Malachi Subecz was "an invisible child within the system".
That is the devastating conclusion of an investigation into the death of the five-year-old murdered by his caregiver Michaela Barriball last year.
The report's author - Dame Karen Poutasi - said "no agency had the full picture of what was happening to him before it was too late" and that Malachi was failed by the system as a whole.
There are 14 recommendations, nine of which have been fully accepted by the Government. The remaining five are being considered by the Government, including mandatory reporting of at-risk children.
Little Malachi Subecz was just five years old when he was killed. A boy who loved dinosaurs and was learning the te reo names for every single one. His aunt still has all his treasures on display.
"He was fun-loving. He was a gentle soul," said Helen Menzies.
All that joy was brutally taken away when Malachi was beaten, burned, and murdered by Michaela Barriball, the woman entrusted with caring for him.
His aunt told Newshub earlier this year she'd always felt something was wrong.
"I'm still angry because the fact is he could've been saved," said Menzies.
Malachi was placed with Barriball when his mother was jailed. Extended family tried and tried and tried to warn authorities, but devastatingly Malachi became invisible in the system until it was too late.
"There should be no invisible child, no child should be invisible to the system when they are in high need," said Dame Karen on Thursday.
The review found Oranga Tamariki failed to investigate concerns raised by members of Malachi's whānau, his interactions with the health system were disjointed, and his childcare centre failed to report Malachi's injuries.
They were all safety nets - and not a single one caught him.
"There were those who tried to act but were not listened to," Dame Karen said. "There were those who were uncertain and did not act. There were those who knew and chose not to act. This is not acceptable and we cannot look away."
Minister for Children Kelvin Davis on Thursday said the system "failed" Malachi and his family.
"For that, I am deeply sorry," he said.
The report has 14 recommendations. The Government has accepted nine, including linking up medical records to ensure there is a complete picture of a child's health and regular public awareness campaigns to encourage people not to look away from child abuse.
"I think it's a very good message for New Zealand, we should not look away, we can not tolerate this, we do not have a good record as a society," said Dame Karen.
But the Government's only committing to looking into the remaining five, including vetting the caregivers of children whose parents are jailed along with regular follow-up checks and mandatory reporting so people who work with children would be mandated to report any suspected abuse to Oranga Tamariki.
The minister says that could have adverse effects itself.
"Better to be safe than sorry but that's going to have resourcing implications because if we've got 70,000 reports of concern now that might top out to half a million and the actual serious case, the actual genuine cases may be missed because of it."
And no one ever wants to see another Malachi missed.
Jenna Lynch Analysis
There was a litany of failures here with utterly tragic consequences.
Davis told us that three senior Oranga Tamriki staff involved in this case no longer work for the agency. Newshub understands two saw the writing on the wall and quit, while the other was sacked.
Associate Education Minister Jan Tinetti said the early childcare centre lost its licence last month - so that's shut down too.
The family didn't want to be interviewed as they wanted to take time to process the report but in a statement Malachi's cousin, who raised the initial concerns with Oranga Tamariki, said, "Nothing in these reports is a surprise because they simply summarise what I experienced, and that is what ultimately took precious Malachi away from us."
