Use of incorrect information, lack of trauma-informed practice, failure to assess children’s safety

Legislation display text:
Ombudsmen Act 1974, ss 13 and 22
Oranga Tamariki
Peter Boshier
Case number(s):
Issue date:

Repeated use of incorrect, unverified information about a mother, including at Family Court—failure to assess safety of children—lack of trauma-informed practice—poor complaints handling process and inadequate apology


In 2019, a mother (the complainant) made a complaint to Oranga Tamariki—Ministry for Children (the Ministry). Her complaint concerned the Ministry’s use of incorrect information about her, its failure to properly assess the safety of her two youngest children, and record keeping errors.

The complainant received an acknowledgement and apology from the Ministry, but felt that these did not adequately address the harm that had occurred. She then complained to the Ombudsman.

The Chief Ombudsman investigated, and formed the opinion that the Ministry had acted unreasonably throughout its dealings with the complainant. This included using incorrect and unverified information about her, failing to assess the safety of her two youngest children, failing to recognise the trauma created by her own experiences in state care, and failing to adequately respond to her concerns.


In April 2014, the Ministry received a report of concern from a District Health Board about the complainant, stating that she had mental health issues and required assistance with her four young children.

The statement about her mental health was inaccurate, and based on a short preliminary crisis assessment. Nonetheless, the Ministry placed the information on the complainant’s file without verifying its accuracy or telling the complainant.

In 2018, the complainant was involved in custody proceedings concerning two of her children. The Family Court requested a report from the Ministry under section 131A of the Care of Children Act 2004, setting out the Ministry’s dealings with the children concerned.

In that report, the Ministry included the incorrect information from four years earlier about the complainant’s mental health. The complainant did not know the Ministry held this information about her until she heard it read in Court. Her view was that perceptions of her mental health then became the focus of proceedings.

The complainant’s older sons then disclosed to her that they had been assaulted while in the care of another adult. Police became involved, and the Ministry completed a Safety and Risk Screen report.

This report found the complainant’s two younger boys were not safe visiting the adult concerned. However, the Ministry provided no further safety assessment, and took no further action. The complainant could not prevent the continued access between the individual and her two younger sons.

Later, an adult at a social event assaulted another of the complainant’s children. The Ministry again became involved, but neither the Ministry nor the Police took further action.

The complainant felt that her concerns about the assault were dismissed due to the Ministry’s perception of her emotional state, and requested a copy of her children’s records from the Ministry. She found that they included incorrect details about her children, and wrongly identified her partner as the perpetrator of the assault at the social event.

In 2019, the complainant complained to the Ministry about the incorrect information it provided to Court, its failure to assess the safety of her youngest children, and its record-keeping errors concerning her children and partner. The Ministry apologised, acknowledged some of its errors, and wrote to the Family Court to correct the inaccurate information.

The complainant did not feel the apology or corrections adequately acknowledged the harm that had occurred. In November 2019 she made her complaint to the Chief Ombudsman.


The Chief Ombudsman investigated the complaint, looking at the issues the complainant had raised and also at whether the Ministry had acted unreasonably in the way that it handled her concerns.

Use of incorrect medical information

The Chief Ombudsman formed the opinion that it was unreasonable for the Ministry to rely on information about her mental health without putting it to the complainant or verifying it with her usual medical practitioners. He also formed the opinion that the Ministry acted unreasonably when it provided the information to the Court in the manner it did.

The Chief Ombudsman noted there must be an absolute, uncompromised expectation that information provided to the Court under section 131A is accurate, and reasonably reflects the balance of information the Ministry has to hand. Showing how information is verified, separating fact from opinion, and giving appropriate explanations where needed, are equally important.

The Ministry’s policy on reports to the Court simply stated they must be ‘accurate, informative, clear and concise.’ There appeared to be no guidance relating to section 131A reports.

The Chief Ombudsman noted that the Ministry had agreed it should have been clearer that the medical information presented to the Court was not a diagnosis. In addition, he found that if the Ministry had made any inquiries of the complainant, it would have become immediately clear that there were no diagnoses of the sort suggested in the records.

Instead, the unverified information continued to be used and referred to throughout the Ministry’s files, including when the Ministry was dealing with concerns about other adults in the children’s lives. This was the case even when the concerns were unrelated to the complainant herself.

The Ministry’s records did not acknowledge the circumstances leading to the 2014 report of concern—that the complainant had four young children, and had recently left her relationship. The records included a second report of concern for which there was no evidence, and which the complainant denied and believed to be related to the ongoing custody dispute.

