A coroner has made a series of recommendations aimed at avoiding a repeat of the murder of five-year-old Malachi Subecz, who she called a "loving and cheerful child who was robbed of his future".
Malachi was murdered by his caregiver Michaela Barriball in November 2021 after she subjected the boy to months of daily abuse and torture.
Coroner Janet Anderson today released her written findings on the Bay of Plenty boy's death, which she called "senseless and barbaric".
Issuing a series of recommendations, she urged the relevant agencies to “take the actions required to progress these matters and other changes that are already in progress”.
“Lives depend on it. No more children should die because of a lack of safeguards, knowledge or training.”
Coroner Anderson 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," she said in her concluding remarks.
"He was a treasured and cherished young boy who should be acknowledged and remembered in his own right, and not just as the victim of a barbaric and senseless crime."

Failures
Former Chief Ombudsman Peter Boshier previously found a “litany of failures” occurred in the months before Malachi’s death, including a failure by Oranga Tamariki to report his injuries to police, despite concerns of his welfare being reported to the agency.
An inquest into Malachi’s death was then held in July 2025. Today's written findings noted the coroner was conscious of many recommendations which had been made since Malachi's death, and she did not want to duplicate or cut across activities which are already underway.
This included findings in a report by the late Dame Karen Poutasi, commissioned by the six state agencies that interacted with Malachi and his whānau in the months leading up to his death.
Barriball, who was a workmate and friend of Malachi's mother, abused the boy for months after his mother was jailed in June 2021, including beating, burning and starving him, until he eventually died of his injuries.
The first recommendation by Coroner Anderson was to take urgent action to identify dependent children when sole caregivers are incarcerated, and ensure there are independent safeguards which are safe and appropriate.
She noted this recommendation could take many forms, but the point was to safeguard the rights of all affected children, including the right to life and right to be free from violence.
She also recommended the roll out of an awareness campaign to encourage the identification and reporting of suspected child abuse by members of the public.
Coroner Anderson also noted it is a “core statutory function of the Oranga Tamariki chief executive” to promote awareness of child abuse, and the unacceptability of it".
While “many previous calls” had been made in the past for a similar campaign, including in Poutasi's report, she said “it must no longer be delayed”.
Guidance for those working with children
Coroner Anderson also recommended the Ministry of Education introduce standardised policies and training for early childhood centres. This would include specific guidance on how to respond when a child presents at a centre with injuries, whether or not abuse was suspected, and types of injuries which “are more likely to be non-accidental in nature”.
She further recommended the New Zealand College of General Practitioners consider whether there should be mandatory child protection education for GPs, including risk factors, potential indicators of abuse, and how to identify possible non-accidental injuries.
It was also recommended the New Zealand Law Society engage with stakeholders such as the Family Law Section, CLE New Zealand and the Family Court to review the education and training requirements for lawyers for the child in order to strengthen the child protection components of the current framework.
Coroner Anderson noted practitioners acting as a lawyer for a child are "not specialist child abuse investigators", and their role is to "make submissions to court, not to give evidence".
"However, it is important for these practitioners to be equipped with up-to-date knowledge and skills that will assist them to obtain information relevant to the safety of the children they represent, and to identify possible risks."
Coroner Anderson said training could include the possible indicators of child abuse, factors that might place a child at increased risk, such as the imprisoning of a parent, and useful collateral sources of information, such as daycare centres.
Guidance on seeking updated information from third parties at key points during proceedings "would also seem beneficial", Coroner Anderson said, "as would training to assist practitioners in understanding the thresholds for making a report of concern" under the Oranga Tamariki Act, and other relevant statutory information sharing provisions.
She also recommended mandatory safeguarding training for medical professionals along the lines required in UK legislation, as recommended by Dr Patrick Kelly, a paediatrician at Starship Hospital who specialises in child protection.
"This is mandated by legislation and there are multiple training levels ranging from non-clinical to clinical staff. There is a level for clinical staff working with children, young people or parents. Another applies to 'named health professionals' who are responsible for child protection clinical leadership in each district, and level five training is required for senior leaders and managers."
Coroner Anderson said the Making Children Visible in the Courts process should be fully implemented and embedded, including appropriate resourcing and education so processes are "consistently followed".
This process was introduced in March last year to improve the information available to the criminal court about the existence of dependent children when a primary caregiver is potentially facing a custodial sentence or remand.
The changes sit alongside existing processes, such as oral submissions, that can be used to bring the existence of dependent children to the attention of the court, Coroner Anderson said.
Case highlights importance of 'acting quickly'
Coroner Anderson said Malachi's death "highlights the vulnerability of young children and the importance of acting quickly when there are concerns about their care environment".
She also noted that Malachi remained in the care of Barriball while a Family Court matter progressed with the niece of Malachi’s mother who tried to take him into her care.
It said the evidence before Family Court was “insufficient” for the niece’s applications to be granted on a without notice basis.

“However, the proceedings relating to Malachi’s care were given priority when the without notice applications were declined, and an urgent hearing was directed.
“Unfortunately, while the matter progressed, Malachi remained in the care of the woman who abused and then murdered him. 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.”
Coroner Anderson said it highlighted how important it is for information relevant to the safety of a child to be made available to the court and to the lawyer for the child.



















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