Appendix B: Agencies’progress on own recommendations
In addition to commissioning the Poutasi report following the death of Malachi Subecz, agencies also completed their own reports and recommended actions for themselves. This table gives an overview of agencies’ progress on the recommended actions they set themselves in their own reports. For actions that were not complete at the time of our 2024 review, we include an update (2025 status) on what agencies have done since to progress the recommendations. Where actions were noted as complete in our last review, no further updates are given beyond the 2024 status.
| Recommendations | 2024 status |
|---|---|
| That as a matter of urgency Oranga Tamariki resets the expectation that only experienced and capable social workers should complete initial assessments and takes steps to ensure this is occurring consistently. | Oranga Tamariki advised this action was complete. |
| That as a matter of urgency Oranga Tamariki reiterates to all staff the requirements of the case recording policy and the need to record and action the voices of and any other people who make contact. This should be done immediately issuing a Practice Note from the Chief Social Worker. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki establish and embed an accountability and reporting mechanism based on the core aspects of statutory social work – the eight Practice Standards. This framework will be used to measure and monitor the application of the Practice Standards, giving social workers, supervisors and managers greater visibility about the extent to which the Practice Standards are being met. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki provides clarity to social workers about their responsibilities to meet the Practice Standards and implement responses when they are not met. These responses must balance the provision of development support and personal accountability and ensure that poor practice is not accepted. | Oranga Tamariki advised this action was complete. |
| Recommendations | 2024 status |
|---|---|
| That as a matter of urgency Oranga Tamariki works with Te Āhuru Mōwai site and the Bay of Plenty regional team to create a support plan to address the specific issues which have been identified in terms of leadership, site culture, professional development and engagement with community partners. | Oranga Tamariki advised this action was complete. |
| That Te Āhuru Mōwai site undertakes work in partnership with , Māori, community and other government services in the re-design of a local approach to Reports of Concern which responds when worries are raised about the safety and wellbeing of . | Oranga Tamariki advised this action was complete. |
| Recommendations | 2024 status |
|---|---|
| That Oranga Tamariki ensures social workers have the opportunity to engage in professional development, training, coaching and mentoring relevant to their level of experience in order to respond confidently and capably in the areas of practice identified within the findings of this review. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki progress the action within the Future Direction Plan to develop and implement a post-graduate professional practice course for statutory social workers. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki ensures Supervisors have access to ongoing training, development, regular internal support, and external supervision. That Oranga Tamariki accelerates work currently underway to lift the capability and quality of supervision practice. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki ensures all site and regionally based managers have access to appropriate training and professional development to carry out their role. This includes the provision and resourcing of professional development plans, leadership training, coaching and regular supervision. | Oranga Tamariki advised this action was complete. |
| Workload and Work Management | |
| That Oranga Tamariki develops a caseload sizing approach, which accounts for complexity and establishes a baseline for an acceptable workload in order for individual practitioners to undertake professional, reflective, and responsive practice. This approach must be able to be applied in relation to an individual practitioner and across team and sites as a whole. | Oranga Tamariki advised this action was complete. |
| That Oranga Tamariki progress the action within the Future Direction Plan to establish a national visibility model for caseload/workload management, that enables regular reporting and identifies gaps in capacity where additional workforce investment and wider resources may be required. | Oranga Tamariki advised this action was complete. |
| Practice Guidance and Policy | |
| That as a matter of urgency Oranga Tamariki, involving the Office of the Chief Social Worker, completes a review of the legal position and policy underpinning initial assessment practice. | Oranga Tamariki advised this action was complete. |
| Child Protection Protocol | |
| That Oranga Tamariki and Police work with Te Whatu Ora (Health New Zealand) to consider their inclusion as a party to the Child Protection Protocol, and to ensure that the CPP provides for greater clarity, support and expertise from health when assessing potential signs and indicators of abuse and neglect. | Oranga Tamariki advised this action was complete. |
| Complaints Processes | |
| That work underway as part of the Future Direction Plan to develop a fit for tamariki and whānau complaint process takes into account the experiences and insights of Malachi’s whānau, with particular regard to the need for greater independence and accessibility. | Oranga Tamariki advised this action was complete. |
| Recommendations | 2024 status |
|---|---|
| Collaborative decision making | |
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That work is accelerated as part of the Future Direction Plan to fundamentally shift how Oranga Tamariki assesses and response to reports of concern with our partner agencies to ensure collaborative decision-making and support. That this work should build on partnered approaches and processes already being used in some parts of the country. That careful consideration is given during design of this approach in order to understand and make provision for the resourcing requirements to enable this model to work effectively. That the following principles and elements should be considered in the development of this approach:
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Oranga Tamariki advised this action was complete. |
| We [Oranga Tamariki] propose consideration of a review of the effectiveness of the Children’s Act 2014. The purpose of this would be to clarify the responsibilities of children’s agencies in supporting timely information-sharing and prioritisation of services for tamariki who come to the attention of Oranga Tamariki, with an emphasis on a collaborative approach to responding to report of concern. | Oranga Tamariki advised this action was complete. |
| Recommendations | 2024 status | 2025 status |
|---|---|---|
| Recommendation 1 Corrections must undertake a review of the Relationship Agreement with Oranga Tamariki, and thereafter ensure a review is undertaken every two years. |
Not achieved. | Not achieved. |
| Update on recommendation 1 The Relationship Agreement is still being reviewed. |
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| Recommendation 2 Corrections must review and refresh its induction processes to ensure that information about a prisoner’s dependent children in the community is identified and recorded. Corrections must consider the Bangkok Rules and the Inspection Standards as it refreshes its induction processes. |