Lacking any input from the complainant, the records appeared unbalanced.

Safety of the youngest children

The Ministry’s files included substantiated allegations of another adult assaulting the complainant’s two older children. They ceased contact with him, but the complainant’s younger children continued to have contact.

Following the assaults, the Ministry undertook a Safety and Risk Screen and reported that the younger children were not safe with the individual concerned. The Chief Ombudsman found no evidence that the Ministry then undertook any further safety assessments of ongoing unsupervised contact. The complainant did not trust that the Ministry would do anything to protect her children and was extremely concerned about the risk of harm.

The Chief Ombudsman found that the Ministry’s failure to further assess the safety of the younger children was unreasonable.

Failure to use a trauma-informed approach

The complainant had herself been in state care as a young person, and had come to harm there. Due to this past trauma, she felt overwhelmed when trying to deal with the Ministry, particularly when her concerns were repeatedly dismissed. She was anxious about the ability of the Ministry to ensure the safety and wellbeing of her own children, and allegations of an adult abusing her children had a particularly traumatic impact on her.

The complainant’s experience in state care as a child would have been clear to Ministry staff from their records, and should have led to a trauma-informed approach in their work with her.

A trauma-informed approach means an agency recognises the trauma a person has experienced, particularly that caused by their interactions with the agency itself. It recognises a person’s background and experiences, enables their perspective to be heard, and actively works to prevent further harm.

The Chief Ombudsman noted that the Ministry will often be engaging with parents who themselves had care and protection needs as children. Some will have suffered harm while in the custody of the State. The difficulties such a person may have in dealing with the Ministry as an adult must be acknowledged and addressed in an appropriate way. He found no evidence that this had happened in this case.

In particular, the Ministry’s decision to not inquire into the safety of her youngest children led the complainant to feel as she did as a young person being harmed in state care: seeking help, but being told her allegations were untrue, and that it was her behaviour that was problematic.

The Chief Ombudsman also found that the persistent use of incorrect information about the complainant appeared to influence the way social workers responded when she raised concerns. It appeared that the focus was solely on what was ‘wrong’ with the complainant, and the social workers’ perceptions of her emotions and behaviour.

The Ministry’s continued reference to the complainant’s mental health issues, based on inaccurate and unverified information, the absence of trauma-informed practice, and the way the Ministry responded to the complainant, meant the Ministry acted unreasonably and failed to prevent further harm. 

Handling of the 2019 complaint

The Chief Ombudsman considered how the original complaint had been handled by the Ministry, and the adequacy of the Ministry’s apology.

He stated that a genuine and effective apology requires:

  • acceptance of what has been done wrong (even where not intentional), and the agency’s responsibility for this;
  • understanding of the effect that this has had on the individual; and
  • explaining what has been done to prevent similar errors from occurring in the future.

An inadequate apology will often do more harm than good, and this is what occurred in this case.

The Chief Ombudsman considered that the Ministry’s apology overlooked parts of the complainant’s concerns, minimised the errors that had occurred, and placed some blame back on the complainant by suggesting that she ought to have challenged the incorrect information about her in Court.

The Chief Ombudsman was particularly concerned by this. He noted that the Ministry was aware of the weight that the Court places on its reports, and the difficulty that a person would have in challenging this. This would be especially so when the report included inaccurate information the person had not been aware of.

The apology did not recognise the seriousness of the Ministry’s errors, or their impact on the complainant. Further, no apology had been made to the complainant’s partner, for having incorrectly recorded him as the perpetrator of an assault on one of the children.


The Chief Ombudsman formed the opinion that the Ministry had acted unreasonably throughout its dealings with the complainant. This included the use of unverified information, failure to ascertain the safety of the youngest children, failure to use trauma-informed practice, and failing to adequately respond to the complainant’s concerns.


The Chief Ombudsman recommended:

  • A full and comprehensive apology to the complainant.
  • An apology to the complainant’s partner for incorrectly recording that he had assaulted one of the children.
  • A senior Ministry manager meet with the complainant in the presence of an independent third party mediator, or another neutral party, to allow her to share her ongoing concerns and her experience, in order to aid better understanding.
  • The Ministry take action to identify whether there are any current concerns regarding the safety of the youngest children. If so, complete an appropriate assessment within four weeks.
  • The Ministry commence a review of section 131A reporting within two months, and report back to the Chief Ombudsman on work arising from that review, including requirements for new guidance and any associated changes in practice, processes, or procedures.

The Ministry accepted these recommendations.

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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