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Full Practice review of social work practice after notification of investigation

Ombudsmen Act 1975
Oranga Tamariki
Peter Boshier
Case number(s):
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Complaint about Oranga Tamariki’s (the Ministry) apparent failure to protect a vulnerable child—the Ministry reviewed the complaint after notification of investigation and began a full case review - Chief Ombudsman felt this was a satisfactory resolution


A complaint was lodged with the Chief Ombudsman from a father and step-mother about their child, who was under the Ministry’s custody and living with her birth mother. They had made several complaints to the Ministry, expressing concern for the child’s safety, as she had experienced several hospitalisations and alleged neglect events.

The complaint was centered on the belief that the Ministry had failed to act to protect the child in a number of ways:

  • Inadequate response to the reports of concern and the ongoing neglect;
  • Inadequate investigation of an alleged neglect event and resulting hospitalisation, and misrepresenting this to Police;
  • Inadequate response to concerns that a childcare centre the child attended had not been properly vetted;
  • Not providing all relevant information to the Court;
  • Reducing the complainants’ contact with the child;
  • Failing to respond to the Social Workers Registration Board; and
  • Failing to respond to their complaints about these issues.

The complainants believed that the Ministry had not kept them updated, including when events occurred. They believed that the Ministry had failed to undertake thorough and unbiased investigations, and to liaise and share information with other agencies such as the Police. They claimed that the social workers did not provide all relevant information to the Courts and did not include alleged neglect events or hospital records, and that this unfairly impacted on the outcomes for the child.

The Ministry had also applied for additional guardianship, and when this was granted they significantly reduced contact with the paternal side of the family, despite assessments stating the child’s relationship with the father was a strength.

The complainants considered that there was insufficient communication when their complaints were raised with the Chief Executive’s Advisory Panel. In addition, when they complained to the Social Worker’s Registration Board (SWRB), the Ministry did not respond to SWRB’s inquiries, which meant that the complaint could not be progressed.


The Chief Ombudsman notified the Ministry that he would be investigating all aspects of this complaint.

Upon receiving this notification, the Ministry acknowledged that although a number of people had looked into the individual issues over a period of time, the decision-making focus was on isolated events and issues. The Ministry made the decision to complete a full practice review to look at the case as a whole, ensuring a focus on the child’s well-being, and looking at whether the decision made had been well supported by the evidence available.  

Given the broad scope of the proposed Practice Review, and the Ministry’s ability to resolve the issue by looking at whether the practice had been correct and in the child’s best interests, the Chief Ombudsman decided to discontinue his investigation.

When the Chief Ombudsman makes a decision like this, he will generally follow up on the outcome of the resolution that the agency has proposed. In this case, the Chief Ombudsman asked that the Ministry provide him with a copy of the Review when it was completed, so that discussion could be had with the complainants about whether they had any remaining concerns.

This case note is published under the authority of the Ombudsmen Rules 1989. It sets out an Ombudsman’s view on the facts of a particular case. It should not be taken as establishing any legal precedent that would bind an Ombudsman in future.

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