Children's watchdogs cannot properly monitor the use of force and seclusion on children in Oranga Tamariki facilities because not enough data is being collected, they say.
The Children's Commissioner has also warned of other "shortcomings" in Oranga Tamariki (OT) record-keeping and information management about children and young people detained in these facilities.
OT said its legacy systems could be a barrier to quality recording and reporting but it now had specific Budget funding to go ahead with an upgrade.
Earlier this week RNZ revealed concerns about record-keeping failures in two families' cases.
This is Part 3 of an RNZ investigative series into Oranga Tamariki. Read Part 1 and Part 2.
The Chief Ombudsman has also raised concerns that similar errors are still happening, despite promises from Oranga Tamariki that it will improve.
Mana Mokopuna Children's and Young People's Commissioner is tasked with monitoring the use of restraint and seclusion in all Oranga Tamariki youth justice and care and protection facilities.
The Independent Children's Monitor Aroturuki Tamaki also has a monitoring role.
Investigation raises concerns over Oranga Tamarki's record-keeping
Both watchdogs produce an annual monitoring report of seclusion and restraining practices under the Optional Protocol to the Convention against Torture (OPCAT), a United Nations treaty that aims to prevent torture and ill-treatment in places where people may be deprived of their liberty.
It is a legal requirement within the Oranga Tamariki (Residential Care) Regulations that the ministry records the 'use of force' and 'secure care', which are more commonly referred to as restraint and seclusion.
But not enough data was being collected to determine whether the practices were justified or being overused, Children's Commissioner Claire Achmad said.
"We are seeing that information that is recorded in the documentation that should support information about the use of seclusion and secure care is often patchy.
"There is often a lack of comprehensive detail about what actually happened in an incident that has led to the use of seclusion and secure care."
OT should be recording the exact length of time in seclusion, what led up to the event and what staff did to reduce the possibility of seclusion being used, Achmad said.
"We are very clear, as is the UN, that there should be zero use of seclusion for children and young people. So when it is used, it is extremely serious and there should be appropriate and adequately documented information about going in, and coming out of secure care."
Achmad believed a lack of qualified or trained staff working in these facilities contributed to the poor record-keeping.
A 2020 Human Rights Commission report found seclusion and restraint were used too frequently, and for too long, in Oranga Tamariki's residences.
The report was a follow-up to a highly critical report in 2017. The 2020 report found little had changed, with Oranga Tamariki noting at the time "the continued need for IT investment to improve the ability to analyse incident records".
Children were being put into seclusion just for making threats, the HRC found.
"Only a small minority of children appear to have actually done something, rather than make threats. The length of stay attached to each reasoning appeared almost random, and it was not entirely clear what the secure placement was meant to achieve," the report said.
The report also raised concerns then about the way data was being collated, with some residences resorting to pen and paper as there was no way to record data digitally.
Independent Children's Monitor chief executive Arran Jones said the lack of data on seclusion and restraint practices meant watchdogs like his and Mana Mokopuna could not determine if things had improved since 2020.
"The data that Oranga Tamariki provides us with isn't as comprehensive as you would like," he said.
"Its usefulness is limited because it doesn't have the necessary granularity. So you can't see, for example, in the data, how those rates of the use of secure and restraint compared to the size of the population.
"That's the stuff that's really important to see so you can understand whether you have it being overly used in a particular facility or not."
Care Plan 'gaps'
Every child detained in a residence has an 'All About Me' plan that provides fundamental information about them and supports their care. But these were often incomplete, Claire Achmad said.
"They often have sections that are blank or information that is outdated, so that has a practical impact on the care of children in residence.
"When information is missing, left off or outdated, that means residence staff are having to essentially learn on the fly about that person. It's a concern."
The issue had existed for more than a year and while OT had assured her it would rectify these "gaps", the pace of change was "not as swift as I'd like it to be," Achmad said.
"The information that you know about children and young people in state care is of such importance to their care and their wellbeing in the care of the state."
Poor records led to some children being held on remand for longer than they needed, she said.
"Reviews regarding remand are either not being undertaken or they're being based on inadequate information that's not taking a specific look at the individual child situation."
A child on remand should have their remand reviewed every 14 days by a social worker, but that was not always happening, Achmad said.
"You see that playing out in terms of children and young people being held on remand for significantly long periods of time in residences."
At least 10 teenagers spent more than 200 days remanded in a youth justice facility, including two who spent more than 500 days on remand, according to 2022/23 figures.
In addition, serious event notifications were often not written until days after the event had happened, and sometimes reports of concerns for children involved in that event were not being filed at all, Achmad said.
A 2023 rapid review of youth justice facilities by former police commissioner Mike Bush, found 'All About Me' plans were " inconsistent in terms of accuracy, completeness and currency."
"This seems to be driven by suboptimal implementation of the Care Standards and issues with the core CYRAS operating system," that review said.
CYRAS is OT's case management system, which the Children's Ministry has described to RNZ as "old and difficult to use". A $62.5 million upgrade is underway but will take about six years to complete.
The Bush review found there was wide variation in record-keeping and the use of evidence-based practices in OT residences.
"We visited community homes in which staff had made up their own spreadsheets and folders for children because they felt they could not rely on 'the system' to provide it for them," the review noted.
It recommended the development of standard plans, the use of quality metrics, and more training for staff.
These concerns were not new, however.
Chief Ombudsman Peter Boshier told RNZ he had "pretty deep concerns" about care plans during visits to care facilities he was the Principal Family Court Judge in 201.
"Sometimes the care plan had in it that a young person would be there for X amount of time, and they were still there, and no one quite knew why," he said.
"Sometimes the plan had set out in it that these were the steps to be taken to reintegrate this particular person into a new home or community setting that hadn't happened and we didn't know why."
Boshier said he was not surprised it was still an issue more than a decade later, because he believed the organisation lacked discipline and a strong culture when it came to record-keeping.
"There needs to be a cultural change. This is just as important as the social work itself."
Oranga Tamariki responds
Oranga Tamariki's National Director of Youth Justice Services and Residential Care Iain Chapman said capturing high quality information in records, plans and review was "an ongoing area of focus for our practice in residences and homes".
"As part of our response to the Rapid Review, and in line with our organisational focus on ensuring residents are operating safely, we have made changes to strengthen practice in this area," Chapman said in a statement.
"This includes increasing the induction period for new staff, trialling new reporting systems, rolling out training for frontline leaders and standard operating procedures to define good practice operational responses in youth justice residences.
"There are specific standard operating procedures for use of secure care and use of force," he said.
"We acknowledge that technology and several of our legacy systems can be a barrier to the quality of recording and reporting that we would like to see. This was recognised by the government, and we have been allocated specific Budget 2024 funding to upgrade our case and care management systems."
While the average rate for remand reviews sat above 90 percent, they were not always recorded in a timely manner, Chapman said.
"On the occasions when there are delays in completing remand review case notes, this does not impact how long the young person stays in the residence."
RNZ's request for OT's latest data on use of force and secure care in its facilities could not be immediately provided. OT said it would respond via an Official Information Act request.
The 2020 Human Rights Commission report found that in the six months between June and December 2019, a total of 76 children and young people aged between 14 and 18 years old were placed in a secure unit on 298 occasions, spending anywhere between a few hours and 20 days there.
These figures had more than doubled since 2016, the Commission found.
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