A second review by Aroturuki Tamariki | Independent Children’s Monitor, on the implementation of the recommendations made by Dame Karen Poutasi following the death of Malachi Subecz has found tamariki (children) are still no safer now than when Malachi died.
The review, Towards a stronger safety net to prevent abuse of children also looks at whether government agencies have done the things they said they would in their own internal reviews, how reports of concern are currently responded to, and if anything is changing after other children die.
Aroturuki Tamariki Chief Executive Arran Jones says 18 months on from its first review, three years on from Dame Karen’s report and four years on from Malachi’s death, work is just beginning. In October 2025 Government accepted all of Dame Karen’s recommendations and started a cross-agency work programme to implement them. In late January a new inter-agency hub for children whose sole parents are in prison was established, and the first phase of mandatory training for core children’s workers got underway.
“These are important first steps. Until change happens on the ground and across all communities, tamariki will continue to be no safer,” says Mr Jones.
Of the 14 recommendations made by Dame Karen, only two are complete. One (recommendation 14) was the Monitor’s first review of implementation, the other (recommendation 11) was considered complete as no action was determined to be required.
The review found tamariki continue to fall through gaps in the safety net. Between December 2021 and June 2025, another 24 tamariki were killed by someone meant to be caring for them. Many were babies, most tamariki were under the age of five. Half of the 24 tamariki were known to Oranga Tamariki – that is, someone had made one or more reports of concern about them. Most of the perpetrators were known to Police.
“Our review also found that even if everything Dame Karen said was needed to close the gaps is done, we are not confident that Oranga Tamariki will be able to respond appropriately.
“Beyond responding to Dame Karen’s recommendations, we need urgent improvements to the child protection system so it can respond effectively to reports of concern about the safety of tamariki. Put simply, Oranga Tamariki social workers need to be able to get in the car and go and see a child with their own eyes. The people reporting concerns include community social workers, police officers, teachers and health staff.
“On every monitoring visit we hear from people who are having to make repeated reports of concern to Oranga Tamariki before action is taken. We hear from frontline Oranga Tamariki staff who tell us how concerned they are about the tamariki they are unable to get to. Every day they are making tough decisions, not based on the safety of tamariki but on who they can get to with the level of resourcing they have,” says Mr Jones.
The data shows this too. Despite the number of reports of concern to Oranga Tamariki increasing, the number that local offices take action on has remained relatively constant over the last nine years – at around 40,000.
This is also reflected in the regional variation in response by Oranga Tamariki offices to reports of concern referred by the national contact centre for further action. Some offices take no further action on more than half of reports of concern referred to them for action by the national contact centre. Yet these are reports of concern that were triaged and considered serious enough to warrant a response. In 2024/25, the Oranga Tamariki national contact centre referred nearly 81,000 reports of concern to local offices for further action. More than 32,000 of these had no further action locally.
What Dame Karen called for was a child protection system that is always able to respond when needed. She also called for a well-resourced community sector that can help ensure all reports of concern are responded to – providing early intervention, organising support for whānau and preventing issues escalating further. While there are prototypes and pilots demonstrating how this can work, New Zealand is far from having a comprehensive response to child protection.
The review also found that most other government agencies are making reports of concern to Oranga Tamariki and have put some training in place for staff in lieu of Oranga Tamariki providing this. More is needed. Across agencies, greater understanding of how to identify abuse is needed. As noted by Dr Kelly, frontline health professionals receive little or no training in interpreting childhood injuries.
The Privacy Commissioner has also provided clear guidance to those working with children that it is okay to share information to keep children safe.
Mr Jones acknowledged the work of the late Dame Karen and her determination to see change after decades of reviews pointing to similar gaps that she found. He briefed her on an early draft of the second review in late 2025.
The review is available online at: aroturuki.govt.nz/reports/safety-net
Notes:
A report of concern can be made when someone is worried about a child’s safety or wellbeing
A report of concern is the term used for when someone tells Oranga Tamariki that they are worried about a child’s safety or wellbeing. The person making the report of concern may believe that the child is being abused, harmed or neglected. Abuse can be physical, sexual or emotional.
If someone believes a child is in immediate danger they should call the Police. To make a report of concern about a child or young person you are worried about contact Oranga Tamariki 0508 326 459.
About Aroturuki Tamariki | Independent Children’s Monitor
Aroturuki Tamariki | Independent Children’s Monitor checks that organisations supporting and working with tamariki, rangatahi and their whānau, are meeting their needs, delivering services effectively, and improving outcomes. We monitor compliance with the Oranga Tamariki Act and the associated regulations, including the National Care Standards Regulations. We also look at how the wider system (such as early intervention) is supporting tamariki and rangatahi under the Oversight of Oranga Tamariki System Act. Aroturuki Tamariki works closely with its partners in the oversight system, Mana Mokopuna – Children’s Commissioner, and the Office of the Ombudsman.
