An independent review into the murder of five-year-old Malachi Subecz by his caregiver has found the abuse slipped through holes in safety nets, which must be fixed with urgency and determination.
The Tauranga boy died in Starship hospital in November last year after sustaining months of physical abuse - including being beaten and burnt - by Michaela Barriball. She pleaded guilty to his murder earlier this year and is serving a life sentence.
The report by Dame Karen Poutasi was commissioned by the six state agencies that interacted with Malachi and his whānau in the months leading up to his death.
“At no time was the system able to penetrate and defeat Barriball’s consistent efforts to hide the repeated harm she was causing to Malachi that culminated in his murder,” said Dame Karen in her report.
In late June 2021, Malachi’s mother was sent to prison, and he was put into the care of her workmate and friend, Michaela Barriball. There was no formal authority for this decision, and none was needed.
The report found this was a “red flag” event and said this gap needs to be closed.
“Where a sole parent is facing a custodial sentence, there should be a requirement for Oranga Tamariki involvement to support the parent in the choice of a caregiver,” said Dame Karen.
Malachi’s cousin raised concerns with Oranga Tamariki in the early days of his care with Barriball, including sending a photo which showed bruises. But the report was dismissed after Oranga Tamariki received assurance from Malachi’s mother in prison that she had no concerns.
Oranga Tamariki now acknowledges it was a significant practice mistake to close the report without fuller investigation.
Dame Karen Poutasi’s report found five critical gaps:
- In identifying the needs of a dependent child when charging and prosecuting sole parents through the court system.
- In the process of assessing the risk of harm to a child, which is too narrow and one-dimensional.
- Agencies and their services not proactively sharing information, despite enabling provisions.
- In a lack of reporting of risk of abuse by some professionals and services.
- In allowing a child to be invisible. The system’s settings enabled Malachi to be unseen at key moments when he needed to be visible.
She said Malachi became an “invisible child” within the system. Those that tried to act were not listened to, those who were uncertain didn’t act, and those who knew chose not to act, said the report.
“The settings for the care and protection system we have in place are still not strong enough to ensure children do not slip through the gaps. The system could have been more ‘fail safe’ and the settings must be addressed so that it is,” said Dame Karen.
“I conclude the sharing of information is critical to child safety as ‘everyone has a piece of the jigsaw but no one has the full picture."
Dame Karen made a number of recommendations to the six agencies that would help avoid similar tragedies from happening again.
One of the key recommendations is mandatory reporting by professionals who work with children at high risk of abuse.
She said the best way for mandatory reporting to be effective is to have a stronger information-sharing process across the system, better guidelines on the risks of high-probability harm and compulsory training on how to recognise risk and how reporting should occur.
Dame Karen also recommended that Oranga Tamariki vet any proposed carer when a sole parent is arrested and taken into custody.
She said the recommendation would work with changes that the courts are already making to ensure the children of single parents’ safety is considered when said parent is arrested or sentenced.
“Currently, children of sole parents in custody can be in the care of another person without formal authority for long periods, with no consideration for their safety.
“This is not right and had terrible consequences for Malachi,” she said.
In a statement, the chief executives of the six organisations - OT, NZ Police, Department of Corrections, Ministry of Social Development, Ministry of Education and the Ministry of Health - accepted the findings of the investigation and agreed to make changes.
“At the heart of Dame Karen’s findings is that agencies failed in their duty of care for Malachi. The system focused on the adults around Malachi rather than on him and what he needed,” the statement read.
“Malachi was let down by the system that should have protected him, and we are determined to do everything in our power to learn from this and keep children safe.”
The chief executives say some of the recommendations are already being worked on, with a project underway to join up medical records and implement proactive information sharing across agencies.
They said some of the recommendations would require legislative change to be implemented and have agreed to provide advice on these and report to ministers in the new year.
They said that mandatory reporting would need the approval of cabinet, saying it would take “further consideration.”
“It is only by everyone working together – whānau, communities and government agencies – that children and young people will be kept safe. We must do better to protect our tamariki,” the statement said.
The Government has also accepted the findings of the report and said they would be implementing the majority of recommendations.
Minister for Children Kelvin Davis said Malachi’s death was “heartbreaking” and said the government needs to do everything it can to ensure mistakes aren’t repeated.
“It’s essential the system changes. Mistakes were made, and the Government is committed to fixing them, so they are not repeated,” he said.
“Dame Karen has made 14 recommendations, of which the Government has fully accepted nine and is committing to look carefully at the remaining five.”
He said that recommendations like mandatory reporting and automatic vetting of caregivers when a solo parent is arrested or sentenced would need to be looked into further by ministers and cabinet next year.
Davis also confirmed that the senior staff at Oranga Tamariki who were involved with Malachi’s case no longer work for the organisation and insisted the it is now on the right track.
Associate Minister of Education Jan Tinetti said the Government is initiating changes in the way it reviews early learning services and ensure that child protection policies are enacted appropriately.
“The Ministry and ERO will be working on a plan on how to improve the monitoring of child protection practice at early learning centres,” Tinetti said.
Another recommendation made was for Manatū Hauora (Ministry of Health) to be brought into the Child Protection Protocol system.
“Manatū Hauora has accepted the findings in the review, and work is already underway with other agencies on meeting this recommendation,” Health Minister Andrew Little said.
Malachi's cousin who raised the alarm with Oranga Tamariki said: "While the reports and findings won't bring Malachi back, we are cautiously hopeful that this horrific process may bring about change that ensures a significantly better chance for children in the future.
"We have always known that we did all we could to try and save Malachi, but Oranga Tamariki didn't listen to what I and others were telling them. Nothing in these reports is a surprise," he said.
And Malachi's uncle called Malachi a "change angel", saying "his death cannot be in vain".
Ruth Money, an advocate for the family, said: "This can never happen again."