Closing the critical gaps
2 The process for assessing the risk of harm to a child is too narrow and one-dimensional.
3 Agencies and services do not proactively share information, despite enabling provisions.
4 There is a lack of reporting of the risk of abuse by some professionals and services.
5 The system’s settings enabled Malachi to be unseen at key moments when he needed to be visible.
The Poutasi report was published in December 2022 and echoed themes from previous child death reviews in dating back 30 years. Those themes included a need for greater collaboration across agencies, better information sharing and the need to build awareness and knowledge to better inform identification and reporting of child abuse at both a community and professional level.
Our 2024 review found that recommendations from the Poutasi report had not been implemented and there had been limited progress on actions identified in agencies’ own reviews. Furthermore, what had been done addressed symptoms rather than underlying root causes. The critical gaps identified in the Poutasi report remained.
We found the Oranga Tamariki response to reports of concern was not always sufficiently focused on the safety of and . Oranga Tamariki was not making the best use of its resources to respond to reports of concern. Site decision making on reports of concern was unduly influenced by resourcing and workload, and the threshold for statutory intervention seemed to differ across Oranga Tamariki sites as a result.
We reported there was a lack of trust across the sector about whether Oranga Tamariki would respond appropriately to reports of concern – and noted this trust would need to be rebuilt. We noted that, in tandem with this, the NGO sector would need to be resourced and supported to pick up and respond to reports of concern that do not meet the threshold for statutory intervention – such as early intervention support for . Alongside work to educate professionals on when to report concerns, this might improve the capacity of Oranga Tamariki to investigate reports of concern more fully.
Our 2024 review concluded that the system-level change called for in the Poutasi report had not been realised. We noted that other agencies, particularly children’s agencies, need to respond to wider needs of whānau earlier – including health, education, employment and housing needs – to prevent the escalation of harm to tamariki wherever possible. Expectations that Oranga Tamariki will be able to solve it all need to change.
Following our 2024 review, the Government started to track this work, with a standing agenda item on the recommendations included on the agenda for Child and Youth Ministers.
In early October 2025, while we were writing this review, the Government announced it formally accepted all the recommendations of the Poutasi report. It agreed to take an integrated, all-of-government approach focused on safeguarding children to implement the recommendations with urgency.