At-risk children are no safer now than they were after a series of recommendations after the horrific death of a 5-year-old Malachi Subecz, according to the Independent Children's Monitor.
The assessment comes in a follow-up report by the Aroturuki Tamariki / Independent Children's Monitor into whether the system has improved since the Bay of Plenty boy's murder.
He suffered months of abuse at the hands of his carer, Michaela Barriball, including being beaten and burned, before he was murdered in November 2021. Barriball will spend at least 17 years in prison over his death.
In the wake of his death, a review by Dame Karen Poutasi was commissioned and six government agencies reviewed their work.
But the latest report, called 'Working towards a stronger safety net to prevent abuse of children', stated: "We are not confident that tamariki in similar situations to Malachi are any more likely to be seen, or kept safe by the system, than they were when Malachi died."
Aroturuki Tamariki chief executive Arran Jones said it was "disappointing to see the lack of priority given to this by government agencies over the last two years".
"The gaps identified by the Poutasi review were not new and have been raised by previous reviews over decades."
He told Checkpoint of the 14 recommendations in Dame Karen's review, only one had been implemented and that was for this progress report.
"There's been discussions and work done to understand how these recommendations can be acted upon, but they're yet to be implemented."
He said agencies told Aroturuki Tamariki that was because some of the recommendations required legislative changes and lengthy work behind the scenes.
At-risk children no safer now than they were 3 years ago
Agencies had taken some steps in their own reviews since the latest report was finalised, Jones said.
The report said the system change which Dame Karen had called for had not happened.
Agencies had made limited progress and what had been done did not address fundamental underlying problems, the report stated.
"A succession of reviews into the death or serious abuse of children have pointed at the need for greater collaboration and information sharing between government agencies and non-government organisations (NGOs). Not sharing information when the safety of a child is at risk leads to tamariki falling through the gaps, as happened with Malachi.
"While government agencies are continuing to discuss how they can better collaborate, there is still no consistent, nationwide approach. Working together to ensure tamariki are safe must be treated as core business and supported accordingly."
On the other hand, some of the agencies had acted on recommendations from their own reviews, Jones said.
"But again, some of these things, they're reading the symptoms without getting underneath the real causes here, which is about collective effort, working together and information sharing, so that when things are known, agencies can put the pieces of the puzzle together, and when they do that that's when they realise help is needed."
Jones used the Oranga Tamariki recommendation, which they made themselves, to ensure social workers with less than 12 months experience were not making decisions on whether to act, as an example of not addressing underlying problems.
"Now this has been put in place by them but actually the underlying concern is - and what our report shows - is you've got a variable threshold for when Oranga Tamariki act, depending on which side is receiving those reports of concern, and this is unduly influenced by resources they have on the site."
'This pattern ... has to stop'
Barriball became Malachi's full-time caregiver after his mother was imprisoned earlier in the year.
Afterwards, it was revealed his cousin had repeatedly tried to get help.
The cousin reportedly contacted multiple groups six months before he was killed. In June 2021, she contacted police about concerns about worries whether the caregiver could care for him. She alerted his childcare centre and asked them to report any concerns about his wellbeing and visited an Oranga Tamariki office to make a report of concern.
Aroturuki Tamariki's Arran Jones said action was needed.
"This pattern, of a child death followed by a review and recommendations that are not implemented, has to stop. Action needs to be taken to keep children safe. We won't look away and will report whether anything has changed in another 12 months."
Oranga Tamariki must act when there were reports of concern, Jones said.
"The availability of staff has an undue influence on the decisions social workers must make on whether or not to take action on a report of concern. This results in an inconsistent response across sites and an inconsistent threshold for when further action is taken.
"Almost half of reports of concern made by NGOs, and 40 percent of those from early childhood education providers and schools, are recorded by Oranga Tamariki as requiring 'no further action'. When social workers from NGOs, or school staff, report concerns to Oranga Tamariki they don't do this lightly. NGO staff tell us that they have usually exhausted every other option to help whānau before they make a report of concern to Oranga Tamariki."
Bosses of agencies say they are committed to improvement
In response, the chief executives of six public service agencies charged with the wellbeing of children said there were no easy solutions to child abuse.
The heads of Oranga Tamariki, police, Health NZ, ministries of heath, social development, justice, Corrections and education said their departments had worked hard on what was an incredibly complex and challenging process. They said they were committed to changing the system for the better.
Dame Karen's report proposed several changes across the wider children's system to make sure there was an interconnected safety net which protected children.
In a statement, the chief executives said: "There are no easy solutions when it comes to child abuse in our country. The causes lie deep in deprivation, intergenerational trauma, and other unmet needs while there are rarely easy responses when the state is called to intervene in families and whānau to protect children and young people."
They said the Independent Children's Monitor had concluded change had not been quick enough.
"It will take time. The children's system is complex, something the Independent Children's Monitor has acknowledged in its report in the context of Dame Karen's recommendations.
"But child abuse is a problem we must all tackle together - families, communities and government agencies - to keep our children and young people safe."
Jones said they would be checking in on the agencies for a further review in 12 months.
"It's too important to look away.
"The best data we have currently is a child is killed in New Zealand every five weeks, and that's appalling statistic and we have to do something about it.
"Some of the concern I'm now seeing is some of the agencies pulling away from some of this work, when actually, you know, we need to make sure, if someone is pulling away, who's stepping in? And it needs to be co-ordinated, otherwise we're going to create further gaps."
He said he heard the Minister for Children Karen Chhour speak in the House on Thursday about her commitment to ensure the best decisions were made to keep children safe, and he was confident she understood what was required.