'Quantum shift' needed to fix years of failures at Oranga Tamariki

One children's advocate counts 33 reports in 30 years into problems at Oranga Tamariki and its predecessors. Why is change at our child protection agency so hard to come by?

Ten months after five-year-old Malachi Subecz was murdered by his carer, Chief Ombudsman Peter Boshier drove out to Porirua to visit the little boy's uncle and cousin.

He was there to deliver the findings of his investigations into their complaint that Oranga Tamariki had dismissed concerns about Malachi being abused.

As he sat across the table from Malachi's whanau, Boshier remembers choking up.

"It was an incredibly emotional experience, traumatic, in fact," he recalls.

"But it was the right thing to do, to acknowledge the terrible acts of abuse this poor child had suffered.

"And I think they could see that. They could see that we actually cared to the point where it was quite emotional for us."

Boshier had reason to be emotional. His investigation found a "litany of failures" by Oranga Tamariki to follow its own policies after the Children's Ministry dismissed or ignored several reports of concern about Malachi's care.

Just a few months earlier, Boshier had delivered the findings of his investigation into the uplift of newborn pēpi, He Take Kōhukihuki , which found process, system and record-keeping issues.

"These were also underlying factors in Oranga Tamariki's failings in the Malachi Subecz case," Boshier says.

He remembers feeling "enormous change" would be needed to prevent another case like this happening again.

"Oranga Tamariki assured me following my investigation into the case of Malachi Subecz that there would be dramatic change.

"Of course, I hoped it would be the last time I would have to investigate such a case."

It was not to be.

In February this year, Boshier's office released another report.

Children in Care: Complaints to the Ombudsman 2019-2023 again identified poor record-keeping, inaccurate information and failures to follow up reports of concern as recurring themes.

An RNZ investigation last week highlighted similar failures in the cases of two families, with devastating consequences for both.

This is the final part of an RNZ investigative series into Oranga Tamariki. Read Part 1, Part 2 and Part 3.

And despite promises of system-wide changes by agencies involved in child protection following Malachi's death in 2021, a September analysis by Aroturuki Tamariki Independent Children's Monitor found vulnerable children are no better off now than when he died.

The reports added to an already teetering pile.

Child Matters chief executive Jane Searle counts 33 reviews into the ministry and its predecessors over the last 30 years.

"They all say similar things. These problems are not new. It's just that they're getting worse."

So if the problems are known, and the need for change recognised, what will it take to actually make it happen?

A broken system

For Jane Searle, radical investment in the ministry's structure and culture is the only thing that will break the cycle.

"It's going to take a lot of time, a lot of resources and very good leadership to do that. We've struggled to have the political desire to do that on a large level."

There are good social workers trying to do their best in a system that is broken, she says.

"But there are also cases of bad practice that have happened over many years which are difficult to change because it is such a huge organisation."

The many reports and reviews all suggest similar solutions, but few have actually been enacted.

"We haven't invested in the training and capacity building of Oranga Tamariki social workers and also ensuring that their workloads are manageable. And we also haven't invested in the capacity for community organisations to respond and play the important role that they play."

Searle is equally concerned the ministry doesn't have robust IT systems that allow staff to do their jobs properly.

"It's a hard job to protect vulnerable children and young people anyway, but if the organisation is not set up structurally to do that, with the right leadership and investment, it is going to continue to fail."

Central to the issue is Oranga Tamariki's two-decade-old case management system, CYRAS, which its chief social worker Nicolette Dickson admits is "old and difficult" to use.

A $62.5 million upgrade will start next year and won't be completed until about 2030, though the first stage should be complete by the end of next year, Dickson says.

"This will make a significant difference in the way we're managing record-keeping. We won't have solved the whole problem but we will have made a really good start."

"I just want a clear picture"

Behind every record - complete, partial or missing - is a person.

Ihorangi Reweti-Peters was just seven months old when he was placed into state care. Now 19, he's had over 14 different placements and experienced abuse from caregivers who were meant to protect him.

After being officially discharged from state care last year, he's been trying to piece together his early years from Oranga Tamariki's records, but chunks of his time in care are missing from his file.

"There are parts of my time in care which are not accurately recorded or they are parts missing … so I don't know what happened."

Some of the records from his first year of life are missing - lost when the ministry transferred files from paper to digital in 2006, he says.

"I just want to know my whole journey through Oranga Tamariki, from the day that the first report of concern was made to when I left.

"I just want a clear picture, which may be able to provide me with some closure to the negative experiences that I've had within Oranga Tamariki."

Reweti-Peters, who is now a state care advocate, says there are hundreds of others like him.

He's hopeful, but sceptical, that improvements will be forthcoming.

"Oranga Tamariki has on multiple occasions said they are working on changes to accurately record and gather data but we haven't seen the results of that yet.

