Overview of the inquest into Baby Manuia’s death
A Wellington inquest is examining whether systemic changes are needed after the death of a baby known as Manuia. The coroner reopened the inquiry after criminal proceedings concluded, asking police, Oranga Tamariki, and other agencies to report on their involvement and response. The aim is to determine if current practices adequately protect children and to identify lessons to prevent similar tragedies.
What happened to Manuia?
The events unfolded when Manuia, who had been crying throughout a day, was taken to hospital the evening before her death and diagnosed with reflux. She was sent home with a prescription. The next day, her mother repeatedly attempted to check on her daughter, but the father would not allow entry to the sleepout. That evening, the father brought Manuia into the house, unresponsive. Paramedics arrived but could not revive her. A post-mortem showed cardio-respiratory failure secondary to traumatic brain injury, with multiple rib fractures of varying ages—injuries believed to have occurred on the day of her death. The father was later jailed for five years and four months for manslaughter and additional charges of assaulting his partner and a child.
The inquest process and its focus
With criminal proceedings completed, the coroner launched a fresh inquest to assess how agencies responded to warnings and concerning patterns in the family. Senior Sergeant Sharon Price and social worker Jonelle McNeill reviewed agency reports to determine whether responses were satisfactory. Coroner Ian Telford prepared draft findings, which are now subject to debate in a Wellington District Court hearing with representations from police and Oranga Tamariki.
Key questions for the hearing
- Should recommendations from expert witnesses be refined or expanded?
- How effectively are those recommendations being implemented?
- What lessons can improve future responses to similar family harm cases?
Reforms and changes since Manuia’s death
Since the tragedy, New Zealand has enacted changes intended to improve information sharing among agencies. The Family Violence Act enables cross-agency information sharing, though implementation has varied. In addition, a 2018 program called Eyes Wide Open was introduced to understand family harm dynamics and underlying risk factors. Inspector Allies Edge described how the police shifted from a paper-based system to technology-driven processes around the same period of reform.
Family Safety Systems and interagency collaboration
A central topic at the inquest is the Family Safety Systems (FSS), a shared database for police, Oranga Tamariki, Corrections, and Women’s Refuge to upload and access information about family violence calls. The aim is to create a unified, multi-agency response. However, FSS currently operates in only two of Wellington’s four areas, and there are two different models in use—Whāngaia Ngā Pā Harakeke and the Family Violence Interagency Response (FVIARS). The district seeks to implement a single FSS and a coordinated operating model that spans the wider district, but a timeframe for this rollout has not been established.
Interim measures and concerns for unborn children
While changes are welcomed, experts warn of potential gaps affecting unborn children and at-risk families. McNeill suggested interim measures to bridge those gaps, emphasizing the need for rapid, proactive information sharing and early intervention in schools and early childhood settings. A related programme linking police and the Ministry of Education has expanded to 99 schools and aims to extend into early childhood services.
Resource constraints and role clarity
During the hearing, concerns were raised about underreporting of domestic violence and the appropriate agency leading a multi-agency response. Inspector Natasha Allan noted the police cannot shoulder every responsibility with finite resources, stressing the need for clear roles and efficient collaboration. The inquest underscored that improving outcomes requires a multi-layer approach: better training for recruits, stronger family harm supervision, and robust information flows across agencies.
What comes next
The inquest will continue through the week, with findings and potential recommendations refined to address identified systemic weaknesses. While Manuia’s name is a pseudonym, the inquiry seeks concrete steps to prevent similar deaths by strengthening information sharing, standardizing reporting mechanisms, and fostering a truly multi-agency response across districts.
As the process unfolds, stakeholders hope the lessons learned will translate into safer families and fewer preventable tragedies.