Not achieved. | Not achieved. |
| Update on recommendation 2 Specialist advice is being sought on the collection and storage of personal information on dependent children of people in prison. |
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| Recommendation 3 Corrections must review its processes for approving telephone numbers, particularly for prisoners with dependent children in the community. |
Corrections advised this action was complete.. | |
| Recommendation 4 Corrections must remind staff of the requirement to follow practice guidance for video calls at all times. |
Corrections advised this action was complete. | |
| Recommendation 5 Corrections must review and refresh its processes in cases where there is a report of concern about a child. As part of this review, Corrections must engage with key agencies, including Oranga Tamariki and Police. |
Not achieved. | Not achieved. |
| Update on recommendation 5 Corrections has reviewed all material on its intranet on child protection and is updating this so that it is easy to fid and clear for kaimahi. It has worked with Police and Oranga Tamariki regarding the processes for reporting concerns and this is informing the development of updated materials and guidance. The updated materials and guidance are expected to be available to Corrections kaimahi by December 2025. |
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| Recommendation 6 Corrections must remind staff of the responsibility to ensure that prisoner information is appropriately recorded and stored. |
Corrections advised this action was complete. | |
| Recommendation 7 Corrections must remind staff of best practice when correcting errors in official documents. |
Corrections advised this action was complete. | |
| Recommendation 8 Corrections must ensure that review risk assessments are completed in accordance with the Prison Operations Manual. |
Corrections advised this action was complete. | |
| Initiatives | 2024 status | 2025 status |
|---|---|---|
| Initiative 1 A review and refresh of ’s existing MAP (Manuals and Procedures57) and its Doogle (intranet) pages to ensure the information available to staff is clear, relevant and current. |
Not achieved. | MSD advises this action is complete. |
| Update on Initiative 1 MSD updated MAP and the relevant content on its intranet, Doogle, in December 2024. |
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| Initiative 2 Delivering existing training on MSD’s Child Protection Policy to staff in the next year, and frontline-focused training to be adapted for non-frontline staff. |
Not achieved. | MSD advises this action is complete. |
| Update on Initiative 2 MSD refreshed its ChildSafe online learning module and assigned it to all kaimahi to complete in November 2024. |
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| Initiative 3 Increasing the visibility of the Child Protection policy and all the related resources through the various staff platforms on the MSD intranet. |
MSD advises this action is complete. | |
| Recommendations | 2024 status | 2025 status |
|---|---|---|
| Recommendation 1 Change Ministry of Education internal processes for decision making on cases where a child has experienced serious harm so that decisions are passed through and approved by the relevant Hautū (Deputy Secretary) of each region, in consultation with the Hautū of Te Pae Aronui (Operations and Integration). |
Not achieved. | The Ministry of Education advises this action is complete. |
| Update on recommendation 1 Ministry of Education implemented its revised internal process for decision making on cases where a child has experienced serious harm in July 2024. |
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| Recommendation 2 The Early learning Operations Group within Te Pae Aronui58, in conjunction with Takiwā Hautū (Deputy Secretary Regions), uses what it has learned through the review of Abbey’s Place Childcare Centre following the death of Malachi Subecz to inform regulatory work, including: |
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| i. A current state assessment of how it monitors safety checking and child protection policies to make recommendations for change | i. Ministry of Education advised this action was complete | |
| ii. The delivery of a blueprint for being a modern regulator as part of the Te Mahau work programme, including the development of specific recommendations for ECE regulator practice | ii. Not achieved | ii. Not achieved |
| iii. The establishment of an education sector regulatory group for agencies with regulatory accountabilities for education. | ii. Not achieved | ii. Not achieved |
| Update on recommendation 2 Ministry of Education advised that its report into Abbey’s Place Childcare Centre has informed and been incorporated into the ECE regulatory sector review. It did not provide specific updates on sub-recommendations ii and iii. |
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| Recommendations | 2024 status | 2025 status |
|---|---|---|
| Recommendation 1 Endeavours towards joined up medical records with appropriate point of care access continue to be supported. It noted that priority should be given to joining up the medical records of children, particularly those in vulnerable situations given they often move between different services and geographical locations, which increases the risk of indicators being missed. |
Not achieved. | Not achieved. |
| Update on recommendation 1 Health NZ is progressing a programme of work to join up medical care records across the health system. In addition, Health NZ has been working with Oranga Tamariki to progress an initiative that would flag all under the care of Oranga Tamariki in primary care IT systems. Health NZ is in the final stages of approval for resourcing to progress the work. |
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| Recommendation 2 Consideration be given to extending Gateway assessments59 to children who are placed into the care of others as a result of their parent(s) being imprisoned. |
Not achieved. | Ministry of Health advises this action is complete. |
| Update on recommendation 2 Consideration was given to extending Gateway Assessments as part of the Gateway Assessment Review and redesign. A decision was made not to extend assessments. The current priority for agencies is on making national improvements to the Gateway service to enable earlier access to health, education and disability services for tamariki in the care of or at risk of being in the care of, Oranga Tamariki. A phased approach to progressing the improvements is planned. |
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| Recommendation 3 Improvements be made to the report of concern process to incorporate multi-agency reviews of a report, to help determine an appropriate response. |
Not achieved. | Not achieved. |
| Recommendation 4 The findings of the review are shared with relevant agencies to inform opportunities for inter-agency working to identify response to abuse in future. |
Not achieved. | Not achieved. |
| Update on recommendations 3 and 4 The Ministry of Health advised that agencies are progressing this as part of overall work on improving the response to the report of concern process. |
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| Recommendation 5 A cross-agency review be carried out for every case where a child dies from abuse and actively monitor themes at a national leadership level. |
Not achieved. | Rejected. |
| Update on recommendation 5 The Ministry of Health confirmed that this action has now been rejected and will not be progressed by agencies at this stage. |
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