The Chief Ombudsman has called for changes “on a scale rarely required” at Oranga Tamariki after unearthing “extremely distressing” stories including that of a disabled mother whose newborn was uplifted without warning and never returned.

The woman stands no chance of regaining custody of her now-10-year-old due to “the passage of time and subsequent decisions”.

Other cases revealed in a report by Ombudsman Peter Boshier include a youth kept at a care and protection secure residence for 18 months, and a youth with complex needs who was kept in a respite care facility for about five years longer than their family had agreed to.

Boshier reviewed about 2000 complaints over four years for his report, Children in care: complaints to the Ombudsman 2019-2023, released today, and said he could not yet provide reassurance Oranga Tamariki’s practices and processes were consistently operating as they should.

He uncovered multiple incidences of unjust or discriminatory decisions, procedural failures, factual or legal errors, inadequate advice or reasons, and more.

He also identified issues with Reports of Concern not being actioned or recorded properly.

Oranga Tamariki has acknowledged Boshier’s findings and said changes are already under way.

“For Oranga Tamariki to regain the trust it has lost from the people it serves and the wider public, it needs to change on a scale rarely required of a Government agency,” Boshier said in the report.

“While there are areas of good practice and outcomes, which I have acknowledged, my report contains some extremely distressing stories,” he said.

He hoped sharing these stories would prompt Oranga Tamariki and the new Government to “really make profound changes to the way the Ministry operates”.

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Disabled mother’s newborn uplifted from hospital

Child Youth and Family (CYF), Oranga Tamariki’s predecessor, became involved with the woman during her pregnancy due to concerns she would be unable to safely care for her baby.

The baby was uplifted at five-days-old as the mother remained in hospital.

The child was placed with a caregiver and ultimately entered a “home for life” arrangement.

In 2015, she laid a complaint that she had been discriminated against due to her disability, which was not described in the report. CYF did not uphold the complaint.

She and another relative made further complaints to CYF as they believed there had been no attempt to understand the mother and the nature of her disability, that CYF staff had predetermined that the child should be permanently removed, and ultimately that there had been no opportunity for the mother to show that she could parent her child.

Oranga Tamariki reviewed the complaints in 2019 and found her concerns were unsubstantiated. But Boshier said the treatment of the woman was unreasonable and that CYF had failed her in multiple ways, including failing to identify available supports for her, or understand her strengths or the nature of her disability.

Oranga Tamariki has since made changes to its practice including that uplift orders should be made “on notice” unless there was a clear need to do it without warning. Practice leaders at each site must also review all Reports of Concern for unborn and newborn babies, and wider services should be engaged with when dealing with disabled people.

Boshier recommended the agency provide a financial remedy to the complainants, noting it was now impossible to be certain the mother was unable to parent the child, and “that the passage of time and subsequent decisions meant that there was no prospect of te tamaiti being returned”.

Youths held against wishes in facilities

In the case of the youth held in a care and protection residence, they had already been held for 18 months previously, and by the time they complained to the Ombudsman they had been put back in the residence for another seven months.

Chief Ombudsman Peter Boshier released the report today.

When they were put in the residence a second time, they were told it would only be a short stay, but the months dragged on, and Boshier found Oranga Tamariki did not act as urgently as they could have.

“[The youth] watched others come and go, and felt as though they were losing their teenage years,” the report said.

“The harmful effects of residence in a secure care facility are well known. Young people should enter a care and protection residence only if there is no other option, and should be there for the shortest amount of time possible.”

During Boshier’s investigation, a placement for the youth was found.

In the case of the youth who was held at a respite care facility against their parent’s wishes, the parent had sought help from Oranga Tamariki in dealing with their child’s “complex intellectual, behavioural and physical needs”.

The parent agreed for the child to spend a few weeks in respite care, and then further agreed for them to spend a year at the facility.

