This review is undertaken in accordance with section 26 of the Oversight of Oranga Tamariki System Act 2022. It is the result of Recommendation 14 of the independent review undertaken by Dame Karen Poutasi Ensuring strong and effective safety nets to prevent abuse of children (Poutasi review), which was published on 1 December 2022. Recommendation 14 asked that Aroturuki – the Independent Children’s Monitor review the Government’s progress against the 13 other recommendations in the report, one year on from its publication.
The Poutasi review was commissioned by the chief executives of six government agencies2 following the death of Malachi Subecz. Its purpose was to improve the children’s sector identification of, and response to, abuse of children and young people. It looked across the interactions that six government agencies had with Malachi Subecz, his , and his caregiver, identified where the system failed to protect Malachi, and made recommendations to address those failures to prevent abuse of tamariki in similar situations to Malachi in the future.
While the Poutasi review drew on the reviews undertaken by agencies as a source of information, it deliberately looked across the system to see what improvements could be made at that level, rather than focusing on individual agency changes. It considered this in terms of layers within the system to protect tamariki. In the report, Dame Karen Poutasi notes that:
“Throughout this review, I have envisaged a children’s playground climbing frame with layers of safety nets so that if a child falls through the first net they are caught by the second or third safety net. A system of mutually reinforcing, purposefully structured safety nets is essential to offering the protection and care that children like Malachi are owed.”
Malachi Rain Subecz was born on 28 September 2016. He was in his mother’s care until she was remanded into custody at Auckland Region Women’s Corrections Facility on 21 June 2021. At this time Malachi’s mother placed him in the care of Michaela Barriball.
Malachi suffered abuse inflicted by Ms Barriball. Reports of concern were made by Malachi’s to Oranga Tamariki, as well as contacting NZ Police and Malachi’s daycare. Oranga Tamariki determined there were no care and protection concerns for Malachi and that no further action was required by Oranga Tamariki. Crucially this decision was made without anyone from Oranga Tamariki going to see Malachi. In July 2021, a Probation Officer from the Department of Corrections also contacted an Oranga Tamariki social worker with concerns. Oranga Tamariki determined that the concerns were beyond its scope to respond to, as it had already determined that there were no care and protection concerns. No other agency working with Malachi or Michaela Barriball raised concerns with Oranga Tamariki, although it was later found that Malachi’s daycare had concerns but did not notify Oranga Tamariki.
On 1 November 2021 Malachi was taken by ambulance to Tauranga Hospital and then airlifted to Starship Children’s hospital. His medical presentation was consistent with having suffered a traumatic brain injury. That same day, a hospital staff member made a report of concern to Oranga Tamariki. That report of concern said that Malachi had been admitted to Starship Children’s Hospital and there were indications that he had suffered non-accidental injuries. The report of concern was allocated to an Oranga Tamariki social worker the following day.
On 2 November, in direct response to the report of concern from the hospital, a multi- agency professionals meeting took place. This involved health professionals, NZ Police and Oranga Tamariki. A multi-agency safety plan was created for Malachi, which considered how Malachi’s safety needs would be addressed.
On 12 November 2021, Malachi died from the non-accidental injuries which he was hospitalised for on 1 November. He was five years old.
2 Department of Corrections, Ministry of Education, Ministry of Health, Ministry of Social Development, New Zealand Police and Oranga Tamariki – Ministry for Children.