Warning: This story deals with child abuse and may be distressing.

In the last six months of Malachi Rain Subecz’s life, “everything possible went wrong for him”.

Malachi was 5 years old when he was tortured and murdered by his caregiver, Michaela Barriball, who is now serving a life sentence with a minimum non-parole period of 17 years.

Malachi’s sole parent, his mother, Jasmine Cotter, was jailed in June 2021 for importing drugs and signed over guardianship of the boy to Barriball, who was a friend from Tauranga.

Earlier inquiries into the boy’s death have put forward measures for preventing the abuse of children, and now a coroner has made further recommendations.

“No more children should die because of a lack of safeguards, knowledge, training or funding,” Coroner Janet Anderson said.

After Malachi’s death in November 2021, six government agencies that had contact with him, his mother, and Barriball carried out practice reviews.

These were the New Zealand Police, the Department of Corrections, Oranga Tamariki, the Ministry of Social Development, the Ministry of Education and the Ministry of Health.

The chief executives of the six agencies also jointly commissioned a review by the late Dame Karen Poutasi, whose report was released in November 2022.

Poutasi noted that “at no time was the system able to penetrate and defeat Ms Barriball’s consistent efforts to hide the repeated harm she was causing to Malachi, that culminated in his murder”.

Malachi was an “invisible child” within the system, she said.

Malachi Subecz was 5 when he was murdered by his caregiver, Michaela Barriball. Photo / Supplied

She identified five critical gaps and made 14 recommendations, which the Minister for Child Poverty Reduction recently announced the Government would implement.

Following an inquest in Auckland last year, however, Coroner Anderson noted the pace of change had been slow, and “the frustration of Malachi’s family members and some of the professionals who gave evidence was palpable”.

A Children’s Monitor report, dated May 2024, found that at that stage only one of the recommendations made by Poutasi had been implemented, and “children were no safer at that point in time than when the 5-year-old died”.

Coroner Anderson said changes that need to be made in Oranga Tamariki’s practice have been identified, but are “not happening fast enough”.

Coroner Anderson has made additional recommendations, intended to be “read alongside” existing recommendations by Poutasi, Chief Ombudsman Peter Boshier and the Independent Children’s Monitor, as well as the findings and actions identified through the individual Government Agency Practice Reviews.

Coroner Anderson said Malachi was the victim of “unspeakable cruelty and deliberate evil” and potential opportunities to identify what was going on were not picked up.

His injuries had been missed and his decline unnoticed by those who interacted with him, and they had believed Barriball’s explanations for bruises and burns.

The coroner has recommended widespread education for the public, and training for healthcare professionals, and those who work in child education, to better identify and report concerns.

‘Inherent vulnerability’ in children of incarcerated caregivers

Coroner Anderson’s first recommendation related to the care of children whose parents were incarcerated.

Malachi’s mother, Cotter, was working at a packhouse in Te Puna, just outside Tauranga, when she befriended Barriball and Barriball’s mother, Judy Te Wheoro.

In late 2020 and early 2021, Te Wheoro asked Cotter to receive several packages from overseas on her behalf, and to accompany her on a trip to Christchurch to pick up a package.

Those packages contained drugs, and Cotter pleaded guilty to drug importation charges, accepting her name was on the packages but telling the court she had been naive about what they contained.

Upon entering a guilty plea, she was remanded in custody until sentencing, where she was sentenced to three years’ imprisonment.

Her co-defendant, Te Wheoro, was sentenced to 11 months’ home detention.

The sentencing judge noted Te Wheoro had been recruited into a scam that originated in West Africa, and those involved convinced her she was the beneficiary of a $10 million inheritance, and needed to collect packages and pass them on as a condition of receiving the inheritance.

Arrangements were made for Barriball to take Malachi, as Cotter was worried that if Malachi went to stay with her family further down the country, he wouldn’t be able to visit her in prison.

Coroner Anderson noted that Cotter was overwhelmed by the prospect of going to prison.

“Jasmine lacked the resources and support to understand the risks involved with sending Malachi to live with a friend who was a close relative of a person who had caused her to become involved in a methamphetamine importation operation,” Coroner Anderson said.

“Jasmine loved her son dearly and could never have foreseen the horrific events that would follow. However, her decision for Malachi to live with Michaela was not a sensible one.”

Malachi's cousin Megan Cotter fought to get care of him in the period before his death. Photo / Supplied

Jasmine Cotter’s adult niece Megan Cotter was concerned about the arrangement and made “persistent and valiant efforts to try and ensure that Malachi was safe”.

It was also a decision that “did not sit well” with the probation officer who prepared Cotter’s pre-sentence report.

While the concerns primarily related to pressure that might have been applied to Jasmine Cotter, and the use of the boy as leverage, the coroner’s view was even if Barriball had not been the daughter of a co-offender, “placing Malachi with a relatively young woman, who was not a family member and who had no children of her own, was an arrangement that required close scrutiny”.

Coroner Anderson said it could not be assumed that a parent going to jail would make the best and most appropriate care arrangements, even if they are given additional support.

