Even though it is small it is precious

I want to start this piece by saying it’s not about blame. I believe that most people, especially people who work with kids, do their best in difficult situations. When things go wrong, it’s usually systems and politics that have let these people down - and if we don’t talk about those systems and politics, we won’t see change.

Years ago, when I still lived in Naenae, I faced one of the most difficult dilemmas of my life - something I think about to this day.

I knew a whānau who were doing it tough. They were good people, and my friends - warm and funny and loyal, even if they sometimes did my head in. But if they sometimes did my head in, it was because they were contending with stuff I wasn’t. Housing instability, including a stint living in a van. Meth. And that incredibly difficult balance: being gang affiliated, wanting something different for their kids, but still needing the support of their social networks, in that utterly human way each of us does.

And there was the violence. It was between the adults, not against the children, but it was serious. I knew that exposure to family violence is itself a form of violence, harming children even when they’re not direct victims.1 And I knew that these particular children - much as they were loved and resilient and all-round great kids - weren’t always OK. I’d done my best to be supportive to my friends in the hope it might help things, but sometimes friendship isn’t enough.

I felt I had to do something more, yet I didn’t quite know what. Insofar as I’d thought about a situation like this, I’d assumed it would be clearcut. I’d simply call the authorities: back then, Child, Youth and Family, the forerunner of Oranga Tamariki. But now, faced with reality, my tidy theories seemed to fall flat.

I was out of my depth and I knew it.

We’re about to step into a world of challenging ethical issues. I faced some of them as an individual - but they also play out for services that work with children, and the policymakers who create the rules for those services. And in this world of challenging ethical issues, nothing is clearcut at all.

Malachi Subecz died in Starship hospital, on 12 November 2021, aged five. I wish I could write more about his life - his grin in photos, his love of Lego, his small boy’s obsession with dinosaurs to the point he was learning their names in te reo - but like most of us, I know of Malachi only because of his death.

When a terrible tragedy like this happens, one or more government reviews will typically follow, trying to understand what went wrong and what could stop it happening again. After Malachi died, the then Labour Government commissioned Dame Karen Poutasi to undertake what is called the Poutasi review, which reported back in 2022.2

The report began with this whakataukī: Ahakoa iti, he māpihi pounamu. It means, Even though it is small, it has its own mana, it is precious.

In her report, Dame Karen described the events that led to Malachi’s death. He’d spent his first four years loved and well cared for by his mother, who was raising him alone. He had an extended family who loved him too. But in early 2021, when his mother was arrested on charges that led to a prison sentence, Malachi’s mother needed to find a caregiver for Malachi, and fast. She chose a friend called Michaela Barriball, even though Malachi’s extended family wanted to take him. This was a decision Malachi’s mother had the right to make without any formal process - and indeed at this point, because no welfare issues had been raised, neither Oranga Tamariki nor the courts had the power to involve themselves in her choice.

Malachi’s extended family were immediately worried for his safety. They got in touch with Oranga Tamariki, something they would do several times over, providing a photo suggesting Malachi was hurt. Their concerns always seemed to go nowhere.

A Corrections officer also contacted Oranga Tamariki. They too were worried, because they thought Barriball might only have taken Malachi as a form of leverage over Malachi’s mother. (This was owing to a complex situation - Barriball’s mother was a co-accused of Malachi’s mother, and Malachi’s mother was in a position to give evidence against her co-accused.)

However, Malachi’s mother was still comfortable with Barriball being Malachi’s caregiver, believing Barriball was her friend. Oranga Tamariki decided no action was needed.

Now Malachi’s extended family tried the Family Court - but between procedural issues and Barribal’s unwillingness to take part, the wheels of the justice system turned too slowly to help.

Malachi’s ECE saw that he was injured, and even went as far as documenting it - but they didn’t report the injuries to anyone, despite their internal policy saying they had to. However, no government agency was checking whether the ECE was actually following its policy.

In the eight months Malachi was with Barriball, there were other contacts with government agencies too: the health system, police, and the benefit system.

Malachi was admitted to Starship on 1 November 2021. His mother was allowed leave from prison to be with him. His injuries were not survivable, and after twelve days, he passed.

Malachi had been what Dame Karen called an ‘invisible child’ within the system. She described the adults around him in this way:

• there were those who tried to act but were not listened to;
• there were those who were uncertain and did not act; and
• there were those who knew and chose not to act.

Dame Karen made a series of recommendations to stop children becoming invisible. These recommendations included government agencies paying much more attention when a child’s only caregiver gets taken into custody, and ensuring information on at-risk children is shared between agencies, because when nobody sees the whole picture abuse is more likely to go undetected.

The Labour Government accepted some of Dame Karen’s recommendations - and just last month, the current National Government accepted the rest. One of the newly-accepted recommendations is making it mandatory for people who work with children to report suspected child abuse to authorities.

