There were several alarm bells raised over the safety of five-year-old Malachi Subecz before he was murdered by his carer last year. But these were either dismissed or not followed up.
On 1 December, 2022, a report by an independent panel found five gaps in the system, and made 14 recommendations. The government has said it will adopt nine and "look carefully" at the remaining five - which includes the mandatory reporting of children at a high risk of harm.
The panel asked police, and the ministries of education, corrections, justice, health, and social development to conduct reviews into their interactions, while Oranga Tamariki was carrying out its own separate review into its handling of events.
Chief Ombudsman Peter Boshier accused Oranga Tamariki of "a litany of failures".
What happened to Malachi Subecz
28 September, 2016 - Malachi Rain Subecz born in Tokoroa, his mother's only child.
Pre June, 2021 - Malachi's mother was arrested and began to consider who might care for Malachi if she were jailed. Malachi's extended Wellington whānau confirmed they wanted to care for him, but his mother decided Malachi should live with her friend, Michaela Barriball. She began the process for having Barriball appointed as an additional guardian through the Family Court.
21 June, 2021 - Malachi's mother remanded in custody - Malachi goes home with Barriball.
22 June, 2021 - Malachi's cousin contacts several authorities to alert them about Barriball's ability to care for Malachi and her motivations. She contacts police about the fact Barriball's mother has a non-association order with Malachi's mother. She contacts his childcare centre, Abbey's Place, advising them of the situation and asking them to immediately report any concerns for Malachi's wellbeing. She visits an Oranga Tamariki office to make a Report of Concern, which is transferred to the Tauranga West office.
23 June, 2021 - Malachi's cousin telephoned Oranga Tamariki to advise she had contacted a lawyer about making a without notice application for a parenting order to gain day-to-day care of him.
Another member of Malachi's whānau phoned the agency expressing concern that his mother was in prison and he may not be in a good environment.
Barriball applies to the Ministry for Social Development for a Sole Parent Benefit.
Throughout that month, she made requests for emergency housing support for herself and Malachi.
26 June, 2021 - Malachi's cousin received a photo of him from Barriball via Facebook, which appeared to show bruising around his eye.
28 June, 2021 - Malachi's cousin spoke to an Oranga Tamariki duty social worker via telephone and was asked to email the photo to the National Contact Centre, which she did.
30 June, 2021 - Oranga Tamariki closed the Report of Concern made by Malachi's cousin. Oranga Tamariki reported they held no specific care and protection concerns and Malachi's mother had no concerns with his care arrangements.
At the end of that month, Malachi's mother filed an application in the Family Court at Tauranga to have Barriball appointed an additional guardian.
July 2021 - Barriball began to receive financial assistance from the Ministry of Social Development for looking after Malachi.
As part of the Family Court process, a 'lawyer for the child' was appointed to represent Malachi's interests.
22 July, 2021 - The probation officer who was preparing the pre-sentence report for Malachi's mother contacted Oranga Tamariki to raise concerns regarding the care and wellbeing of Malachi. In the internal pre-sentencing notes, the probation officer noted they had been advised by Oranga Tamariki the file was closed because there were no concerns regarding Malachi's well-being or his care arrangements but was not satisfied with this.
23 July, 2021 - The probation officer contacted the prison intelligence team by telephone, followed by an email, outlining concerns Malachi could be used as "leverage" and a way for Barriball's mother to contact Malachi's mother indirectly, even though there was a non-association order in place.
An intelligence officer shared the probation officer's email with their supervisor, who suggested the probation officer should contact police. This advice was not relayed to the probation officer.
24 July, 2021 - Malachi's cousin made a complaint to Oranga Tamariki about the decision to close the Report of Concern.
26 July, 2021 - Malachi's cousin spoke with the lawyer appointed to represent Malachi's interests and repeated her concerns about Malachi's care and protection. The lawyer also confirmed to Malachi's cousin she supported her participation in the Family Court proceedings.
At the end of July, Barriball approached the Ministry of Social Development again for further housing assistance, citing issues with her current housing.
30 July, 2021 - In response to her complaint, Malachi's cousin was advised by Oranga Tamariki they had reviewed matters, including speaking with Malachi's mother, and decided an investigation would not be carried out.