“There are too many complex factors at play, and too much risk that the needs or wishes of the parent may not align with what is objectively best for their child,” she said.

She said the arrangements to ensure Malachi’s safety were “grossly inadequate”, and not the fault of any single individual or agency.

“It resulted from the absence of a clear, child-centred framework that could identify and respond to the particular risks that he was facing when his mother was incarcerated. ”

She noted there was no requirement for oversight, vetting or prior checks to be carried out before a child is placed in the care of a third party when their sole caregiver is imprisoned.

“Given the inherent vulnerability of this cohort of children, this state of affairs is alarming.”

The findings noted an estimated 1280–1430 sole caregivers are incarcerated each year, affecting an estimated 2000 to 2300 children.

Gaps in information-sharing

Megan Cotter continued to raise concerns with Oranga Tamariki, and attempted to have Malachi put in her care through Family Court “without notice” applications.

Proceedings relating to Malachi’s care were given priority, and a hearing was allocated on an urgent basis, but while waiting for the hearing date, Malachi remained in the care of the woman who later murdered him.

“During this intervening period, he was abused and tortured,” Coroner Anderson said.

Barriball was untruthful about a number of things, including where she was living, her relationship status, whether Malachi was attending school, and how Malachi’s injuries occurred.

She failed to disclose relevant information, such as the suspension of her Ministry of Social Development benefit and violence that occurred between her and her boyfriend in a tavern carpark.

Some of the obvious examples in the gaps in knowledge the coroner noted included Oranga Tamariki and a lawyer for the child not knowing Malachi had attended his daycare with facial injuries, and the police not knowing Malachi was in Michaela’s care when they visited her after a violent incident at the Te Puna Tavern.

“If the officer had known this, it is possible that there would have been further questions asked about where Malachi was at the time of the incident as well as his whereabouts and wellbeing at the time of the police visit.”

While there were legislative frameworks for information sharing, there was a lack of understanding and confidence in making “discretionary decisions” about sharing information, the coroner found.

The coroner said she was “very conscious” that many recommendations had already been made since Malachi died.

“Unfortunately, history has shown that issuing lengthy reports, and making recommendations for change, often makes little difference. Historically, few of the recommendations have been implemented and children have continued to be injured and killed,” Coroner Anderson said.

Coroner’s recommendations include child-centred approach

While not wanting to cut across the activities already underway, she made seven recommendations.

Coroner Janet Anderson has made several recommendations after the inquest into Malachi's death was held in Auckland last year.

These included taking urgent action to identify dependent children when sole caregivers are incarcerated, ensuring there are independent safeguards to confirm care arrangements are safe and appropriate.

She recommended ensuring that a recently adopted process, called “Making Children Visible in the Court”, was fully implemented, ensuring dependent children are considered in court proceedings.

As part of that, legal counsel can expect judges to ask questions about parental responsibility at an early stage, including at the time of bail and when setting bail conditions.

The coroner recommended the development and rollout of an awareness campaign to encourage the identification and reporting of suspected child abuse by members of the public.

“In making this recommendation, I note that it is a core statutory function of the Oranga Tamariki chief executive to promote awareness of child abuse, the unacceptability of it, and ways that abuse can be prevented.”

She recommended that relevant government agencies heed Starship children’s hospital paediatrician Dr Patrick Kelly’s advice regarding the need for comprehensive “Safeguarding Training” and to involve him, and his colleagues, in the development of “child protection education”.

Dr Kelly gave evidence at the inquest, stating that in the 34 weeks between October 31, 2021 and June 31, 2022, 16 children presented at Starship children’s hospital with serious abusive head trauma, almost one every two weeks.

Of those 16, six died.

Another recommendation was that the Ministry of Education introduce mandatory standardised policies and training for Early Childhood Education Centres, to include specific guidance on how to respond when a child presents at a centre with injuries (whether or not abuse is “suspected”) and types of injuries that are more likely to be non-accidental in nature.

“These policies should also be developed in conjunction with paediatric child protection experts and draw on relevant research and development.”

There were two further recommendations that related to training and tools for GPs, and for stakeholders and lawyers in the Family Court.

She made a general comment about the vulnerability of young children and the “importance of acting quickly when there are concerns about their care environment”.

“While I intend no criticism of the court in this case, the tragic circumstances demonstrate how crucial it is for the Family Court to be adequately resourced so that the court, and court participants, have the resources they need when dealing with matters that involve potential risk to children.”

She encouraged Health New Zealand in its role as an active partner in the child protection sector, and the need for social workers and other professionals to have “timely and appropriate access to specialist clinicians with expertise in identifying non-accidental injuries”.

She encouraged government agencies to have a child-centred approach.

Finally, she said Malachi was a loving and cheerful child who was robbed of his future.

“His story is an important one to tell, but the tragedy that befell him should not overshadow his memory or define the life that he lived.

“He was a treasured and cherished young boy who should be acknowledged and remembered in his own right...”

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.