Our approach
This review focuses on the five critical gaps within the system that the Poutasi report identified, whether those gaps are closing and whether are safer as a result.
As with our last review, we requested information and data from all agencies with responsibilities for implementing recommendations from the Poutasi report. We also requested data and information from agencies about their progress in completing actions arising from their own internal reports.4
In our information requests, we asked agencies about the recommendations they are responsible for, including what work has been completed since our last review and whether the impact of any change is being measured.
For this second review, we engaged with a wider range of agencies, including Corrections, ECE providers and representatives from several government agencies and non-government organisations () who are part of multiagency response teams responding to either Police callouts for family violence or to reports of concern made to Oranga Tamariki across the motu.5 These engagements included kaimahi from Police, other government agencies, NGOs and /Māori services.
We spoke with kaimahi from Oranga Tamariki to understand if their response to reports of concern had changed in any way. This included the Oranga Tamariki National Contact Centre.
We also surveyed some frontline kaimahi in the Ministry of Social Development ().
Our 2024 review noted our intention to look at whether the system’s response when a sole parent of a dependent child is incarcerated has changed in response to the Poutasi report. For this review, we heard from some sole parents in prison faced with the decision of deciding who would care for their dependent tamariki when they received a prison sentence.
In our 2024 review, we found the Poutasi report recommendations had not been implemented and the system change called for had not happened. Given this lack of progress, we wanted to understand how agencies are applying findings from other reviews of child deaths to make the system safer for other tamariki.
To provide context about child death reviews in , we requested information from five of the children’s agencies: Ministry of Education, Ministry of Health, Ministry of Justice, Police and Oranga Tamariki. In addition, we requested information from the Health Quality & Safety Commission | Te Tāhū Hauora. All six agencies responded to our request. Information was not requested from the Coroners Court | Te Kōti Kaitirotiro Matewhawhati.
Police and Oranga Tamariki provided data and information, including copies of the child death reviews they had undertaken between December 2021 and June 2025.
An overview of the status of agency responses to recommendations in the Poutasi report is set out in Appendix A. A similar overview of the status of agency responses to their own recommendations is provided in Appendix B.
| April | April 2025 we requested information from agencies with responsibilities for responding to the actions in the Poutasi report on progress and, where relevant, what actions they have undertaken in response to their own agency reviews. |
| May | May and June 2025, we spoke directly with sole parents in prison with dependent children being cared for by someone other than a parent, and to kaimahi and leadership from across ECE services, Corrections kaimahi, and multi-agency teams responding to family violence. We also surveyed some Ministry of Social Development frontline kaimahi and spoke with leadership at NZ Customs Service. |
| June | |
| August | August 2025, we spoke with six members of the leadership team from the Oranga Tamariki National Contact Centre (NCC) to hear more about how the process of the NCC triaging reports of concern is working. |
| September | September 2025, we provided a draft report to the agencies. |
| December | December 2025, we submitted the final report to the Minister for Children, and to agencies for formal response (under legislation, agencies that are the subject of this report have 35 working days to provide a written response). |
In addition to the more than 1,200 people we engaged with in our regular monitoring in 2024/25, for this review we also heard from
- 13 mothers
- 52 ECE kaimahi
- 19 Corrections kaimahi
- 46 Ministry of Social Development kaimahi
- 6 kaimahi from the Oranga Tamariki NCC
- Oranga Tamariki kaimahi as part of our community monitoring in the Bay of Plenty, Greater Wellington and Te Tai Tokerau
- 32 kaimahi who are part of local multi-agency responses (for either family violence or reports of concern) in their rohe from five different localities – Auckland, Bay of Plenty, Hastings, Gisborne and Canterbury.
We selected communities to visit based on the numbers of reports of concern made to Oranga Tamariki in 2024 by ECE services and Police.6 The communities we visited included some with high numbers and some with fewer numbers of reports of concern from ECE services and Police. We worked with the Education Review Office (ERO) to identify a range of ECE providers in each area that had not been subject to review by ERO in the past year (so providers were not overburdened). We engaged with ECE kaimahi from a range of provider types, including larger organisational structures, independently owned services and kōhanga reo.
Police helped us connect with multi-agency teams responding to family violence7 that are operating in the same communities so we could look at how those responses are working in practice.
We worked with Corrections to identify and engage with mothers in Christchurch Women’s Prison and Arohata Prison who had dependent tamariki being cared for by someone other than a parent. We also spoke with Corrections kaimahi in these prisons and Christchurch Men’s Prison about how they work with parents in prison and Corrections’ responsibilities relating to child protection.
The table below explains how we use terms in our reviews when referring to what we heard.
| Quantity | Term used |
|---|---|
| One, used as an example of a theme | For example, a |
| Two | A couple |
| Three or more but less than half | Some |
| Around 50% (where this is more accurate than some or most) | Many/Around half |
| More than half | Most |
| 90%+ | Almost all |
| 100% | All |
4 We have used the most recent data provided to us by Oranga Tamariki. As this is operational data, in some cases, the figures reported differ slightly to data in our 2024 review. Where the most recent dataset did not contain the data we required, we have used older datasets that do not reflect recent updates to the operational data.
5 Our previous review included qualitative information from engagements with Oranga Tamariki kaimahi only. This was because only Oranga Tamariki had progressed changes sufficiently for us to seek information about the impacts they were having.
6 Police reports of concern that were specific to family violence.
7 Multi-agency responses were recommended by Dame Karen Poutasi in recommendation 3 of her report. Our last
review identified the models that were operating, but we did not speak with any for our last report.