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Police, child protection personnel and medical authorities did not share information and identified the risks in the case of the boy beaten in such a way that he suffered injuries similar to a car accident, according to an investigation.
Five-year-old Leon Jayet-Cole died in Christchurch Hospital on May 28, 2015 from serious head injuries deliberately inflicted while at home under the exclusive care of his mother’s boyfriend, James Roberts.
Roberts was eventually charged with Leon’s murder, but died before he could face trial.
In a conviction, Coroner Brigitte Windley found that medical, police and child protection personnel were not performing their jobs competently and thoroughly.
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Windley said the systems within and between the agencies responsible for protecting León were “largely adequate” but not used properly.
The agencies – CYFS, Police, Canterbury District Board of Health – had focused only on the most recent incident that resulted in injuries, with little evidence of anyone looking at the cumulative risk, despite the “enormous resources” that CYFS dedicated to Leon and his family.
The risks to León and other members of his household that go unnoticed are the result of a lack of open-minded and critical thinking and a significant degree of gullibility and naivety, especially on the part of social workers, he said.
Injuries to the children in Leon’s household – major bruising to the head, severely cut tongue, broken foot, black eyes – began to pile up once Roberts began living with Leon’s mother, Emma Jayet, in 2012.
The injuries occurred when he was alone with the children.
Windley said Leon’s mother likely suspected Roberts inflicted the fatal injuries on Leon on May 27, 2015, but tried to provide police and medical personnel with an account that would exonerate him.
“It’s hard to escape the conclusion that Emma knew or suspected that James had been harming the children and that she covered up for him from time to time.”
The investigation, conducted last year, heard that Leon’s head injuries were only seen in traffic accidents.
Windley said overwhelming evidence supported that the injuries were consistent with contact with recently broken plasterboard in the hallway of Leon’s home.
Iain McGregor / Stuff
Coroner Brigette Windley presented a conviction to authorities that should have protected Leon.
In findings released Friday, he said Leon’s lack of protection was due in the first place to the three agencies collecting and recording relevant information on the risk of violence “in a way that was, to say the least, suboptimal.”
“Second, the inter-institutional exchange of relevant information was manifestly inadequate and incompatible with the operational principles of information exchange and, consequently, did not provide any body with a complete picture.
“Along the same lines, the agencies never conducted an effective joint assessment of the general risk of violence revealed by the information they had.”
Incidents were predominantly dealt with by each agency on a transactional, incident-by-incident basis, as each one emerged without thinking about whether a troubling pattern was emerging, he said.
“… rather, the risk of violence in this case went unnoticed until León was assassinated.
“To be frank, the people who applied the relevant policies, in the three agencies, did not do the necessary in-depth analysis regarding what I accept to be a complex and challenging family situation.
“I discovered that prior to his death, Leon was exposed to an increased risk of violence from James that CYFS, the police and the CDHB (Canterbury District Health Board) should have collectively identified (taking into account the extent of their respective mandates), but no.
“If that risk had been identified, that could have led to the agency’s intervention.”
Martin van Beynen / Things
Michael Cole feels vindicated after an apology from Oranga Tamariki.
Leon’s father, Michael Cole, who repeatedly warned CYFS about suspected abuse and neglect in the home, said he was hurt. The CDHB appeared to be accepting responsibility for its role in Leon’s death.
It was passing the ball and not allowing any room for improvement, “he said.
He had no faith in Oranga Tamariki (formerly CYFS) ability to change for the better, he said.
“Try putting yourself there. It was a nightmare to know that the children were in danger and that they were simply ignored. They helped put him in the grave. “
Windley said that social workers had accepted the selfish guarantees offered by Roberts and Emma Jayet “when any objective analysis would have indicated that caution and skepticism were required.”
Police had been unwilling to act on the serious threats James made on two separate occasions, which contributed to James never being identified as a source of danger to Leon.
Things
Emma Jayet, left, on her way to the investigation into the death of her 5-year-old son, Leon Jayet-Cole.
“My research has demonstrated the fundamental need for those charged with detecting and responding to the risk of violence to children to be open-minded and critical analysts capable of evaluating and reassessing information as new incidents occur, even when previous incidents have been formally resolved and classified as benign. “
Children & Families South Deputy Executive Director of Oranga Tamariki, Alison McDonald, said that while the case predates Oranga Tamariki, it was important to consider what could be learned.
“It is clear that opportunities were missed to identify the danger that James Roberts presented, and he was seen as a support to the family, rather than a threat.
“The coroner’s report made it clear that there was a backlog of evidence between agencies that should have raised the level of concern for the safety of children.
“We have accepted the coroner’s findings and will carefully consider them in conjunction with other government agencies mentioned in the report.”
CDHB’s Acting Medical Director, Dr. Richard French, his organization accepted the systems and processes in place at the time, they could have been better utilized, “and we remain committed to improving the exchange of clinical information among other public sector organizations.”
“We recognize that many of the recommendations are nationally relevant to DHBs across the country and we will work together with the Ministry of Health to confirm how best to implement them.”
James Roberts was accused of killing his stepson, Leon Jayet-Cole, in Christchurch in 2015. He was wearing a T-shirt emblazoned with the words “World’s Best Daddy” when he was arrested.