August, 2021 - Barriball and Malachi met with the lawyer for the child. The Ministry of Social Development approved payment for housing for Barriball and Malachi. They moved into a cabin on Barriball's father's property, which had power but no running water.
13 September, 2021 - Malachi's care arrangements were formalised in the Tauranga Family Court, with Barriball being temporarily appointed as an additional guardian, pending a full hearing regarding Malachi's guardianship scheduled to be heard on 1 November, 2021. Barriball opposed applications made by members of Malachi's immediate family, who were themselves seeking custody and guardianship of him.
24 September, 2021 - Barriball took Malachi to Te Puna Primary School for a pre-school visit. A staff member noticed that Malachi was slim and had bruising around his eye and on his forehead.
27 September, 2021 - Barriball took Malachi to his childcare centre, Abbey's Place Childcare Centre. Staff noted Malachi's hairstyle had been changed, with his fringe covering his forehead. Malachi had 'a cluster of bruises under his chin, a scratch on his jawbone, a large swelling on his forehead (which his hair had been pulled over), and a progressively blackening left eye. They contacted Barriball, who advised that the bruising was caused by Malachi falling off his bike, which he denied. He also said Barriball would not be happy with him. They took photos of the injuries and put a note on his childcare centre file. However, they did not complete an incident form, investigate, or escalate the incident further, as required by their own Child Protection Policy.
28 September, 2021 - Malachi celebrated his fifth birthday at the childcare centre.
29 September, 2021 - Malachi attended the childcare centre for the final time.
Between 12 and 20 October 2021 - Barriball sent a series of text messages to her partner. In one message she stated she hated Malachi, in another that she was scared she would kill him, and in another that she would hurt him badly. Further messages included Malachi was in too much pain and she could not take him to the hospital because they would think she abused him, that she had a lot of anger towards Malachi and could not calm herself down, that she was going to kill him if she saw him again, and she was going to take him to Wellington.
19 October, 2021 - Barriball sent a text message to her sister saying she wanted to take Malachi to hospital but was too scared.
20 October, 2021 - Barriball sent her father a series of text messages, advising she had not taken Malachi to hospital because her partner told her not to, because the bruises on his face would make it look bad for her, and she didn't want to get into trouble.
23 October, 2021 - Barriball took Malachi to a family function at a restaurant in Mount Maunganui. Several family members voiced concerns about burn on his forehead but she claimed he had burned himself in the shower and had seen a doctor. CCTV footage shows him hunched over and walking slowly.
27 October, 2021 - Barriball's lawyer sent an email to the lawyer for the child advising they had been told Barriball had taken Malachi to Hamilton and had remained there because her understanding was they could not return to Tauranga under the Covid-19 lockdown restrictions which were in place at the time. In reality, Barriball and Malachi had not gone to Hamilton, and continued to reside in the cabin on her father's property.
The lawyer for the child was also advised Barriball had flu-like symptoms and was awaiting the result of a Covid-19 test.
The lawyer for the child asked Barriball to attend the hearing on 1 November 2021 via audio visual link but was told Barriball did not have access to a computer. Malachi's cousin offered to deliver a laptop to Barriball, but Barriball declined the offer.
28 October, 2021 - The lawyer for the child requested the hearing not be vacated until the Covid-19 test result was known.
Barriball and her father took Malachi to a medical centre, as she wanted him assessed for autism to support her bid for permanent guardianship.
She did not mention the serious burn on Malachi's abdomen, and no physical examination was deemed required, nor was undertaken.
29 October, 2021 - The Family Court hearing for 1 November was deferred as the Covid-19 test result was not available and because Barriball claimed she had been in a region that had been locked down due to a Covid-19 outbreak.
1 November, 2021 - About 8.30am, Barriball carried Malachi from the cabin into the main house. Malachi was unconscious and suffering seizures as a result of multiple blunt force injuries to his head inflicted by her.
An ambulance was called, and Malachi was taken first to Tauranga Hospital and then Starship Children's Hospital in Auckland. Malachi had emergency surgery that same day.
The Department of Corrections enabled Malachi's mother to be present with Malachi in hospital. The multiple injuries Malachi was subjected to by Barriball proved to be unsurvivable.
12 November, 2021 - Malachi dies.
30 June, 2022 - Barriball is jailed for life with a non-parole period of 17 years.