Wellington inquest reopens scrutiny of agency responses after tragedy
The Wellington inquest into the death of baby Manuia is progressing this week, with coroner Ian Telford weighing whether reforms are needed in how authorities share information and respond to family violence and child safety concerns. Manuia’s death has prompted a critical review of how multiple agencies coordinate, and whether current systems safeguard vulnerable children who move through districts or are at risk from domestic violence.
The sequence of events and the legal backdrop
Manuia’s last days were marked by a medical visit for reflux, followed by a troubling turn when the baby’s mother tried to check on her daughter while the father barred access to the sleepout. That evening, Manuia was brought into the house unresponsive; paramedics could not restore her. A post-mortem showed cardio-respiratory failure linked to traumatic brain injury, with multiple rib fractures. While the injury’s timing was linked to the afternoon of the death, the methods by which it was inflicted remain unclear. The father was later jailed for manslaughter, alongside several related assaults.
The coroner’s reopened inquiry and expert input
With criminal proceedings concluded, Coroner Telford reopened the inquiry and requested reports from relevant agencies. Two experts, Senior Sergeant Sharon Price and social worker Jonelle McNeill, reviewed agency responses to determine sufficiency. The hearings have since evaluated whether the agencies’ actions aligned with best practices, and draft findings have been prepared for consideration in court.
What the inquest is assessing
At the Wellington District Court hearing, the focus is on refining expert-witness recommendations, measuring the implementation of reforms, and identifying lessons to prevent future deaths. Since Manuia’s passing, laws enabling information sharing among agencies have formalised some practices, though experiences have varied in effectiveness. The inquest is examining how these changes function in practice and whether further adjustments are needed.
Eyes Wide Open and information-sharing frameworks
One notable change discussed is the Eyes Wide Open program introduced in 2018 to understand the wider dynamics of family harm. Inspector Allies Edge noted a shift in policing towards digital systems, moving away from paper-based processes. A central topic is the Family Safety Systems (FSS) — a shared database where police, Oranga Tamariki, Corrections, and Women’s Refuge can upload, collate, and access family-violence data. The system currently operates only in two of Wellington district’s four areas, prompting questions about consistency and reach when families move across districts.
Models and the path to a unified approach
The inquest heard about two distinct models in Wellington: Whāngaia Ngā Pā Harakeke and the Family Violence Interagency Response (FVIARS). The district aims to merge these into a single, district-wide FSS with a multi-agency operating model that supports information sharing beyond local boundaries. While Inspector Edge could not provide a timeline, the goal is a seamless response for families who frequently relocate within the district.
Concerns and interim measures
McNeill highlighted concerns about unborn children and suggested provisional measures while broader reforms continue. There are also ongoing efforts to extend early intervention and information sharing between police and the Ministry of Education to at-risk children, with pilots already in 99 schools and plans to broaden into early childhood services. Police representatives acknowledged resource constraints and the need to define clear core roles, asking whether the police should be the primary owner of a multi-agency response.
What comes next
As the inquest progresses, counsel will consider whether existing reforms are sufficient and how they can be improved. The coroner underscored that ensuring high-quality recruit training, reliable reporting by family-harm supervisors, and robust information-sharing across agencies are all part of a multi-layer approach, not a single intervention. The rest of the week will continue to unpack these threads and determine actionable lessons for preventing similar tragedies.
Note: Manuia is a pseudonym; the baby’s real name is withheld to protect privacy.
