A toddler died from abuse after a hospital failed to notice his injuries and discharged him before Oranga Tamariki had checked his home was safe.
Health and Disability Commissioner Anthony Hill said the hospital failed to provide an adequate safeguard for the boy, and its failures were systemic.
Despite four visits to the hospital, staff failed to spot the boy's fractured leg or other injuries including bruising, a broken tooth, and blackened fingernails.
It was only when he was referred to a second hospital on his fourth visit that the injuries were noticed.
Mr Hill said the first hospital should have acted on the injuries much sooner.
The hospital's social worker asked for Oranga Tamariki to undertake a safety plan before the boy was sent home, but a doctor discharged him anyway.
The district health board has been ordered to apologise to the family, follow-up with Oranga Tamariki and the police on the Commissioner's findings.