Staff at the hospital where murdered toddler Comfort Jay Witeri-Thompson spent the first four months of her life were so worried by what they saw they filed a report to Oranga Tamariki.

But despite that report joining three other reports by people worried about the toddler before her death, the child protection agency closed its file on her in December 2017, apparently happy that her home was being tidied up and a heat pump installed.

Seven months later Comfort was dead, her mother Southern Thompson has been convicted of her murder.

Oranga Tamariki confirmed to Stuff, via an Official Information Act request, that four reports of concern were received about the toddler, who died in July 2018.

Oranga Tamariki and Waikato Hospital declined to confirm the hospital filed a report, both citing privacy concerns.

But Stuff understands hospital staff did indeed raise concerns with the agency after months of observing Comfort Jay and Thompson after the child was born with a birth defect and spent four months getting hospital treatment.

The fact concerns were raised by qualified medical professionals who spent months with Comfort Jay was a huge red flag, two child advocates say, adding the warning should have had 'huge credibility”.

By the time Comfort Jay died in July 2018, her injuries ranged from a knocked-out tooth and nappy rash peeling skin off her buttocks to 'extensive healing scratch marks”.

Police found she was subject to ongoing neglect, on top of regular assaults.

In May, Thompson was jailed for life with a minimum term of 17 years at the High Court in Rotorua, having pleaded guilty to murder, ill-treatment, injuring with intent to injure and for failing to seek medical care.

Oranga Tamariki had 'received four reports of concern about Comfort Jay and had involvement with her and her whānau including home visits”, the Official Information Act request revealed.

The last visit was in October 2017, when a social worker noted positive steps, a statement from deputy chief executive services for children and families, Dee McManus​​, says.

Comfort Jay's file was closed in December 2017.

'The whānau were receiving support from community agencies, which included referrals from Oranga Tamariki and there was positive feedback from the key professions involved about their progress,” says deputy chief executive for service delivery Rachel Leota in the Official Information Act response.

'As no new concerns were raised during the assessment, the case was closed.”

McManus says: 'By then Southern had the support of her whānau, Māori health services and community providers”.

Oranga Tamariki's last visit to the whānau was in October 2017, and according to social worker notes, 'they observed a new heat pump in the home and significant steps had been made to tidy the property”.

'After we closed the file, we did not receive any further reports of concern in relation to Comfort.”

The chief executive of child advocacy group Child Matters, Jane Searle,​​ says it's particularly disturbing that qualified health professionals, who spent four months caring for Comfort Jay, had raised concerns.

'That should have huge credibility,” she says. 'We have to ask serious questions.”

Searle says there are good people working at Oranga Tamariki, but 'we know the system is broken”.

She says caseloads varied across sites and Oranga Tamariki lack a consistent process across the board.

'It's a lottery as to what care and protection is in place.”

She says that while bringing outside agencies and community groups into cases, as happened with Comfort Jay, was sometimes the correct thing to do, she had concerns about how well resourced they were, and the level of staff training.

Safeguarding Children chief executive Willow Duffy echoes Searle's sentiment about concern that hospital staff were among those raising concerns.

'People who had four months to get to know the family and that child,” she says.

'A report of concern from experts ... that should get people running.”

Duffy also queried the level of abuse recognition training that other agency staffers may, or may not, have undergone.

She believes that the Coroner's report into Comfort Jay's death would provide 'exactly the same recommendations and findings as Nia Glassie, Moko Rangitoheriri, Malachi Subecz”.

'It's not just Oranga Tamariki, the whole system around children, there's gaps everywhere,” she says.

'Are we learning nothing?”

Asked whether she was confident Oranga Tamariki handed the case correctly, McManus said she was unable to comment, citing the Coroner's investigation.

A Ministry of Justice spokesperson confirmed to Stuff her death is subject to a coronial investigation, adding 'however at present that is on hold, pending completion of criminal proceedings”.

It was revealed in court , Thompson 'would hit Comfort Jay on a regular basis”.

'These assaults were primarily to her head and face, but also to her body. Comfort Jay had been seen by a number of people with two black eyes. She was also seen with a cut lip as a result of being hit in the face.”

Thompson would also scratch her daughter 'regularly over her body”.

'Comfort Jay was covered with extensive healing scratch marks all over her body, but particularly over her neck and chest areas,” the summary of facts said.

She was malnourished, confined to a room for hours at a time and also had an ulcer under her chin, most likely caused by dribbling.

It was described as 'large and raw”.

'Regular bathing and cleaning of Comfort Jay would have properly dealt with the issue,” the summary of facts said.

Their home was also described as being in a 'dreadful state”.

Cold, damp, broken windows, no working lightbulbs, old and rotting food on the floor of the living area as well as dirty nappies and 'a mouldy bowl of noodles infested with maggots on the kitchen bench”.

'Cannabis and alcohol cans were found in various locations around the house.”

Comfort Jay was pronounced dead on July 24, 2018 after specialists from Waikato and Starship Hospital found she had sustained 'an irreversible brain injury which was not survivable”.

-Benn Bathgate/Stuff.