In his report released to the public this morning, Coroner Garry Evans has called on the Government to give 'favourable consideration" to creating the specialist teams - like the one at Starship Hospital - which would work alongside health providers, as well Child Youth and Family (CYFS) and police.
The new teams could provide an integrated system of training, support and integration which would encourage better information sharing between agencies.
Mr Evans has also called on authorities to consider introducing a law that would see health professionals being legally obliged to report instances of physical abuse to CYFS.
He has also asked for further laws to be looked at that would require health and education authorities to have a statutory responsibility for the protection of children and to work alongside child protection agencies.
Babies Chris and Cru Kahui died of head injuries at the Starship hospital in 2006. Two years later, in the High Court at Auckland, Mr Kahui was acquitted of their murders. The inquest held into the death of the twins finished in June last year.
Citing Victor Hugo's Les Miserables and the Victorian author Charles Dickens, Mr Evans said child abuse was a "centuries-old" problem.
He said the problem has continued and there is no single strategy to solve the complex issues involved.
Mr Evans heard from child protection experts at the inquest that sat over 20 days at the Auckland DIstrict Court.
One of those was paediatrician and the clinical director of the child abuse centre at Starship Hospital, Dr Patrick Kelly. He told the inquest that there were systematic weaknesses in information gathering.
He said health and education authorities should have a statutory responsibility for the safety of children.
Dr Kelly went on to say those working in the health sector should form the "front line" because few children are known to CYFs at the time their abuse is first recognised.
"In contrast all children born in New Zealand are known to a health practitioner."
In his finding, Mr Evans said even with the best care, some cases cannot be prevented.
But he said that was not the case with the Kahui twins.
"The lethal abuse that occurred in this case could have been anticipated and protective steps taken, had the existence of the earlier injuries been known."
However, CYFS were only alerted to the case once the twins were admitted to hospital with fatal injuries on June 13, 2006.
"The fact that the twins were being nurtured in an unsafe environment and were at risk of further injury also remained unknown to authorities," Mr Evans said.
THE NUMBERS
• New Zealand has the highest rate for deaths from accidents or injuries in children under 19 years. The rate of maltreatment of children under 15 is the fifth highest amongst the 26 OECD countries.
• There were 124,291 "care and protection notifications" to CYFS during the 2009/2010 year.
• More than 11 per cent of all incidents reported to police were family-violence related.
• In the year ending June 2009, police notified CYFS of 14,430 concerns about child safety.
