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WARNING: This story contains details of violence against young children, which some readers may find distressing.

Shortly before a 3-month-old was killed by her father, the baby girl’s mother had pleaded for help to keep herself and her children safe from the man.

Details of the couple’s chaotic and violent relationship have been revealed during an inquest into the death of the girl, held this week in Wellington.

“I have had enough,” the mother told police three months before the girl was killed by her father, whose name is suppressed.

Her father was subsequently convicted of her manslaughter and jailed for four years and five months.

At the inquest, being held in the Wellington District Court, Coroner Ian Telford has considered what, if any, changes could be made by police and Oranga Tamariki to prevent similar tragedies.

A section of his draft report released to ��һ�ǿ����� paints a dysfunctional picture of the couple’s relationship, leading up to baby Manuia’s* death in Wellington in November 2018.

The inquest heard the couple led a transient life, marred by alcohol, drugs, and unemployment.

The week before the girl’s death, the family had moved into a converted garage.

According to the police reports, the couple would argue at home, in their car, in their driveway, and at a transitional house the woman moved into.

Sometimes they’d hit each other, at other times he’d stomp around the house, taking his frustrations out on the walls or a window, causing a deep cut to his arm, which required surgery.

Coroner Ian Telford is hearing the inquest into the girl's death.

In the 18 months before Manuia’s death, police were called nine times; four of those occasions involved a child being used as an intermediary of abuse.

Yet the incidents weren’t escalated by police because many were arguments and weren’t deemed serious enough to warrant further intervention.

A cry for help from the man’s mother that her son had an anger management problem came to nothing.

There was talk of taking out a protection order, but the woman didn’t have a cellphone. A referral to a non-government organisation for help went nowhere, and letters from police and Oranga Tamariki sat in letterboxes because the family had already moved on.

Mother: I have had enough

On the occasions when a child was used as a weapon, three involved Manuia’s older sibling. These included the man holding the child in a bid to prevent the mother from leaving, or he’d refuse to hand her back to her mother. The fourth incident, in August 2018, involved Manuia.

During a violent altercation, the father damaged property, punched holes in the walls, yelled at and abused his partner.

At one point, he picked up Manuia, waking her from her sleep. The mother grabbed her and took refuge in the bathroom, locking the door and calling the police.

Before police arrived, he’d smashed his way into the bathroom, assaulting his partner as she held Manuia before fleeing.

The woman’s statement to police concluded by saying: “I want to keep myself and my children safe. This has all happened so many times before, but this is the very first time I have called the police. I have had enough.”

Months later, Manuia died.

Agencies respond to baby’s death

Fast forward to the present, in a windowless courtroom, two days have been spent discussing the impact of violence on young babies, to an almost granular analysis of agencies’ policies and practices, much of which was acronym-heavy.

The hearing revealed inconsistencies at both a national and district level, and services that are stretched and under-resourced.

“I’m still not entirely clear that if you had another Manuia – and there are lots of baby Manuias out there, anecdotally – everyone’s nodding so that’s good – that these kinds of patterns would be picked up in a room full of people who know what they are doing,” Coroner Telford told the hearing.

An inspector reassured the coroner that there were processes and safeguards in place.

“Is it perfect? No, it’s not, but we are working towards that space.”

The inquest heard that in the intervening years since Manuia’s death, police have gained a much greater understanding of coercive control.

Incidents like what police encountered back in 2018 would now trigger a much stronger multi-agency response and more discussion between family violence staff.

There were also moves afoot to align the four areas, Wairarapa, Kāpiti Mana, Hutt Valley, and Wellington City, which currently run two different systems for reporting family violence.

An updated child protection protocol has also been prepared, but has yet to be signed.

For the first time, it included Health New Zealand, with police and Oranga Tamariki, and gave special consideration to non-verbal tamariki aged 3 and under.

But perhaps most staggering was the sheer number of family violence callouts.

In the past 12 months, police in the Wellington district alone attended 24,136 cases of reported family harm occurrences – about 66 cases a day.

Yet, as the inquest heard, police were called to fewer than half of the domestic violence incidents to have actually occurred, either because they were not reported or were reported to another agency, which don’t regularly report them.

Kiri Alexander, Oranga Tamariki’s director of programmes, spoke of several significant changes at the agency since 2018.

Some took immediate effect, others would take longer to implement, she explained.

The inquest heard the agency’s involvement with Manuia’s family began after police informed the agency they’d attended four family harm incidents in the past 12 months.

Two months later, social workers attempted to visit the family at home, only to be told they’d moved.

A month later, the agency sent a letter to the parents, expressing its concern and explaining the impact of family harm on young children. It referred them to an NGO, before the file was closed.

Alexander defended the decision to involve the NGO, but said there should have been a joint visit to the family.

She agreed the agency should have made greater efforts to find where the family had moved to, and since 2018, it had changed its approach from a transactional one to a conversational approach with families.

While she couldn’t say with certainty that such a response wouldn’t be repeated, there were now more checks and oversight by supervisors.

The hearing ended with the coroner promising to release his findings as soon as possible.

*Manuia is not the baby’s real name. It is a pseudonym given to her by the coroner.

FAMILY VIOLENCE

How to get help:
If you're in danger now:
• Phone the police on 111 or ask neighbours or friends to ring for you.
• Run outside and head for where there are other people. Scream for help so 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:
• : Crisis line - 0800 REFUGE or 0800 733 843 (available 24/7)
• : Helpline - 0508 744 633 (available 24/7)
• : Family violence information line - 0800 456 450
• : Specialist services for African, Asian and Middle Eastern women and children.
• Crisis line - 0800 742 584 (available 24/7)
• : For information on family violence
• : National Network of Family Violence Services
• : Aiming to eliminate men's violence towards women.
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Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.