'Hell' at Oranga Tamariki Tauranga office a key factor in Malachi Subecz’s death

Friday, 2 December 2022

Malachi Subecz, 5, died in Starship Hospital on November 12, 2021.

Staff at Oranga Tamariki's Tauranga office had raised concerns with management at least nine times before Malachi Subecz's death that they were “increasingly worried about the health and safety and quality of social work” being provided to the community.

Oranga Tamariki provided a report to Dame Karen Poutasi as part of her investigation into how government departments could have intervened to prevent Malachi Subecz’s murder at the hands of his caregiver, Michaela Barriball.

This report included an admission by Oranga Tamariki that staff at its Tauranga office had raised concerns with management at least nine times before the child’s death.

Staff were quoted as saying they were “increasingly worried about the health and safety and quality of social work we are providing the community”.

Between August 2020 and November 2021, nine health and safety incidents were lodged by six different staff members at the Te Āhuru Mōwai office.

* 'Critical gaps in the system' made Malachi Subecz an 'invisible child': Dame Karen Poutasi review

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Reports raised by staff related to the impact of high workload, a high number of unallocated cases, lack of capacity on site, burnout and stress, and concern about the flow-on impact on social work practice.

The office first received concerns about Malachi being in Barriball’s care in June 2021. By November 2021, the four-year-old boy was dead, murdered at the hands of Barriball.

The report into Oranga Tamariki’s failures that could have prevented Malachi’s death cited issues at the Tauranga office as a key factor.

Minister for Children Kelvin Davis speaks to media following a review into the death of Malachi Subecz.

“When workload pressures are high, a greater tolerance for risk may occur and reasons may be found to close an open case rather than exploring the best response,” it said.

The report also acknowledged that at the time concerns were raised for Malachi’s safety, Te Āhuru Mōwai social work staff were at capacity and experiencing “long-standing workload pressures”.

“The supporting environment for social work staff within the Te Āhuru Mōwai site contributed directly to the quality of practice decision-making in regard to Malachi.

“Social work staff at Te Āhuru Mōwai site were clear at the time of their involvement with Malachi and his whānau, that workload and resourcing issues were having a direct impact on their practice.”

An example of this pressure and lack of process, the report said, was the allocation of Malachi’s initial assessment to a new social worker.

Michaela Barriball at the High Court in Rotorua where she was sentenced for the murder of Malachi Subecz.

Te Āhuru Mōwai is one of two Oranga Tamariki sites in the Tauranga region and is based in Tauranga central.

The ‘Report of Concern’ for Malachi arrived at Te Āhuru Mōwai site in late June 2021, when Malachi’s family raised concern that the four-year-old was put into Barriball’s care on June 22, 2021 after his mother was imprisoned.

On November 12, Malachi died in Starship Hospital from blunt force injuries inflicted by Barriball after months of horrific torture in her care, including being slammed into walls, burned, starved, made to stand for hours, hit, deprived of medical attention, and physically and psychologically abused.

The review revealed that Malachi’s case was assigned to a social worker who had been on a student placement with Oranga Tamariki and employed permanently since February 2021.

This social worker, being a recent graduate, did not usually undertake assessments, and would normally be under supervision by more experienced staff.

“The social worker’s relative lack of experience was likely to have contributed to the level of quality of the initial assessment,” said the report.

The social worker did not contact any outside agencies for information about Malachi and his whānau, including the police who held information about the relationship between Malachi’s mother and Barriball, nor did she contact Malachi’s day-care or visit the place he was living with Barriball.

“Oranga Tamariki did not meet their obligations to Malachi or his whānau. Members of Malachi’s whānau made repeated, sincere and considered efforts to raise their concerns about the care, safety and wellbeing of Malachi. The Oranga Tamariki response to these concerns was inadequate,” said the report.

Staff in Tauranga painted a shocking picture of the Te Āhuru Mōwai office under pressure from a high workload and office culture challenges.

One staff member said: “The volume of work is unbearable….after hours is hell – you pray that the phone is not going to call. We are in a horrible cycle of dealing with crisis during the day.”

Another said there was a “lack of trust in the site leadership team”.

“I don’t know how many times I have to tell [site] management that it is not okay … you never know what you are going to get. I don’t feel they are supportive of me or us.”

In June 2021, an Oranga Tamariki senior human resources advisor had met with Te Āhuru Mōwai staff who spoke of “a punitive atmosphere, and an inability to speak out due to fear”.

Staff had also mentioned “relationship difficulties between senior staff members in site management and regional management positions”.

From 1 July 2020 to 30 June 2021, Te Āhuru Mōwai received 1500 Reports of Concern. From this total, social work staff at Te Āhuru Mōwai assessed that more than half of these reports required further exploration by Oranga Tamariki.

The review found key failings in practice in relation to the handling of the concerns reported to Oranga Tamariki about Malachi.

“Correct practice was not followed when it was decided to take no further action in regard to the first Report of Concern made by Malachi’s whānau,” it said. “When further concerns were subsequently reported, the decision to take no further action was not revisited.”

The Te Āhuru Mōwai site was resourced to have 17 full-time social workers, and the site had one vacancy at that time.

While allocated social work caseload sizes were equivalent with other sites, it was observed that Te Āhuru Mōwai had large numbers of tamariki who were not allocated to a social worker.

In addition, the site was averaging Reports of Concern about 120 tamariki each month, a high flow of referrals, and at times long wait lists for tamariki to have an initial assessment.

The report recommended that as “a matter of urgency”, Oranga Tamariki works with Te Āhuru Mōwai site and the Bay of Plenty regional team to create a plan to address the issues raised in the review.