The Chief Ombudsman Peter Boshier says Oranga Tamariki failed to take the ‘‘bare minimum’’ action over safety concerns about Malachi Subecz who was later murdered by his carer.

"Oranga Tamariki’s own law and policy puts the well-being of a child at the centre of decision-making that affects that child. Malachi’s wider whānau raised concerns about his welfare at the hands of his carer.

"I can only describe Oranga Tamariki’s response as a litany of failures," Mr Boshier says.

The five-year-old died in hospital of his injuries in November 2021.

Five months before his death his mother, who was imprisoned, had placed Malachi in the care of a friend. That person was convicted and jailed earlier this year for the murder and mistreatment of Malachi.

"The circumstances surrounding Malachi’s death are extremely distressing. I launched an investigation after his cousin and uncle complained to me about the actions of Oranga Tamariki."

Mr Boshier says the cousin first made a report of concern about the boy’s welfare to Oranga Tamariki in June 2021.

Issues were raised about actual and potential harm, including medical neglect and suspected physical abuse.

"A number of things are supposed to happen following a report of concern in cases where a child is at risk of harm or neglect and if it appears an investigation is necessary or desirable.

"If an investigation is begun, Oranga Tamariki is required to do an assessment followed by a safety and risk screen-the screen identifies whether immediate action is required to secure the safety of the child."

Mr Boshier says these steps were not taken.

He says Malachi’s cousin provided the agency with a photo of Malachi with a suspected bruised eye but Oranga Tamariki did not report it to Police as required under the Child Protection Protocol (CPP).

"There is no record that Oranga Tamariki considered its obligations under the CPP at any stage, nor did it record any consideration of the suspected bruising."

Oranga Tamariki spoke to Malachi’s mother in prison, who had no concerns about his placement with the carer and Oranga Tamariki decided to take no further action. Mr Boshier says this decision was wrong.

"Malachi’s welfare and interests were not prioritised; they were instead wrongly assumed to be addressed or overridden by his mother’s endorsement of his carer, in spite of evidence that he may not be safe."

Malachi’s cousin complained to Oranga Tamariki in July 2021 about its decision to take no further action. Mr Boshier found its response to her complaint to be inadequate.

Mr Boshier says there is also no evidence Oranga Tamariki met with Malachi to find out what he felt about his living situation nor did it do a safety check on the carer’s home.

"It is my view that Oranga Tamariki omitted to do all that was necessary and desirable, and it should have investigated the report of concern."

After Malachi was admitted to hospital, his uncle called Oranga Tamariki to complain but was told at first that there was no complaints process. Malachi died shortly afterwards.

"I am concerned about the advice and information that is publicly available about Oranga Tamariki’s feedback and complaints process. There isn’t a dedicated complaints line nor is there information available on its website about how the complaints process works."

Overall, the Chief Ombudsman has found Oranga Tamariki acted unreasonably and wrongly.

"Oranga Tamariki’s response to Malachi’s cousin’s report of concern does not appear to have fulfilled the bare minimum of the process required to ensure Malachi’s safety. It also acted unreasonably in providing incorrect information to Malachi’s uncle."

Mr Boshier says he wants Oranga Tamariki to apologise at a time and in a way that is right for the whānau.

"The apologies should recognise the impact of Oranga Tamariki’s actions."

Oranga Tamariki has accepted the Chief Ombudsman’s recommendations.

Mr Boshier says he will be closely monitoring the progress of two reviews into this case.

Oranga Tamariki is conducting a review into its practice while Dame Karen Poutasi is conducting an independent review looking at the roles and responsibilities of the different agencies involved in Malachi’s care, he says.

"I believe my findings will help inform these reviews. The objective must be to prevent such tragedies from happening again."

"I want Oranga Tamariki to report to me once those reviews are completed and explain how they will influence its policy, practice and guidance. I may make further recommendations or undertake a further investigation if I am not satisfied with its response."

Mr Boshier has decided to publish his Final Opinion on this case in the public interest, for reasons of transparency and accountability.

• Read the final opinion here

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