The Poutasi report found system settings allowed Malachi to be invisible. He was not seen or focused on by professionals working within the children’s system and did not have a voice. It noted there were those who tried to act but were not listened to, those who were uncertain and did not act and those who knew and chose not to act.
Critical gap 5
The system’s settings enabled Malachi to be unseen at key moments when he needed to be visible
The Poutasi report made four recommendations to make like Malachi more visible to professionals working within the children’s system. It included recommendations to more explicitly state which agencies are children’s agencies and what responsibilities those agencies have as well as a recommendation for regular public awareness campaigns to be undertaken.
The final recommendation was for the Independent Children’s Monitor to review the Government’s progress against the recommendations in the Poutasi report a year on from its publication. We fulfilled that requirement with our 2024 review.
The Poutasi report made recommendations aimed at clarifying the responsibilities of children’s system agencies regarding child protection. This included a recommendation that the agencies that make up the “formal Government’s children’s system” should be specifically defined in legislation.
The Poutasi report went further to recommend that specific responsibilities be included in children’s agencies’ founding legislation so it is clearer that they share the responsibility for checking the safety of and .
For this review, we were informed that the recommendation to define the agencies that make up the “formal Government’s children’s system” in legislation is complete. While no legislative changes were made, the Minister for Children agreed in May 2024 that existing legislation meets the requirements of this recommendation. This is despite the Poutasi report noting it was not clear enough.
We note there are groups of agencies with statutory responsibilities making up the formal Government’s children’s system, but as these cross several different pieces of legislation, it is complex. For example, the Children’s Act sets out children’s agencies in section 5, defines which agencies must have a child protection policy in sections 14 and 15 and specifies which agencies and organisations are required to safety check children’s workers in section 24. The Oranga Tamariki Act specifies which agencies are child welfare and protection agencies in section 2. Across these Acts and sections of Acts, there is considerable variation in the agencies listed, and it remains unclear which agencies constitute the “formal Government’s children’s system”.44
Specific responsibilities of children’s agencies have not been clarified in founding legislation as set out in the recommendation, and the Government has advised that it will not be possible to do this as envisaged by the Poutasi report as not all children’s agencies have founding legislation.<sup><a href="#note45" id="para45">45</a></sup>
In its decisions to accept the recommendations of the Poutasi report, the Government noted that it is important to consider the recommendation to clarify the responsibilities of children’s agencies in founding legislation in the context of other changes being implemented that will strengthen agency accountability for checking child safety. It noted that checking the safety of tamariki already exists in Part 2 of the Children’s Act and that agencies will take immediate steps to ensure that all children’s agencies are complying with these provisions. Officials will also assess whether there are any gaps and consider what further legislative change may be required to fully implement the intent of this recommendation.<sup><a href="#note46" id="para46">46</a> </sup>
The lack of progress to date on recommendations focused on the responsibilities of children’s agencies is a missed opportunity for Government to ensure agencies across the system can focus on and be held to account for their roles in keeping children safe. Through our future monitoring, we will be looking to understand how recent commitments the Government has made to address these recommendations are making a difference.
Work to respond to these recommendations has not clarified roles and responsibilities for child protection across the children’s system.
The Children’s Act requires prescribed agencies to have a child protection policy that sets out how the organisation identifies and reports child abuse and neglect.47
At the time of our last review, only two of the agencies we reviewed had a child protection policy that met the requirements under the Children’s Act. Positively, for this review, all of the agencies we reviewed that were required to have a child protection policy had an up-to-date policy, with most agencies having updated their policy since our 2024 review.
For this review, seven48 of the eight agencies we reviewed advised they have up-to-date child protection policies. Six had updated their child protection policy since our 2024 review.
Oranga Tamariki updated its policy in late November 2025, just prior to the finalisation of this review. It had not reviewed its policy since November 2020 so was well overdue.
ERO does not have a child protection policy and is not currently required to under the Children’s Act, but it told us that its Manual of Standard Procedure and associated resources provides its kaimahi with clear guidance on practices, which helps ensure child protection.
Corrections told us it has elected to have a child protection policy although it is not required to under the legislation.
The table at Appendix E sets out agencies’ compliance with child protection policies in more detail.
In 2024, Oranga Tamariki told us that public awareness campaigns will be an ongoing programme of work and ideally become part of its business-asusual operations.
Despite this, no observable progress has been made since we last reported. In response to our information request, Oranga Tamariki noted this work was delayed.
A December 2025 Cabinet paper noted that two separate campaigns are planned by Mokopuna – Children's Commissioner and Accident Compensation Corporation (ACC). The campaigns are respectively focused on child maltreatment and child sexual abuse prevention. The paper notes that as implementation of these campaigns progress, the agencies responding to the Poutasi recommendations will consider whether a broader campaign is needed.
We note that both Mana Mokopuna and ACC are Crown entities that were not tasked with responding to the Poutasi recommendations. While the campaigns seek to fill gaps in public awareness, government agencies should not fully rely on these campaigns to address their responsibilities. As noted in critical gap four, there remains a responsibility in the Oranga Tamariki Act for the Chief Executive to educate the public, and professional and occupational groups, on how to identify, prevent and report cases of child abuse.
Child death reviews continue to highlight the invisibility of and to the system. More must be done if this critical gap is to be closed.
Of the 17 child death reviews provided by Police and Oranga Tamariki, at least seven highlight that tamariki were not visible to the system that needed to protect them.
“[The child] is not visible in the case work. The case work became very adult focused, and [the child] got lost in the adult issues. [The child] was a vulnerable child who was unable to speak for themselves, their voice is missing from the assessment.” ORANGA TAMARIKI CHILD DEATH REVIEW
44 The children’s system is focused on all children in and is therefore wider than the Oranga Tamariki
system, which is focused on , and who are at risk of, currently receiving or have received
services or support under or in connection with the Oranga Tamariki Act.
45 Paragraph 30 refers: msd.govt.nz/documents/about-msd-and-our-work/publications-resources/information-releases/cabinet-papers/2025/update-on-government-response-to-the-dame-karen-poutasi-review/paper-update-on-government-response-to-the-dame-karen-poutasi-review.pdf
46 ibid
47 Under the legislation, these child protection policies must be available on agencies’ websites and must be reviewed every three years.
48 Corrections, Police, Ministry of Health, Ministry of Justice, Ministry of Education and .