A Coroner has criticised a disability service for not urgently addressing a mother's safety fears for her autistic, non-verbal son who was later found dead in a pond at his home in rural Gisborne.
Five-year-old Khyzah Tawhai Raukaponga DeLaCroix went missing from his home at Mangawehi Station in the Hangaroa district of Gisborne on August 11 last year.
It sparked a huge search involving hundreds of local people, specialist search teams, rescue dogs and a helicopter.
Coroner Meenal Duggal found that Khyzah's death was accidental, and that he died by drowning in a large pond about 180 metres from his house.
She said a meeting Khyzah's mother had with disability service Your Way Kia Roha, in which she asked for safety locks on windows and doors, should have sparked immediate action.
The search
Khyzah had been diagnosed with autism and was non-verbal. He had developmental delays and did not have a "typical sense" of danger, safety or pain, Coroner Duggal said.
The boy had been referred to Your Way Kia Roha by his paediatrician, a service contracted by the Ministry of Social Development's Disability Support Services.
"Khyzah liked to leave the house to explore and was particularly attracted to water as well as a shed where he liked to play among items stored there. On several previous occasions, he had made his way to the main road," Coroner Duggal said.
He had been home watching a movie at 2pm on August 11 while his mother was showering and she heard the door out from the laundry opening. His mother left shortly after Khyzah, estimating she was about one minute behind him.
Police were called at 4pm and a Land Search and Rescue operation started about 5.30pm. By this time, Khyzah's father and his employer had searched a 400-metre radius of the house including the water holes, the coroner's report said.
The search continued into the night and resumed again the next morning. The national dive squad found Khyzah's body in the pond covered in green algae about 3.40pm.
Coroner Duggal's report said there were several routes from the house to the pond which were "easily accessible" for a 5-year-old who was good at climbing.
'Mother's safety concerns required urgent action'
The Coroner said Khyzah's mother had met with Your Way Kia Roha in June and expressed concerns about his safety, saying that he could run off and asking for locks on windows and doors.
The mother was told to speak to a neurodevelopmental therapist to ask for a safety assessment for the home.
"It is concerning that Ms DeLaCroix's concerns about Khyzah's ability to get out of the house were not proactively addressed. This raised immediate safety concerns which in my view required urgent action", Coroner Duggal said.
She said it was a "reccurring" theme from families with health and disability issues that services were not joined up, and they often needed to repeat concerns to multiple agencies or providers.
While the Coroner accepted the disability service was not directly able to provide safety assessments, it was part of Your Way Kia Roha's agreement with the Ministry of Social Development that "immediate safety concerns were to be proactively addressed with urgency".
She said given Khyzah's mother lived rurally, and she was trying to look after a child needing full-time daily help, as well as two other small children, any safety concerns she raised should have been "actively addressed".
In her report, Coroner Duggal said Your Way Kia Roha accepted the response to safety concerns was not sufficiently prompt but said it was not due to systemic issues or a lack of training.
It said it had taken measures to strengthen compliance including drafting a formal risk matrix for urgent actions, and undertaking enhanced training.
The Coroner said she endorsed the steps Your Way Kia Roha had taken.
In a statement, Your Way Kia Roha CEO Megan Thomas said the loss of a child was an unimaginable tragedy and their thoughts and condolences were with Khyzah's whānau.
Thomas said the Coroner's findings acknowledged the organisation's position that it had robust systems and processes in place to identify and respond to risks, and had endorsed, as part of the recommendations, steps taken to strengthen safeguards and training.
"However, in this circumstance, we recognise that a more proactive approach - particularly involving Child Development Services to assess the home environment - could have provided additional support.
"We remain committed to learning from this experience and to continually improving our processes, so that families receive the most responsive and coordinated care possible."
