Leith Hutchison was just 15 months old when his father Dane Blake became frustrated at his crying and shook him until he lost consciousness in April 2015.
Blake pleaded guilty to manslaughter in 2017.
But Coroner Louella Dunn is this week holding an inquest into the child's death in a bid to see if more could have been done by authorities, including police and Oranga Tamariki, to keep him safe.
The inquest heard that a month before he died Leith was injured during a visit with his father.
Despite that, Blake was later allowed further unsupervised access with the little boy.
The inquest heard today from a police officer that "supervised access clearly should have remained until it had been demonstrated that Dane had the ability to parent safely and well".
The officer said in the lead-up to Leith's death his mother's life "took a real downward turn" and it was "clear" Leith needed more safety and support.
"There were signs within the whanau and within friends that things were happening to Leith," the officer said.
"If there had been a putting some safety around Leith through that period of time potentially we could have had a better outcome."
The officer said that safety should have by way of "independent support" that may have picked what was going on in the child's life.
There was also a lack of information sharing between agencies, including police and Oranga Tamariki.
Coroner Dunn asked the officer:
"If it was to happen again today, this month, this year, would things happen differently in Greymouth?"
The officer replied: "I think we still have a long way to go … It comes down to experienced resourcing and support
"It all comes down to communication. Everything here has been about information that was communicated or not communicated and having the right people together at the right times."
The Coroner will also hear evidence about "steps decided on to ensure Leith's safety" after the March incident to his death including specific safety plans and "whether they were adequate and appropriate".
And she would look to determine the role of each agency involved with the toddler before his death and what could be done to prevent other children from dying in similar circumstances.
The inquest also heard from a relative of Blake's today about what she saw before the child died.
She recalled seeing Blake give "Leigh a smack in the face, an open hand to the cheek" when he would not eat his breakfast.
"It was pretty hard ... it was pretty hard," she said, breaking down in tears.
She claimed she was told by family members not to mention the incident to police during the homicide investigation after Leith died.
The inquest is set to continue this week.
The Greymouth Star previously reported that Blake only found out Leith was his son just before he turned 1.
He'd had a casual encounter with Leith's mother Kate Hutchison and the pair were never in a relationship.
When Hutchison found out Leith was Blake's son she wanted them to have a relationship.
She said she believed she was doing the right thing by letting them get to know each other.
"Any child deserves to have a mother and a father, and I let Leith be with his dad," she said.
Recalling that fateful night when she had left Leith in Blake's care, she said she was woken by the police and told her boy "wasn't well".
"He could have come around and woken me up," she said.
"He could have said, 'I can't get Leith settled.'"
Hutchison said she would always blame herself.
"I loved my baby boy as much as I possibly could have, and I didn't save him."
Despite counselling, she struggles to talk about what happened.
"I wish I could turn back the clock and I wish Leith was still here."
It comes just days after a scathing report by the Chief Ombudsman into the murder of 5-year-old Tauranga boy Malachi Subecz in November 2021.
Over a number of months, Malachi suffered repeated beatings at the hands of his carer Michaela Barriball, including being held under bathwater, burnt in a shower and twice thrown against a wall by his hair.
Staff at the daycare centre Malachi attended photographed multiple injuries and questioned Barriball, but did not alert authorities to the suspected abuse occurring at home.
The daycare failed to alert police or Oranga Tamariki of the suspected abuse, and photographs of the abuse weren't discovered by police until after his death.
Several of Malachi's relatives tried to report suspected abuse, but effectively no action was taken.
After an investigation Chief Ombudsman Peter Boshier last week said Oranga Tamariki failed to take the "bare minimum" action over safety concerns about Malachi.
"Oranga Tamariki's own law and policy puts the wellbeing of a child at the centre of decision-making that affects that child," Boshier said this morning in releasing his report.
"Malachi's wider whānau raised concerns about his welfare at the hands of his carer.
"I can only describe Oranga Tamariki's response as a litany of failures," Boshier said.
Malachi's cousin and uncle, who prompted the Chief Ombudsman's investigation with a complaint, said Boshier's opinion validated concerns they had about the way Oranga Tamariki mismanaged their complaints.
"It is bittersweet that the Ombudsman has found what we knew to be true," Malachi's cousin said.
The pair were firm in their view that "there is no doubt Malachi would still be alive if Oranga Tamariki had acted appropriately".
Child abuse - how you can help
If you are worried about a child or have information about any young person being abused, please contact the police.
Information can be passed on to your local police - click here for a list of stations and contact details - or anonymously through the Crimestoppers reporting line on 0800 555 111.
If you're worried about a child you are urged to contact Oranga Tamariki immediately on 0508 326 459; or email contact@mvcot.govt.nz.
If the child or young person is in immediate danger, call police on 111.
-By Anna Leask
