A coroner is calling for compulsory spot checks of children up to the age of 5 to ensure they are safe and to avoid a repeat of the ''horrific'' death of toddler Nia Glassie.
The Rotorua 3-year-old died in Starship Hospital on August 3, 2007, 12 days after being kicked in the head by brothers Wiremu and Michael Curtis.
They were convicted of her murder and jailed for 17 years, while Nia's mother, Lisa Kuka, was convicted of manslaughter and jailed for nine.
Coroner Wallace Bain today released his findings into what he described as an ''horrific'' death.
''In my 19 years of conducting inquests...I have never had to endure such horrendous evidence which lead to the death of this little girl in horrific circumstances,'' Bain said in his comments.
He said his earnest wish was that no-one had to experience that again.
''Had there been adequate steps in place and checks carried out then leaving Nia in the day-to-day care of young males would have been nipped in the bud at an early stage.''
Bain recommended a return to the ''good old days'' where every child was seen regularly by the Plunket nurse.
He said the state must have the power to override the decisions of mothers of parents in those at-risk families who want to opt out of services.
Bain went on to say that New Zealand had one of the ''very worst records'' in the Western World in terms of how it treated its children on a comparison of education, deprivation, suicide and infant mortality.
''The evidence is crystal clear. New Zealand has a huge child abuse problem. It is sickening that it takes a case like Nia Glassie and all of the things that happened to her to act as a final wake up call.''
Bain said violence protection for young children was almost non-existent, particularly in the Rotorua area. Any moves by authorities to address child abuse were heartening and must be properly funded.
He supported the Government's step of making witnesses to parental child abuse criminally liable if they did not report the abuse. He said this would remove the conflict for family members.
His recommendations also supported an expert forum that called for more data sharing between agencies. He also recommended an 0800 number for reporting cases of child abuse.