Towards a stronger safety net to prevent abuse of children

In 2024, we published our review of the recommendations of Dame Karen Poutasi in her 2022 report on the children’s sector response to abuse following the death of Malachi Subecz. Dame Karen’s report was not the first to look at the failure of state agencies following the death of a child, but she was the first to request a review of the implementation of changes her report had recommended.

The findings of our 2024 review were disappointing and disheartening. We found the lack of priority given to addressing child abuse in AotearoaCloseAotearoa
New ZealandView the full glossary New Zealand hard to understand. Even some of the simple recommendations had not been progressed. As a result, we concluded that tamarikiClosetamariki
Children (plural) aged 0-13 yearsView the full glossary (children) were no safer than when Dame Karen completed her report. Because of this lack of progress, we committed to come back after another 12 months and see what, if anything, had changed.

Overall, the story is much the same. However, in October 2025 – as we were finalising this review – the Government made the decision to accept all of Dame Karen’s recommendations and to get a cross-agency work programme underway to implement them.

This was a first step. What is now needed is careful and thoughtful implementation. Until change happens on the ground and in communities, tamariki will continue to be no safer. As this review finds, the gaps identified by Dame Karen have not closed and tamariki continue to fall through the safety net.

Beyond responding to Dame Karen’s recommendations, we need urgent improvements to the child protection system so it is able to respond effectively to reports of concern. This review sets out what is needed. It also points to examples of positive change that can guide the way.

It is important to note that the majority of tamariki in Aotearoa are safe and Oranga Tamariki social workers respond to many reports of concern. But the fact remains that they are simply not always able to get in the car to see with their own eyes all the tamariki that others are concerned about, including social workers, police officers, teachers and health staff. Even if those who are uncertain about a child's safety, or know a child is unsafe choose to act, we cannot say with confidence that Oranga Tamariki will respond.

The highest number of deaths at the hands of carers are tamariki aged under 1. These babies are some of the least visible in our country and checking on them, in person, must be a priority. The decisions announced by the Government in October are a good start. Now we need to see some action.

Arran Jones
Chief Executive

He whakamihi l Acknowledgement

Kupu whakataki

Foreword

Key findings

• Tamariki are still no safer than when Malachi died

Scope

Our approach

Introduction

• Since Malachi’s death, a further 24 tamariki have been killed by someone who was supposed to be caring for them

Closing the critical gaps

• The Poutasi report found five critical gaps

Critical gap 1: The needs of a dependent child when charging and prosecuting sole parents through the court system are not formally identified

Critical gap 2: The process for assessing the risk of harm to a child is too narrow and one-dimensional

Critical gap 3: Agencies and services do not proactively share information, despite enabling provisions

Critical gap 4: There is a lack of reporting of the risk of abuse by some professionals and services

Critical gap 5: The system’s settings enabled Malachi to be unseen at key moments when he needed to be visible

Responding to reports of concern

• The child protection system is not currently able to respond when needed
• Significant numbers of reports of concern are already being made and the number is increasing
• Oranga Tamariki has a two-stage approach in deciding whether to respond to a report of concern
• Decisions on whether to act on a report of concern are also unduly influenced by site resources
• Oranga Tamariki site decisions on whether to take action do not always put the child in the centre
• Professionals who make reports of concern tell us the threshold for Oranga Tamariki to act is too high
• Oranga Tamariki is continuing to refer tamariki and whānau to community providers despite contract cuts, loss of resources and limited capacity
• A resourced and capable community sector could help Oranga Tamariki focus on where a statutory response is most needed and reduce harm

Child death reviews

• Child death reviews are not leading to the systemic change needed to prevent further harm
• Death reviews further demonstrate the critical gaps identified in the Poutasi report
• Oranga Tamariki may be missing opportunities to identify, learn from and address risks
• There is a lack of a well-resourced, independent death review mechanism supported by system-level accountability

Glossary

Appendix A: Summary of agency progress on Poutasi recommendations

Appendix B: Agencies’ progress on own recommendations

Appendix C: MSD survey results

Appendix D: Child death review mechanisms in Aotearoa

• Police process for reviewing some child deaths
• Oranga Tamariki process for reviewing the death of a child known to it
• National mortality review functions

Appendix E: Child protection policy compliance

Appendix F: Resources and support