But after the agreement lapsed in 2016, Oranga Tamariki sought custody of the youth so they could stay at the facility, where they ended up staying for the majority of the time until 2021.

Oranga Tamariki's Nicolette Dickson thanked Boshier for the "comprehensive and considered" report.

“Their parent and older sibling sought on a number of occasions in this time to have them returned to the family, saying they were concerned the rangatahi had been institutionalised against their will. They were also concerned that the rangatahi had been excluded from any decision-making and their views had not been sought,” the report said.

“It was apparent from the evidence I had that Oranga Tamariki did not make enough effort to fully understand the wellbeing of the rangatahi, their best interests or their own wishes. In fact, the records showed little consideration of the wellbeing of the rangatahi outside of their medication regime and physical wellbeing at the facility.

“I was particularly concerned by a record showing an intention in 2020 to keep the rangatahi at the facility until they could transition to an adult disability service, against their will and that of their family.”

The agency did not document the child’s wishes until 2020. They had made it clear they wished to live with their parent.

“In spite of this, their wishes were overridden by Oranga Tamariki which required them to continue to live at the facility. Requiring them to live in an institution in these circumstances was an unjustifiable breach of their right to choose where they lived and to be cared for by their parents.”

While he condemned the agency’s actions in that case, he also commended their positive actions since the youth was returned home, including helping with wraparound disability support, providing a plan which included a funded communications assistant or speech and language therapist, and providing a social worker with disability qualifications and lived experience caring for disabled people.

Improvement plan needed, multiple failures identified

In his report, Boshier also identified issues with dealing with complaints for children, failures around uplifts and complaints, and issues with tikanga- informed practice.

He has recommended Oranga Tamariki create an organisation-wide quality improvement plan, ensure staff understand and apply legislation and policy, pay better attention to detail and accurate information in decision making, provide more training and supervision, regular tracking and reporting, and keep better records overall.

Boshier said he had already achieved some changes, including that Oranga Tamariki’s court documents must now include a comprehensive, balanced and accurate analysis of the risks and benefits of placements.

Oranga Tamariki and its predecessors have been investigated in the report. File photo / Jason Oxenham

There is also a new section on Oranga Tamariki’s Practice Centre on seeking the views of tamariki and rangatahi in decisions that affect them. There has also been a review of Oranga Tamariki policies and procedures to ensure a full search for whānau, hapū and iwi is undertaken and documented as early as possible in the placement process.

Meanwhile, Oranga Tamariki is in the process of implementing a disability strategy.

Despite these changes, Boshier said it was “abundantly clear” more things needed to change.

Oranga Tamariki’s deputy chief executive of quality practice and experiences Nicolette Dickson thanked Boshier for the “comprehensive and considered” report.

“We acknowledge the distressing nature of some of the individual stories of those who have come forward to share their experiences, there are people who deserved a lot better from us.

“Whilst we acknowledge the sentiments of the Ombudsman, we’d like to assure the public that significant, positive change is already under way.”

Dickson said their practice has improved “substantially” on the use of without-notice uplift orders for newborn or unborn babies, and that by working closely with professionals, responding early, and offering more tailored support, they had been able to support more babies remaining safely in the care of their whānau.

Oranga Tamariki says it has been able to support more babies to stay safely with their families. Photo / 123rf

“It is incremental but crucially important change like this, that is essential to us earning public trust and confidence.”

She said the agency received 70,000 Reports of Concern, and acknowledged Boshier’s finding that these were not acted on, recorded properly or responded to adequately.

“We are making ongoing improvements to the way we respond to reports of concerns for tamariki and rangatahi in care, including regular reporting and analysis of these reports and the subsequent case work recording.

“We will continue to address and implement the practice and process improvements outlined by the Ombudsman in a timely way, with regular updates on the progress that is being made.”

Melissa Nightingale is a Wellington-based reporter who covers crime, justice and news in the capital. She joined the Herald in 2016 and has worked as a journalist for 10 years.