An independent review of the months leading up to the death of five-year-old Malachi Subecz, who was murdered by his caregiver, has found agencies "could have done more" after fears for the child's safety were raised.
The review of the high-profile case was released on Thursday by former health public servant Dame Karen Poutasi. It comes after a separate report by the Chief Ombudsman into Oranga Tamariki's handling of the case, released in October, found the children's agency's response was "a litany of failures" and did not prioritise Malachi's welfare.
Malachi died in Auckland's Starship Hospital last November after being found with injuries a judge said were obtained through abuse considered no less than torture.
The carer who murdered Malachi, 27-year-old Michaela Barriball, was jailed for at least 17 years in June.
Malachi had been placed in the care of Barriball by his imprisoned mother.
Dame Karen undertook an investigation into agencies' handling of the case after being asked to do so by multiple Government departments including Oranga Tamariki, Corrections, the ministries for children, education, health and social development, and the police.
Her report painted a sad picture of how Malachi became an "invisible child" within the system.
That was because there were people who "tried to act but were not listened to", those who were "uncertain and did not act" and others who "knew and chose not to act".
"This is not acceptable," the report said. "The settings for the care and protection system we have in place are still not strong enough to ensure children do not slip through the gaps. The system could have been more 'fail safe' and the settings must be addressed so that it is."
Dame Karen said more steps needed to be taken to ensure Malachi's safety.
"The system has not been designed with layers of safety nets to eliminate gaps."
Dame Karen said one of her 14 key recommendations was to make it mandatory for Oranga Tamariki to vet a proposed carer when a sole parent is taken into custody.
Currently, children of sole parents can be cared for by another person for long periods without formal authority. That was wrong and had "terrible consequences for Malachi", Dame Karen said.
"For Malachi, this gap meant from the day his mother was denied bail and incarcerated, he was with Ms Barriball informally for three months," her report said.
The report said more needed to be done to work out how children in Malachi's position could be supported immediately.
"If my first recommendation is not accepted, I believe consideration should alternatively be given to [the] provision of legal representation for children who are facing the loss of a sole parent to incarceration when a sole parent is in the criminal courts.
"In this way, children would have a voice in what happens to them if their sole caregiver is indeed incarcerated."
The agencies concerned, overall, must "recognise the need to improve the system such that overlapping safety nets are hard-wired into it".
Dame Karen said she was also recommending more priority be given to increasing iwi, multi-agency and non-Government organisation (NGO) partnerships in communities.
"In my view, these collaborative teams extend and reinforce the child care and protection system and promote sharing critical information across a far wider range of sources. I believe these teams have been a key missing link and inquiries of the past did not have the benefit of these new ways of working."
The Government agencies have accepted Dame Karen's findings, they said in a joint statement. According to the statement, changes would be made.
"We recognise Malachi's life was cut short and acknowledge the deep grief his whānau will no doubt feel for the rest of their lives," the statement said.
The agencies acknowledged Dame Karen's finding they focused on the adults around Malachi, rather than Malachi himself.
They assured changes were already being made while Dame Karen finalised her review.
"It is only by everyone working together - whānau, communities and Government agencies - that children and young people will be kept safe," the joint statement said. "We must do better to protect our tamariki."
Children's Minister Kelvin Davis, in a statement, said changing the system was essential. The Government has pledged to adopt the majority of Dame Karen's recommendations.
"Mistakes were made and the Government is committed to fixing them so they are not repeated," Davis said. "Dame Karen has made 14 recommendations, of which the Government has fully accepted nine and is committing to look carefully at the remaining five.
"The death of a child is heart-breaking so we need to do what we can to ensure we have a system that keeps kids safe and well in New Zealand. These changes will help to achieve that."
Dame Karen's recommendations:
- Oranga Tamariki should be engaged in vetting a carer when a sole parent of a child is arrested and/or taken into custody
- Oranga Tamariki should be engaged in regular follow-up checks and support for such an approved carer while the sole parent remains in custody
- Multi-agency teams working in communities in partnership with iwi and NGOs resourced and supported throughout the country to prevent and respond to harm
- Medical records held in different parts of the health sector should be linked to enable health professionals to view a complete picture of a child’s medical history.
- The health sector should be added as a partner to the Child Protection Protocol between Police and Oranga Tamariki to enable access to health professionals experienced in the identification of child abuse, and to facilitate regular joint training
- The Ministry of Social Development should notify Oranga Tamariki when a caregiver who is not a lawful guardian, and who has not been reviewed by Oranga Tamariki or authorized through the Family Court, requests a sole parent benefit or other assistance, including emergency housing support, from the agency for a child whose caregiver is in prison.
- The enhancement of understanding of the information sharing regime in the Oranga Tamariki Act 1989, to educate and encourage child welfare and protection agencies and individuals in the sector to share information with other child welfare and protection agencies on an ongoing basis
- Professionals and services who work with children should be mandated to report suspected abuse to Oranga Tamariki.
- The introduction of mandatory reporting should be supported by a package approach that includes a mandatory reporting guide, defining mandatory reporters and for professionals to be deemed mandatory reporters, there should be undergraduate courses teaching risks and signs of child abuse and mandatory regular updated training
- There should be active monitoring of the implementation by early childhood education services of their required child protection policies to ensure they are providing effective protection for children
- The agencies that make up the formal Government's children's system should be specifically defined in legislation
- These agencies should have a specific responsibility included in their founding legislation to make clear that they share responsibility for checking the safety of children.
- Regular public awareness campaigns should be undertaken so the public is attuned to the signs and red flags that can signal abuse and are confident in knowing how to report this so children can be helped
- So change can be monitored, the recommendations made in this report should be reviewed in one year's time by the Independent Children's Monitor in its new system-wide role.
