The family of murdered five-year-old Malachi Subecz say the reports released today confirm their view that his death was preventable and he was failed by Oranga Tamariki.
And Minister for Children Kelvin Davis has acknowledged Malachi would probably still be alive if Oranga Tamariki staff and other agencies had done their jobs properly.
"It's quite likely that he would still be alive if all the agencies had done what they were meant to do," he told Checkpoint.
Listen to Kelvin Davis
Dame Karen Poutasi's review has found critical gaps in information-sharing between government departments, making vulnerable children such as Malachi at risk of becoming "invisible".
Malachi died in hospital in November 2021 after prolonged abuse at the hands of Michaela Barriball, who became his full-time caregiver after his mother was imprisoned earlier in the year. Barriball was jailed for life with a minimum non-parole period of 17 years in June.
In a written statement, Malachi's maternal cousin and uncle say the reports reveal a long list of fatal errors in Oranga Tamariki's (OT) handling of their concerns.
His cousin, who had repeatedly tried to get help for Malachi, said while the reports would not bring him back, the family was hopeful the horrific tragedy would bring change for other children.
"Inexperienced staff, inappropriate supervision, leadership, resourcing and cultural issues within OT sites and regions, and gaps in the safety nets that should keep children safe are all listed within the report/s," the cousin said.
Malachi's uncle said Oranga Tamariki had acknowledged that it did not follow its own guidelines, never spoke to Malachi, or engaged with whānau.
"Malachi is a change angel; his death cannot be in vain," he said.
The family said the report only confirmed what the whānau already knew - that Malachi's death was preventable.
"We have always known that we did all we could to try and save Malachi, but Oranga Tamariki didn't listen to what I and others were telling them," said Malachi's cousin, who filed the initial report of concern in June 2021.
"Despite multiple attempts, I was not heard, and my information was not assessed by appropriately trained and experienced staff," Malachi's maternal cousin said.
An advocate for Malachi's family, Ruth Money, said the report revealed that Malachi's views were not sought at any point.
"There was plenty of external and independent information that was proactively supplied to Oranga Tamariki about Malachi's vulnerable situation, and yet systems and people failed him. This can never happen again," Money said.
A detailed plan was needed to urgently deliver all the report's recommendations, she said.
The report showed what the family already knew - that there had been a long list of fatal errors, she told Checkpoint.
"There's been over 33 reviews into child abuse and deaths in 30 years, so what has changed, and that's what the whānau are asking."
"Children are taonga, why are we not supporting mandatory reporting?" - Advocate for Malachi's family, Ruth Money
While the independent panel recommended mandatory reporting of children at high risk of harm, the minister said officials would review that indepth before deciding whether to commit to it.
There could be unintended consequences from implementing such a measure, he said, including "a potential flood of unnecessary reports".
But Money called the hesitancy "a cop out".
"Mandatory reporting is a no-brainer if it can save one teeny tiny child, what is the problem? "
Both Malachi's cousin and uncle remain convinced that "there is no doubt Malachi would still be alive if Oranga Tamariki had acted appropriately".