A report from Aroturuki Tamariki, the Independent Children’s Monitor, on the implementation of the recommendations of Dame Karen Poutasi following the death of Malachi Subecz has found tamariki (children) are no safer now than when Malachi died.

Malachi was not in State care but reports of concern had been made about him. Six government agencies completed reviews of their own processes, and chief executives also commissioned a system-wide review from Dame Karen Poutasi (the Poutasi review). The Poutasi review referred to there being those who tried to act but were not listened to, those who were uncertain but did not act, and those who knew but chose not to act.

Aroturuki Tamariki Chief Executive Arran Jones says the report, Towards a stronger safety net to prevent abuse of children, looks at whether the recommendations made by the Poutasi review have been actioned. It also looks at whether the actions arising from the individual agencies’ own reviews have been completed and whether tamariki are safer as a result.

"It is disappointing to see the lack of priority given to this by government agencies over the last two years. The gaps identified by the Poutasi review were not new and have been raised by previous reviews over decades," Mr Jones said.

The agencies with responsibility for implementing Dame Karen’s recommendations are children’s agencies Oranga Tamariki, NZ Police, Ministry of Education, Ministry of Health, Ministry of Social Development, and Ministry of Justice, and other agencies, Department of Corrections, Education Review Office and Health NZ – Te Whatu Ora.

Since our report was finalised, agencies have progressed some actions from their own reviews, but we are still not confident that tamariki in similar situations to Malachi are any more likely to be seen, or kept safe by the system, than they were when Malachi died.

This is because:

• the recommendations of the Poutasi review have not been implemented and the system change Dame Karen called for has not happened
• individual agency reviews have made limited progress, and what has been done does not address the fundamental underlying problems
• across the children’s system, agencies are not adequately prioritising child protection and struggle to collaborate and share information
• when people report concerns, Oranga Tamariki is not sufficiently focused on the safety of the child and social workers are forced to make decisions on when to act based on staff availability. 

“A succession of reviews into the death or serious abuse of children have pointed at the need for greater collaboration and information sharing between government agencies and non-government organisations (NGOs). Not sharing information when the safety of a child is at risk leads to tamariki falling through the gaps, as happened with Malachi.

“While government agencies are continuing to discuss how they can better collaborate, there is still no consistent, nationwide approach. Working together to ensure tamariki are safe must be treated as core business and supported accordingly.

“Child protection is not the sole responsibility of Oranga Tamariki, but it is the agency with statutory responsibility. When reports of concern are made to Oranga Tamariki, they must act. The availability of staff has an undue influence on the decisions social workers must make on whether or not to take action on a report of concern. This results in an inconsistent response across sites and an inconsistent threshold for when further action is taken.

“Almost half of reports of concern made by NGOs, and 40 percent of those from early childhood education providers and schools, are recorded by Oranga Tamariki as requiring ‘no further action’. When social workers from NGOs, or school staff, report concerns to Oranga Tamariki they don’t do this lightly. NGO staff tell us that they have usually exhausted every other option to help whānau before they make a report of concern to Oranga Tamariki.

“We also heard from Oranga Tamariki social workers that their statutory role is still not clear, an issue raised by the Ministerial Advisory Board in 2021. This lack of clarity has meant that tamariki are not at the centre of decision making. Oranga Tamariki national office told us that its practice shift will address this.

“While Oranga Tamariki needs to improve its response when statutory intervention is required, well-resourced and funded NGOs and iwi and Māori service providers are also needed to provide an early intervention response. This would take the pressure off Oranga Tamariki and increase the likelihood of tamariki being seen.

“The lack of urgency, and what appears to be a lack of priority given to addressing child abuse in New Zealand, is hard to understand. While it is important not to make hasty decisions that may have unintended consequences, it is concerning that there has not been greater progress. The critical gaps that Dame Karen Poutasi identified have not been closed.

“This pattern, of a child death followed by a review and recommendations that are not implemented, has to stop. Action needs to be taken to keep children safe. We won't look away and will report whether anything has changed in another 12 months,” Mr Jones said.

The report can be read on the Aroturuki Tamariki website: https://aroturuki.govt.nz/reports/poutasi-review

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