Source: Radio New Zealand
Children are still no safer than when Malachi Subecz was murdered, according to a new report from the Independent Children’s Monitor.
It is the second review of the implementation of the recommendations from a report into Malachi’s death, and has showed little progress has been made.
Malachi died of a blunt force head injury in Starship Hospital 2021, and weighed just 16 kilograms because he had been starved.
A report into his death by the late Dame Karen Poutasi in 2022 found five critical gaps in the system, and made 14 recommendations.
One of those recommendations was for the Independent Children’s Monitor to review the recommendations themselves.
Malachi Subecz died of a blunt force head injury at Starship Hospital in 2021. Supplied
In 2024, its first review found a “disappointing and disheartening” lack of priority given to them, and committed to review them again.
Just as it did with the prior review, the Independent Children’s Monitor looked at the responses to the report, and the implementation of actions agencies set for themselves.
The 2025 review, titled Towards a stronger safety net to prevent abuse of children, found that little had changed.
“There continues to be a high proportion of reports of concern from professionals that do not result in further action by Oranga Tamariki and where tamariki and rangatahi are not seen,” it said.
The review engaged with a wider range of agencies than in 2024, including Corrections, Early Childhood Education providers, and representatives from agencies and non-governmental organisations that were party of multi-agency response teams responding to police callouts for family violence, or to reports of concern made to Oranga Tamariki.
It also spoke to Oranga Tamariki staff.
“Kaimahi from agencies and services, including Oranga Tamariki, continue to tell us they are concerned about the risk to tamariki and rangatahi,” the report said.
“System settings have not changed, gaps remain and tamariki and rangatahi are still no more likely to be seen by Oranga Tamariki now than when Malachi was killed.”
A report into Malachi Subecz’s death was made by the late Dame Karen Poutasi in 2022. RNZ / Angus Dreaver
The gaps Dame Karen found in 2022 were:
- When sole parents are charged and prosecuted, the needs of dependent children are not well enough identified
- The process for assessing risks to a child is too narrow and one-dimensional
- Agencies and services are not proactively sharing information, despite having the ability
- A lack of professionals’ and services’ reporting of risk of child abuse
- The system allows children to remain “invisible” even at key moments
Her report also made 14 recommendations, including combining medical records to make them available for health workers working with children, and increased education and public awareness.
Initially, the government did not accept all of Dame Karen’s recommendations outright, wanting further advice on five of them, including mandatory reporting of children at high risk of harm.
In 2025, the government decided it would accept the remaining recommendations.
The report acknowledged this was a “first step” but now “careful and thoughtful” implementation was needed.
“Until change happens on the ground and in communities, tamariki will continue to be no safer. As this review finds, the gaps identified by Dame Karen have not closed and tamariki continue to fall through the safety net.”
Progress since the previous report had been slow, and while better visibility and reporting of concerns were important, it could only go so far.
“Even once all the recommendations have been implemented, it would not solve the fundamental problem – Aotearoa does not yet have a child protection system that is always able to respond when needed.”
The report noted a further 24 tamariki had been killed by someone who was supposed to be caring for them, since Malachi’s death.
While it did not go into the specifics of those children’s lives and circumstances, it found 11 were known to Oranga Tamariki before their deaths, and 19 of the alleged perpetrators were known to police in varying ways.
At the time the Independent Children’s Monitor was conducting the report, police had completed 10 family violence death reviews, with a further 12 in progress. Oranga Tamariki had completed seven child death reviews, and two more were in progress.
“Police and Oranga Tamariki, for the most part, undertake reviews in isolation from other agencies. Their reviews focus on internal practices rather than broader systemic issues,” the report said.
A coroner’s report released last week found everything possible went wrong for Malachi in the last six months of his life, with opportunities to identify the abuse and torture he suffered not picked up by those who could have intervened.
Coroner Janet Anderson found similar gaps to Dame Karen Poutasi, which were also found by the oversight agencies.
Even back in 2022, Dame Karen said her findings were not new.
“Implementing the Poutasi recommendations may make tamariki and rangatahi at risk more visible, but to make them safer, Oranga Tamariki and the wider child protection system must be able to respond when needed,” the 2025 report said.
Oversight agencies call on government to go faster
The Independent Children’s Monitor, Arran Jones, said 18 months on from the first review, three years on since Dame Karen’s report, and four years since Malachi’s death, work was “just beginning,” and until change happened on the ground and across all communities, tamariki would continue to be no safer.
“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,” he said.
The oversight agencies, including the Independent Children’s Monitor, the Ombudsman, and the Children’s Commissioner, called on government agencies to act faster.
“The stark truth that 24 children – most of them babies – have died through abuse by the person meant to be caring for them must shock us into action. The lives of other children depend on it,” said Children’s Commissioner Claire Achmad.
The Chief Ombudsman, John Allen, said the findings raised the important need for cross-agency collaboration, but acknowledged there were green shoots out there, pointing to an in-person hub pilot at the Oranga Tamariki national contact centre, and its work with community-based providers.
“Community led organisations know the whānau well and are better equipped to intervene early and provide immediate support while at the same time taking pressure off the wider system,” he said.
Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
