Key findings
The care and protection system keeps many in safe, yet gaps in the safety net remain and tamariki continue to fall through these. Malachi died in November 2021. Between December 2021 and June 2025, 24 tamariki in Aotearoa were killed at the hands of the people who were meant to be caring for them.
Tamariki are still no safer than when Malachi died
The overall key finding of this report is that tamariki are still no safer than when Malachi died. The gaps in the system – as identified in the Poutasi report – have not closed, and Oranga Tamariki is not always able to respond when it needs to. The result is that tamariki are being harmed and killed.
The Government has announced that it will prioritise this work by accepting all recommendations in the Poutasi report and put a plan in place to implement them. This is a start, but this review identifies that, in addition to implementing the recommendations from the Poutasi report, the Government must further prioritise the safety of tamariki by ensuring that the statutory care and protection system – Oranga Tamariki – is resourced and equipped to respond when needed.
Social workers need to be able to see tamariki in person when reports of concern are assessed as requiring further action. Funding and resourcing community organisations to respond to reports of concern that do not require a statutory response could help to alleviate some of the pressure on Oranga Tamariki so it can act to keep tamariki safe.
Critical gaps identified in the Poutasi report remain
The critical gaps identified in the Poutasi report were not new. The report showed that, over the previous 30 years, there had been 33 reviews and reports about child abuse and deaths. Of the 33, eight identified similar practice and system gaps as the Poutasi report. Those eight included high-profile deaths of tamariki killed by those who were supposed to be caring for them.
Our analysis of death reviews since December 2021 found that tamariki at risk of harm can remain invisible. Reviews are mostly fragmented, not child focused and tend to look at an agency’s own practice rather than across multiple agencies or at systemic issues. That means opportunities to close gaps and improve collaboration across government are being missed.
In addition, some of the recommendations that government agencies are working on from their own reviews following Malachi’s death are focused on symptoms rather than underlying causes. This narrow approach is also taken in the 24 death reviews we looked at. This means the oranga tamariki system is not learning or improving in ways that will result in meaningful change.
Three years on from the Poutasi report, progress on implementing the recommendations has been very slow. This work will help to better identify tamariki and (young people) at risk of harm or who are being harmed. What is also needed is improvement to a child protection system that is not always able to respond when called upon.
Oranga Tamariki is not always able to respond when it needs to
Recommendations in the Poutasi report sought to address the gaps around visibility of tamariki in the system, collaboration and sharing of information by agencies, and reporting of concerns by professionals and the public to make tamariki safer. Through our monitoring, we have also identified that changes are needed to how Oranga Tamariki responds to reports of concern. Even if the gaps identified in the Poutasi report are closed, tamariki will not be safer until Oranga Tamariki is able to respond to reports of concern when it must.
In the four years since Malachi died, very little has changed in how reports of concern are responded to. Like Malachi, some of the tamariki who have since died at the hands of those supposed to be caring for them were also known to Oranga Tamariki through reports of concern, but sufficient action was not taken to keep them safe.
While the number of reports of concern has increased, the number progressed for further action by Oranga Tamariki has not. This is not because the reported concerns are low risk. Rather, the static level of action is indicative of Oranga Tamariki sites working to the level of resource they have available. This results in a varied risk threshold between sites and regions. Data shows this, and the voices of community providers, government agency kaimahi, and frontline kaimahi from Oranga Tamariki confirms it. Put simply, Oranga Tamariki social workers are not always able to get in the car and visit tamariki when needed.
Collaboration between Oranga Tamariki and community organisations could provide an early check on safety
Oranga Tamariki needs the support of a well-funded and well-resourced community sector. The sector could then provide the first line of response to reports of concern that are lower risk and not assessed as requiring a statutory response. These are issues such as school attendance, food, housing or clothing. , Māori and community providers are better placed to provide this support, with the help of government agencies. Visits by community organisations could also provide an opportunity to assess any safety risks and escalate any reports of concern back to Oranga Tamariki in the knowledge that it will respond. Providing with support at the earliest opportunity is consistent with an investment approach and can also prevent harm from occurring and further notifications to Oranga Tamariki.
This kind of collaboration is being trialled in reports of concern tables – where multiple organisations sit around the same table to determine the appropriate response. These provide an early intervention that may lead to a reduction in harm and in further reports of concern. But these can only go so far. When a statutory response is needed to keep a child safe, action from Oranga Tamariki is required.
Kaimahi working with these community-led tables tell us that, when they have exhausted options for support and consider a child is in need of statutory care and protection, Oranga Tamariki isn’t always able to respond. It also doesn’t always provide updates to the tables about whether it has visited and checked the child is safe.
In addition, the funding model does not support the establishment of consistent, robust community-based solutions. For example, Oranga Tamariki is rolling over pilot programmes in six-month increments rather than committing to a mediumterm or long-term funding stream. The operating model for the tables is not consistent from one community to the next – and these tables are not available in all communities.
Changes announced by Government in October 2025 are a start but greater priority must be given to keeping tamariki safe
While the Government announced in October 2025 that it has now accepted all recommendations in the Poutasi report and is committed to taking action to respond, the critical gaps have still not been closed. Work has only just started. Training in child safety and information sharing is welcomed. It is essential to better identification of harm and to reducing the risk of overwhelming the system with reports of concern – something that could happen as a result of mandatory reporting.
Oranga Tamariki is already struggling to manage the volume of reports of concern. Any increase due to mandatory reporting will not improve the safety of tamariki if social workers are unable to get out and check on those who may require care and protection. This is why we are highlighting the need to not only address the recommendations in the Poutasi report but also to improve the capacity and ability for the child protection system to respond.
Prioritising child protection must be the collective responsibility of all government agencies that support our tamariki, rangatahi and whānau. While other agencies must step up and play their part, Oranga Tamariki must always act when needed, using its statutory responsibilities and powers to protect children and keep them safe. It should not require repeated alarm bells for Oranga Tamariki to respond.