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Chief Ombudsman’s opinion under the Ombudsmen Act - Malachi Subecz

Children in care
Section 13
Peter Boshier
Issue date:

Note: Please be aware this report contains distressing content.


  1. The Chief Ombudsman received a complaint about the actions of Oranga Tamariki in relation to the death of a young child/tamaiti, Malachi, aged five.
  2. Oranga Tamariki received a report of concern about Malachi’s welfare from his cousin, after he was placed with a caregiver by his mother. Following the intake and assessment process, Oranga Tamariki decided to take no further action on the report of concern. Malachi’s cousin complained to Oranga Tamariki about its decision. In response, Oranga Tamariki indicated that the correct process had been followed.
  3. Malachi’s uncle later contacted Oranga Tamariki to make a complaint. He was advised that there was no complaints process but he could contact the duty social worker to discuss any concerns.
  4. The Chief Ombudsman formed the opinion that Oranga Tamariki acted unreasonably by not investigating the report of concern after completing its intake and assessment process. In doing so, Oranga Tamariki omitted to do all that was necessarily or desirable under section 17(1)(a) of the Oranga Tamariki Act 1989.
  5. While an investigation was only required ‘if necessary or desirable’, it was the Chief Ombudsman’s view that Oranga Tamariki reached the wrong conclusion in deciding to take no further action.
  6. The report of concern raised various issues, including medical neglect and suspected physical abuse. A photograph was provided to Oranga Tamariki of suspected bruising on Malachi’s eye. The Chief Ombudsman noted that the Child Protection Protocol between Oranga Tamariki and Police required matters of this nature to be referred to Police. This was not done. Nor were a child and family assessment or risk screen done, as the matter was not investigated.
  7. The Chief Ombudsman was also concerned that the vulnerable infant and disability practice triggers, present due to Malachi’s young age and level of development, did not prompt action.
  8. Oranga Tamariki completed a pathway rationale record for the decision to take no further action. The information considered as part of the pathway rationale included the concerns raised by Malachi’s cousin and comment obtained from his mother.
  9. No reference was made to the photograph of suspected bruising. Nor was any information obtained from Malachi or in relation to the caregiver. Oranga Tamariki concluded there was ‘nothing to say’ that Malachi was unsafe with the caregiver.
  10. The pathway rationale did not demonstrate that Malachi’s welfare and interests were prioritised and at the centre of decision-making. His mother’s endorsement of the caregiver was regarded as more significant than evidence suggesting he might not be safe.
  11. The Chief Ombudsman formed the final opinion that Oranga Tamariki acted unreasonably and wrongly in its response to the report of concern by Malachi’s cousin.
  12. The Chief Ombudsman also considered Oranga Tamariki’s response to Malachi’s cousin’s complaint about its decision to take no action, was inadequate.
  13. During the Chief Ombudsman’s investigation, Oranga Tamariki acknowledged that Malachi’s uncle was originally misinformed when he was told there was no complaints process. The Chief Ombudsman concluded that Oranga Tamariki acted unreasonably in this regard. The Chief Ombudsman commented that Oranga Tamariki’s feedback and complaints process was not easy to access or understand.
  14. The Chief Ombudsman recommended that Oranga Tamariki apologise to Malachi’s uncle and cousin at a time and in a way that they agree on.
  15. The Chief Ombudsman also recommended that Oranga Tamariki report back to the Ombudsman in a timely manner on the outcome of a practice review by Oranga Tamariki and a wider systems review by an independent reviewer that are underway. In particular, on what system changes will be made to address the situation.
  16. Oranga Tamariki accepted the Chief Ombudsman’s recommendations.
  17. The Chief Ombudsman may make further recommendations or conduct a further investigation focused on systemic issues, depending on the outcome of these reviews.
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