"This is really important work. I would hope it would be able to get done quicker, to provide closure to survivors and to accurately monitor and record information."

The IT and record-keeping upgrade can't come soon enough for Aroturuki Tamariki Independent Children's Monitor chief executive Arran Jones, as it will finally allow him to do his job properly.

His agency, established in 2019 to monitor Oranga Tamariki's compliance with National Care Standards regulations, has struggled to carry out this task for the last three years due to "gaps" in OT's data about the children in its care.

The regulations prescribe basic standards that must be met for children in state care, such as regular school attendance or whether they see a dentist or doctor once a year.

But Jones doesn't know if the ministry is complying with all these standards.

"They just don't have the information centrally to be able to tell whether the kids are getting what they need. These are legal requirements on Oranga Tamariki, and they are still unable to provide the information."

Through its own self-monitoring process, Oranga Tamariki admits it has only been "partially compliant" with the national care standards the last two financial years.

Jones also worries the recent loss of 419 back office jobs at Oranga Tamariki - including cuts to its information management and a reorganisation of its data team - could hinder progress.

"I have spoken to the chief executive to gain an assurance that it wouldn't impact on the supply of information to us so that we can do our work. I guess my response to this will be a wait and see what impact it may have."

Nicolette Dickson says keeping track of 80 standards for more than 5000 children in state care is challenging, due to the limitations of the case management system.

Instead, the ministry has opted to report on a few lead indicators, and Dickson says what it has reported so far has shown improvements.

"For example, in 2022, 72 percent of children in care had had an assessment of their needs completed. By 2024, this had risen to 90 percent.

"So whilst I do accept the monitor's concern that the level of our detail and data and information doesn't enable a full picture over every aspect of the care standards, we have progressively improved the quality of information we provided to the monitor and seen progressive improvements."

The upgrade in the pipeline will allow them to provide better quality information about children in state care, she says.

Children's and Young Person's Commissioner Claire Achmad says the ministry has a duty and obligation to collect information about a child's situation in state care that can be held on their file and made available to them - which needs to be done even without a reliable case management system.

"Because that will form an important part of their understanding of their identity and their story, and so Oranga Tamariki needs to be maintaining a clear focus on this all the time, regardless of whether it's in the process of upgrading its information and record keeping system."

Like Searle, she says this will take resourcing and a culture change to get right.

"I continue to call for Oranga Tamariki to focus on getting the basics right to ensure every child in the care of the state has their full range of rights upheld in all circumstances every day.

"We know right now that Oranga Tamariki is too far away from that. But I do believe that with that focus, change is possible."

"We have an absolutely clear focus on what needs to change"

Dickson admits the ministry has lost its focus.

"Oranga Tamariki and its predecessors have had a history of trying to be all things to all communities, to all families, and falling short actually."

Dickson should know. She's worked at the ministry for more than 20 years, starting as a social worker before rising up the ranks to management. She's now its chief social worker and deputy chief executive of professional practice after the two roles were combined in a restructure earlier this year.

She says the basic tenets of social work haven't changed much over that time - though it has become more complex with the rise of methamphetamine - but support for social workers has declined.

"When I was a young social worker we had really strong systems of support, supervision, training and for a while that slipped away," she says.

"I can't speak to why things may have slipped away, but I do know there's been a very clear shift back to focusing on the core fundamentals to make sure our social workers have the support they need to do a really busy, complex and demanding job."

This shift came after a 2021 Oranga Tamariki ministerial advisory board report, Kahu Aroha, recommended the ministry get back to its core social work purpose and offer better support and training for social workers.

"That's really provided a blueprint for making sure that we are focused on developing the best tools, resources, learning and support and coaching supervision for our staff," Dickson says.

The ministry has three key priorities: providing a high level response to the kids that need it the most; enabling communities to take a lead and early response; and working with other agencies in health and education to plug the gaps.

There's no timeframe for when these will be achieved, as it's about "progressive, long-term sustainable change over time," Dickson says.

"Real, substantive, complex change isn't something that you can put a timeframe on. It's something you have to be relentlessly focused on day by day.

"We have an absolutely clear focus on what needs to change."

When it comes to record-keeping issues, the ministry regularly reviews cases and we "look at our practice really closely" so it knows where it can improve, she says.

"We know there are areas where we've still got work to do, but what I am confident about as chief social worker, is that the areas that get in the way of our social workers doing a good job are actively being addressed."

Despite the challenges, ministry social workers are doing amazing work every day, Dickson says.

"We have social workers who, on a daily basis, are out there changing lives, sometimes saving lives. I understand why that's a narrative that sometimes doesn't get a lot of air time but there are truly amazing professionals we have working for this organisation."

She strongly disagrees with suggestions that significant work is not being done to improve its record-keeping track record.

