Two teenagers escaped from a youth justice residence in 2021 when scaffolding was erected too close to a fence during a teaching exercise, giving the runaways a step up to freedom.
They then stole a vehicle and led police on a high-speed chase, during which a patrol car was rammed.
Just over three weeks later, four teens escaped the same facility, Te Au Rere a te Tonga in Mokaha Place, Palmerston North.
Those escapers jammed a lock so residence staff couldn't reach them, then bashed their way out a window.
An Oranga Tamariki preliminary review of the incident found ongoing delays to dealing with "known infrastructure weaknesses" at the facility were a major concern and contributing factor to what happened.
First escape
On 3 December 2021, the two teens were taking part in a programme teaching them about scaffolding.
According to Oranga Tamariki documents obtained by RNZ, residence staff said the scaffolding must be erected in the middle of a concrete area. But the scaffolding instructor decided to place it against a fence for safety.
The two teens climbed the scaffolding to the top of the fence, ran along the fence to an outer wall, jumped over and escaped from the residence.
Police swarmed the area and then pursued the runaways, who had stolen a Ford Ranger, in a high-speed chase during which a patrol car was rammed.
The chase continued even when the Ranger had four blown-out tyres after police used road spikes.
There was a third passenger in the stolen vehicle, but they had not been identified.
The two escapers were arrested when the chase ended in Horowhenua two hours later. No one was injured.
The Oranga Tamariki documents redact the duo's names. One was described as a 16-year-old boy who was highly volatile and easy to anger.
He was stood down from his school for fighting and possessing a knife.
Among the few details not redacted about the other escaper was: "Offending started at an early age and has shown no signs of lessening."
Second escape
Late on 29 December 2021, four teens were in the same wing of the residence left their rooms while afternoon staff handed over to the evening shift.
One teen jammed a lock, preventing staff from reaching them initially.
The teens then went into a bedroom, but staff who had run along the wing couldn't get inside because the teens stuffed paper into the keyhole.
In the room, as staff watched on through a window panel, the four escapers, whose details are redacted, stomped on a wooden shelf unit until a chunk of wood broke off. They used this to smash a window and jump outside to a ring-road area still within the facility's boundaries.
A contracted security guard was patrolling this area, but when she saw what was happening she fled to the staffroom, worried the wood could be used as a weapon. The guard then left the residence completely, saying she was scared.
From there the four teens climbed on to a roof and ran along it towards an external wall, from where they escaped.
Because they were armed with the wood, residence staff decided not to give chase.
They were subsequently found - one on 1 January 2022, in what police described as a "suspicious vehicle" in Palmerston North; two on 11 January at a Palmerston North property; and the final one on 17 January after attempting to flee a Masterton property.
What went wrong?
An Oranga Tamariki "lessons learned debrief" found that once staff realised what was happening, they should have rushed to the areas the teens were most likely to escape from, and try to prevent that happening.
It also found afternoon-shift staff should have been more vigilant and watched for "secretive planning-type behaviour".
The debrief identified required improvements to the residence, such as better locks that couldn't be jammed; a better camera system; improvements to shelving so it couldn't be used as a weapon or escape tool; better staff placement in the unit; and developing an absconding risk plan.
A January 2022 "preliminary review of escape incident" uncovered "several potential systemic safety and security issues".
"A major concern, and contributing factor in this incident, has been the ongoing delays in addressing known infrastructure weaknesses at Te Au Rere a te Tonga."
The preliminary review said a 2020 escape of two serious offenders from the Korowai Manaaki residence in Auckland led to a review of security systems at youth justice facilities.
The report, from ICARAS Security Consultants, found a lack of investment and planning in the way residences were run across New Zealand.
Progress made to address these shortcomings, but that stopped when, in mid-2021, the programme manager resigned.
"The contributing factors identified in this latest escape incident demonstrate the need to restart this work programme with urgency," the preliminary review said.
As well as improvements identified in the lessons learned debrief, the preliminary report urged that windows be replaced with stronger glass.
It said Te Au Rere a te Tonga, which opened in 1999, was Oranga Tamariki's oldest youth justice facility. It was "well overdue for a significant infrastructure renewal programme".
"The combination of a lack of investment and delays in addressing critical infrastructure issues, along with an increasingly challenging cohort of rangatahi, have combined to a point where there is an elevated level of risk."
The report said the residence would often deal with high-needs teens other facilities couldn't manage, while staff would be called to help at other sites.
It said on 29 December, 2021, police didn't arrive at the residence until one hour and seven minutes after a 111 call was made.
Police though say they were called at 11.07pm and a patrol crew was immediately sent out to hunt for the escapers. A second crew and a dog unit followed.
"Once the attending units had exhausted their area patrols, one unit returned to the facility to speak with staff there," police said.
"Staff arrived at the facility at 12.03am, after extensive area searches were conducted, which is why there would have been a delay in the reported attendance time.
"Subsequent inquiries led to all four youths being located and returned to the facility in the days following."
Oranga Tamariki responds
Parani Wiki, its general manager of service delivery, said Oranga Tamariki acknowledged mistakes were made leading to the escapes, but said the organisation was committed to ensuring teens in its care, staff and the community were safe.
"Considerable" work to improve youth justice facilities was under way, to buildings, security systems, culture, policy and practice.
"There have been refurbishments at Te Au Rere a te Tonga following the [29 December] escape, including changes to the shelving units, and we are working with a specialist window manufacturer to develop a custom window frame for all residences."
So far three of its four units were "refreshed" and further work was planned.
Oranga Tamariki was auditing its five youth justice facilities to identify the most urgent improvements and changes required.
Unfinished work from the 2020 ICARAS report was included in the "current delivery plan for improvements to critical assets".
The youth justice facilities had developed new processes to respond to escape attempts, including how staff were deployed to cover "infrastructure vulnerabilities".
Wiki said there had been no successful escapes since December 2021.
RNZ
