-old Nia Glassie in 2007.
Ms Raukawa-Tait says there's also a need for specialised Māori services.
"Who the hell goes to a government department if we are honest? I suspect you can count on the hand the number of Māori families that'll do that. The Ministry for Vulnerable Children definitely comes after the event," she says.
Senior Bay of Plenty Detective Inspector Mark Loper also gave evidence this morning.
He told the inquest that in the eight years between the two toddlers' deaths that 94 children had fallen victim to fatal child abuse.
He said since Nia's death in 2007 significant changes had been made to the way that police dealt with child abuse cases.
That includes dedicated child protection team supervisors, extensive training for investigators and more detectives to investigate reports of child abuse.
"NZ Police recognise child abuse as a significant part of violence in the family home, and recognise the impact family violence has," he says.
"There has been a cultural shift that is more victim-focussed."
Children's Commissioner says red flags missed
Children's Commissioner Judge Andrew Becroft and child health specialist Dr Johan Morreau both spoke of the red flags that should have alerted authorities that Moko was an at-risk child.
Judge Becroft said these flags began at Starship Hospital when no help was given to Moko's mother to find suitable accommodation for him while a sibling was being treated there. He noted Moko had also been a Starship patient.
Red flags were also missed by the Ministry For Vulnerable Children - Oranga Tamariki and the Taupo Māori Women's Refuge to which Shailer had gone while Moko was in her care.
"The missing of these red flags indicated a need for collaborative intervention," Judge Becroft said.
"There were sufficient eyes and ears into Moko's circumstances and care at various stages, yet the eyes didn't see and the ears didn't hear, nor did they trigger proper investigations about his real condition and risks."
He said Moko's abhorrent death was preventable and clearly lessons should be learnt from it, adding an important part of training for those working with at-risk children should be to ensure collaboration between organisations.
He supported the coroner's call following the Nia Glassie inquest for a national register recording every child born in New Zealand, something that had been repeated by others over the years, yet failed to gain traction.
Questioned by Arama Ngapo-Lipscombe, the lawyer acting for Moko's mother Nicola Daly, the commissioner said it should be the government's responsibility to provide training for social workers at the front line, including those involved in non-governmental organisations.
"This isn't a job for well-meaning amateurs," he said.
Reserving his decision, the coroner gave lawyers until October 26 to provide written submissions.
NZN / Newshub.