"I do appreciate the sense that change isn't happening as quickly as people may want."

She also rejects Boshier's assertion that the ministry intentionally or systematically provides incorrect information to the Family Court.

"We've taken action in each case to understand the recommendations he's made. We've looked at areas of recording and the way we manage our court practices," she says.

"These are longstanding challenging problems that exist across many care and protection systems across the world."

But she agrees with Boshier that the ministry needs a sustained plan of improvement.

"I have confidence that the plan is in place, underway and actively being worked on."

A matter of records

Proposed law changes may also beef up record-keeping at Oranga Tamariki, along with other government agencies.

As part of its response to the Abuse in Care Inquiry, the government announced last week that it will amend the Public Records Act.

The proposed changes will give greater powers to Archives New Zealand to make sure agencies are fulfilling their legal obligation to keep and maintain proper records of everything they do.

The changes are a direct response to problems raised by survivors during the Inquiry about trouble accessing their state care records, including being given heavily redacted documents and incomplete files.

The man in charge of ensuring all government agencies complies with their obligations is Archives New Zealand's director of government record-keeping Antony Moss.

He believes the amendments could be a game-changer for a public sector that's "still struggling with the fundamentals of good record-keeping".

"Overall we'd say the maturity in public sector information management is not at the level that we as the regulator would want it to be."

At the moment, Archives can only audit government agencies on their information management practices every five years, and compliance with any issues that pop up are largely voluntary, Moss says.

The proposed changes will allow Archives to conduct more frequent audits, issue improvement notices for any problems identified, and set deadlines for agencies to fix them.

Moss says large, complex agencies like Oranga Tamariki, which have been through multiple reiterations over the years, often struggle with good record-keeping.

A 2023 audit commissioned by Archives found most of the ministry's information practices were sub-optimal. Only five of the 20 areas assessed were operating well.

While failures to comply with the Public Records Act can incur fines of up to $10,000, not a single individual or organisation has ever faced prosecution since it was brought into force in 2005.

Moss says it's better to work with government agencies to lift their game than to prosecute them, and he hopes the proposed changes will encourage the whole public sector to invest in this area.

"Of course, getting those investment plans in place for agencies to keep their systems up to date over years and decades is always a challenge, certainly in the current fiscal environment."

His small team audits around 20 of public agencies a year, but he's hoping this will increase, and that they can encourage more agencies to undergo self-audits to monitor their own progress.

A long way to go

It will take more than new IT systems and tinkering with laws to avoid the same mistakes being repeated at Oranga Tamariki, Peter Boshier says.

He believes there are two fundamental reasons for the systemic failures in record-keeping at Oranga Tamariki: discipline and culture.

Boshier, a former Family Court Principal, says he came from a background where there is a strong culture in record-keeping.

"Other agencies like the police, or health, also have strong record-keeping cultures, so there is no reason why Oranga Tamariki cannot.

"I just think there is a lack of culture in how important these things are. There needs to be a cultural change, that this is just as important as the social work itself."

The culture of an organisation is driven by its leadership, he says, although he is reluctant to directly criticise Oranga Tamariki's leaders.

"That's an area for discussion between the chief executive and the Minister," he says.

"But you've got to ask, is there a disconnect between the head office of Oranga Tamariki and perhaps what senior leaders aspire to and the way that's being interpreted inside offices?

"I don't know the answer, but I would suggest to you that that could be an issue."

He's frustrated by the lack of consequences for the organisation when it makes the same mistakes again and again.

"We've found in our various reports that the organisation's own policy and guidelines are not being followed and kept.

"Is there a consequence? We were told that there was so in Malachi Subecz's case. The chief executive said: 'This is unacceptable to me, and I will take steps in that particular site to require accountability.'"

This perhaps explains his exasperation when a few weeks ago he issued yet another opinion highlighting the same issues.

"How come that happened? Why is it that leadership appears not to be able to bring about a change at that fundamentally important site office level?," he asks.

Boshier doesn't have the answers.

"I sense the culture of the organisation needs to be shifted, and that will take time. I would like to see strident, clear, forceful leadership of expectation and consequence in the same way that most agencies would require it."

He believes that every time his office issues another repetitive warning highlighting the same problems "faith diminishes" in the ministry's ability to do its job.

"People are bound to become a little cynical, so that really is what Oranga Tamariki is facing."

And while he's critical and possibly also cynical himself, he is also genuinely hopeful - optimistic even - that positive change can occur.

"I am an inherent optimist that behaviour is capable of change, and culture is capable of change, providing there is a will and a willingness, and there is strong, concerted, clear leadership.

"Both of those things are going to ultimately determine whether this organisation is capable of the quantum shift that's needed.

"I will only be satisfied when I have actual measures of change; I want to see a decrease in serious complaints of the kind I am seeing now. This agency has a long way to go."

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