Warning: This article contains descriptions of child injuries that may disturb some readers.
Bay of Plenty coroner Wallace Bain has delivered stinging criticism of New Zealand's child care system and called for far-reaching measures to reduce the mounting death toll among our young.
And ruling on the death of three-year-old Moko Rangitoheriri, he has called out Prime Minister Jacinda Ardern personally to take action.
Little Moko was battered to death by his caregivers in August 2015. Tania Shailer and David Haerewa are already 18 months into their 17-year prison terms for the hideous beating of the toddler.
That's the longest sentence ever issued in New Zealand for the manslaughter of a child, and the convicted have already lost an appeal to have it reduced.
By the time Moko died, he could barely walk. Shailer had stomped on his abdomen and stomach, and Haerewa had kicked him in the lower back.
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He had bite marks on his face and he was covered, head to toe, with bruises.
But Mr Bain has pointed an accusing finger at the system that let Moko down - a system that seemingly hasn't learnt from previous mistakes.
And he's challenged Ms Ardern, who also carries a ministerial role for child poverty, to fix it.
His main recommendation is "that all children, from birth, be compulsory registered with Government agencies and health providers and other voluntary organisations, and that they be compulsory monitored through to and including the age of five".
Mr Bain continues: "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."
This recommendation is not new. Word for word, it's the same one Mr Bain made after he investigated the death of three-year-old Rotorua girl Nia Glassie in very similar circumstances 10 years ago.
"Had that recommendation been in place and, for example, midwives and Plunket were empowered to check on children and enter homes and properly funded to do so, Nia Glassie and Moko would probably still be alive today," he says.
Reflecting on the Glassie case, Mr Bain used words like "horrendous" and "horrific", and hoped that no-one would ever have to endure that treatment again.
Yet, here we are, a decade on - this time, even worse.
"This court has had to go through this again, but the horrific circumstances surrounding Nia's death have been surpassed beyond belief with the violence perpetrated on Moko," he says.
"Whatever it takes, whatever it costs, we cannot allow this child abuse to continue."
As part of his summary, Mr Bain highlighted some of the statistics that illustrated New Zealand's poor record in child welfare, namely high suicide rates, child poverty, violence.
Since Nia Glassie died, 94 child homicides (aged under 14) have occurred, which means one every five weeks.
Most of those victims were under the age of five and 90 percent knew their killers.
On average, a child is admitted to hospital every second day with injuries resulting from assault, neglect or mistreatment - nearly half are aged under five.
Mr Bain supported the work of Children's Commissioner Judge Andrew Becroft in this field and expressed some hope that the new Labour-led Government, under Ms Ardern, had a clear plan to improve the system.
Ms Ardern assured Newshub that this case certainly had her Government's attention and determination to make the changes necessary.
"There's no doubt that the statistics are devastating, but in this particular case, we have an individual child and we have the story that led to their death, and it is hard not to be both moved and totally motivated that these children have a different life in Aotearoa," she said.
"They should have much better than they have now.
"I've read elements of this report and there are multiple points where this child was failed, many. There are recommendations in this report that we really need to consider - it is about action though, so it's about what we do next to make sure that we are supporting our social workers and ulitimately that we change the system."
Among Mr Bain's other recommendations were:
- That the Government and Ministry for Children, Oranga Tamariki work with Judge Becroft to create a registration and checking framework
- That the Government and Ministry work a significant culture change that addressed all the factors contributing to child abuse, particularly in Māori families
- That the Government and Children's Commissioner revamp the youth justice system to create a framework for dealing with cases of abuse, neglect or "risky circumstances"
He also ordered that the inquest findings be delivered to Ms Ardern, Social Development Minister Carmel Sepuloni, and her ministry, and Children's Minister Tracey Martin and her staff.
Using Ms Ardern's own election catchcry, Mr Bain insisted: "Let's do this.
"As a country, we must. This shameful abuse against our children has to stop."
His words seem to have found their mark.
"I think every New Zealander would hear a call to action after the Moko case," said Ardern. "People took to the streets.
"It's devasting and it's now up to us to do things differently.
"This is the Government that wants to find a solution to this, but we can't do it alone."