His mother told the coroner this was driven by \u201ca deep mistrust of the health system\u201d, which she attributed to perceived clinical errors during her previous pregnancies, and another child\u2019s treatment in hospital.<\/p>\n
She told the coroner that her pregnancy with Azariah was normal, his birth was without complications, and he breastfed normally. <\/p>\n
However, on November 12, his parents noted he was \u201cnot his usual self\u201d \u2013 crying more than usual and not settling although he was reportedly feeding normally.<\/p>\n
The next day, Azariah\u2019s feeding noticeably reduced, he was sleeping longer than usual, and his \u201ccheeks were going flat\u201d. <\/p>\n
They started weighing him before and after every feed and \u201ccould see that his weight was slowly going down\u201d.<\/p>\n
They said they prioritised feeding him every hour to get his weight back, and gave him expressed milk with a syringe.<\/p>\n
Coroner Ian Telford has released findings into the baby’s death. Photo \/ Supplied<\/p>\n
Around 6pm on November 15, however, they observed he was having difficulty breathing, with slower breathing than usual and \u201cholding his breath for less than 10 seconds\u201d and \u201chis lips were going blue\u2026\u201d<\/p>\n
They decided to take him to hospital, and began to get their other children ready. At 8pm, they tried to feed him again. He vomited a \u201cclear yellow liquid\u201d, and Azariah\u2019s father said he then \u201cheld his breath for a long time which really worried us, his eyes rolled back, and I was really concerned, so we called an ambulance\u201d. <\/p>\n
The ambulance was phoned at 11.24pm, and the couple started resuscitation immediately, guided by the call handler. <\/p>\n
Azariah was taken to Waikato Hospital but despite \u201cextensive efforts of all those involved\u201d, could not be revived. <\/p>\n
A pathologist later concluded he died because of \u201cfailure to thrive\u201d, with a metabolic disorder considered the most likely explanation.<\/p>\n
Following Azariah\u2019s death, hospital staff notified the police, raising a number of concerns, including that he had not received antenatal, postnatal, or Well-Child oversight, and appeared to be severely underweight. <\/p>\n
Police investigated, which included interviews with Azariah\u2019s parents, and scene photographs recorded a diary documenting feeding and nappy times, as well as a stethoscope on one of the beds.<\/p>\n
The police noted that Azariah\u2019s parents are members of a Christian church, and recovered an audio recording from November 2023, in \u201cwhich a man speaks briefly about healing in religious terms\u201d, offering a prayer of anointing for Azariah, referring to concerns about his weight loss. <\/p>\n
Ultimately, the police determined that criminal liability could not be established.<\/p>\n
While mindful of the \u201cprofound grief\u201d experienced by Azariah\u2019s parents, and not wishing to add to their distress, in Coroner Telford\u2019s view, the baby\u2019s death was preventable, and timely medical intervention would have likely \u201caltered the course of events\u201d.<\/p>\n
Faltering growth, metabolic disorder<\/p>\n
A paediatrician, Dr Soper, engaged by the coroner, found evidence of Azariah failing to grow as expected from shortly after his birth, despite his parents providing adequate nutrition. <\/p>\n
Soper looked at photos from August 27 and 28, taken shortly after birth, that showed a baby, presumed to be Azariah, with rounded facial features, suggesting a normal birthweight and appearance.<\/p>\n
But by September 2023, at approximately four-and-a-half weeks old, two photographs showed a noticeable prominence of the \u201cbony landmarks\u201d on Azariah\u2019s face, and his features appeared less rounded, indicating early signs of \u201creduced subcutaneous fat or growth faltering\u201d. <\/p>\n
By November 11, photos showed markedly prominent \u201cfacial bony landmarks\u201d, despite reports that he was \u201coutgrowing\u201d his clothing at this age.<\/p>\n
By the time of his death, his weight was around 3kg, which \u201cis about what a newborn weighs, even though an 11-week-old would normally weigh almost twice that\u201d, according to the findings.<\/p>\n
Soper advised that \u201cfaltering growth\u201d is now the preferred term for \u201cfailure to thrive\u201d, and signs of it may be subtle: a child may not gain enough weight, may grow more slowly, cry or sleep more than usual, struggle during feeds, or interact less than expected for their age.<\/p>\n
Soper said children with faltering growth needed to be assessed by a paediatrician.<\/p>\n
Soper advised that children\u2019s growth should be regularly tracked by Well-Child Tamariki Ora check-ups and that parents should seek help promptly if any concerns arise in relation to weight or feeding.<\/p>\n
Coroner Telford said that as Soper advised, the signs of faltering growth can be subtle and may be difficult for parents to recognise, \u201cparticularly when caring for a child on a day-to-day basis\u201d.<\/p>\n
\u201cIn Azariah\u2019s case, objectively clear signs of faltering growth were evident for some time prior to his death,\u201d he said.<\/p>\n
Evidence from his parents also indicated that they held particular concerns about his feeding, weight, and appearance at least three days before he died. <\/p>\n
\u201cWith the benefit of hindsight, it is apparent that these concerns warranted urgent medical assessment at the time they arose.\u201d<\/p>\n
In particular, emergency assistance should have been sought \u201cas soon as Azariah first displayed breathing difficulties and cyanosis at around 6pm, as these signs represent a medical emergency\u201d.<\/p>\n
The parents\u2019 \u201cdeep mistrust\u201d had at least in part stemmed from what Ariana Levi believed were shortcomings in care given to one of Azariah\u2019s siblings, which she thought had led to long-term health problems for that child. <\/p>\n
The coroner said it was relevant that this sibling presented to Rotorua Hospital in 2017, at three months of age, with \u201ca clinical presentation similar to that observed in Azariah prior to his death\u201d. <\/p>\n
The child suffered a sudden cardiovascular collapse requiring intubation and ventilation, was found to have severe metabolic acidosis, and was noted to be significantly underweight for their age.<\/p>\n
The coroner said that while his inquiry had not examined those matters, it was \u201capparent that these experiences influenced their decisions\u201d about Azariah\u2019s care. <\/p>\n
While acknowledging these situations could be emotionally complex, in circumstances where a baby does not appear to be feeding or growing as expected, \u201cthe child\u2019s wellbeing must always remain the first consideration\u201d.<\/p>\n
It was important for all infants to attend regular Well-Child Tamariki Ora checks, and parents or caregivers ought to seek medical advice promptly when concerns arose about feeding, weight, or growth. <\/p>\n
\u201cParents and caregivers should call 111 immediately if a young child is struggling to breathe, develops blue lips, has difficulty swallowing, experiences pauses in breathing, or shows sudden changes in behaviour.\u201d<\/p>\n
Parents were advised to enrol their child with a Well-Child Tamariki Ora service and attend routine check-ups.<\/p>\n
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.<\/p>\n","protected":false},"excerpt":{"rendered":"Parents saw weight was slowly dropping According to the findings, Azariah was born at home in Matamata on…\n","protected":false},"author":2,"featured_media":410143,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[211025,211026,9349,12629,634,5504,26641,12518,10170,111,43,139,69,1118,11596,16716],"class_list":["post-410142","post","type-post","status-publish","format-standard","has-post-thumbnail","category-new-zealand","tag-11weekold","tag-azariah","tag-checks","tag-coroner","tag-death","tag-following","tag-importance","tag-infant","tag-levis","tag-new-zealand","tag-news","tag-newzealand","tag-nz","tag-of","tag-raises","tag-wellchild"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/410142","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=410142"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/410142\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/410143"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=410142"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=410142"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=410142"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}