Before we go much further, we need to dispel a possible myth or two. Aotearoa doesn’t have mandatory reporting right now, but that doesn’t mean there are no rules in place. Under the Family Violence Act 2018, certain workers and organisations have to consider reporting - that is, actively weigh up the best thing to do, not just let it slide.3 And child workers have codes of conduct or workplace policies that say they must report abuse, even if the law doesn’t make them.4 But whatever safeguards are in place, the truth is this: the system failed Malachi desperately.5 This failure ultimately led to the ECE he attended being forced to shut down.6

Knowing what we know about Malachi, mandatory reporting might just sound like common sense. If services aren’t doing the right thing by at-risk kids, we need a law to make them do it, right? This is where things get contentious.

We’re going to see that what might look simple at face value is anything but. Who’s responsible for speaking up about child abuse, and how exactly they’re held accountable, are really important questions - and questions that very smart people disagree on, although all feel strongly. Working through some of the arguments for and against mandatory reporting will help us understand why.

In the wake of Malachi’s death, doing nothing isn’t an option. It’s knowing the right thing to do that’s difficult.

Back in Naenae, those years ago, I found the phone number for CYF, came close to dialling, but hesitated. Looking back at my feelings of discomfort, I can see there were three issues bothering me.

Let’s take the biggest, societal-level issue first. I was a Pākehā woman with a professional job: a demographic doing pretty well compared to many. The whānau I was worried about were Māori, and both parents had gone through, and were still going through, things I’d never experienced. Calling CYF felt like having a go at them from a position of privilege, even as I knew I’d struggle to match their resilience in the face of such challenging life stuff.

This might seem like a theoretical thing to fret about, but there’s a lot of history here. When European settlers arrived in Aotearoa, they displaced the ways Māori cared for one another with colonial ideas about welfare, some of them pretty brutal. Pākehā women played an important part in this colonial welfare, carrying out charitable works that sometimes did more harm than good - and later taking part in government institutions, like state care, that inflicted cruelty and violence on tamariki Māori and their whānau.7 Even today, Pākehā women doing clumsy things can still recreate the power dynamics, and rekindle the hurt, of times past.

Now let’s move to a mid-level issue. I had a very real fear that if CYF got involved with the whānau they’d make things worse, not better. Like Oranga Tamariki today, CYF back then had been subject to endless reviews - criticised for intervening inappropriately, making biased judgements, and worse still, putting kids in care situations that were less safe than the ones they’d been taken from. For all I knew, my call could hurt these kids even more.

And at the everyday human level, these were my friends. I knew my call would cause them deep hurt, making them feel they were being judged and betrayed. More than that, I knew that a call would mark them with the stigma of bad parents, when really, they were complicated and imperfect like any of us. I was close enough to them that I saw just how good their parenting could be: how the kids sang out a happy Bye! to their mum and dad every school morning, heading off with tidy clothes and backpacks and full lunchboxes. Every person’s better than their weakest moment, but only weakest moments get phoned into child protection authorities.

In the end, I asked a friend for her wisdom: a wahine Māori with a long career in social work leadership. She understood deeply my dilemma and why it upset me. She also reassured me I knew what I had to do. With a lump in my throat, I made the call.

It turns out these things I was worrying about weren’t figments of my imagination: they’re also challenges for services that work with children and families. Emily Keddell is a Professor of Social Work at Otago University, specialising in child protection policy. She’s opposed to the kind of mandatory reporting recommended by the Poutasi review. We’re going to pick out some of her arguments and walk through them. (I’m simplifying a bit, and the non-academic language - as well as any errors - are mine.)8

At the societal level, Keddell is acutely aware of bias in the child protection system. She points to the 2021 Waitangi Tribunal report He Pāharakeke, he Rito Whakakīkinga Whāruarua - also known as the Oranga Tamariki urgent inquiry. The inquiry was prompted by outrage at Oranga Tamariki’s attempt to uplift a week-old baby from its young mother in hospital in Hawke’s Bay, and it reflected claimants’ desperation and hurt at the sheer number of Māori kids being taken into state care.9 As part of the inquiry, the Crown admitted what claimants knew, and evidence had confirmed for a long time: Oranga Tamariki was still affected by structural racism, had dragged its feet after past reviews telling it to change, and was breaching Te Tiriti.10

And at the mid-level, Keddell acknowledges that when kids are placed in care, it sometimes makes things worse - although, of course, it sometimes makes things better. As she says, the reality is ‘the child protection system both harms and helps’. The data agrees with her. In 2023/24, about 9% of kids put in care by Oranga Tamariki were neglected or abused - and that doesn’t even include the slow burn trauma faced by any child taken from their family by the state.

It’s Keddell’s comments about the human level that especially interest me. Child protection isn’t just about rules and processes: relationships really matter. Let’s take some time to understand how this works.

Keddell argues that mandatory reporting assumes the signs of abuse are pretty straightforward: workers just need to be told how to identify them, like a tick list, and then required to report them. The reality is more complicated, because things that look like ‘red flags’ might not be. (To give you an example, when I was a young first-time mum, I forgot my baby was sleeping in the backseat and left her in the car for a short time. That could’ve been a ‘red flag’ I was neglecting her, but in reality, I was exhausted, the morning’s drop-off routine had changed, I was on autopilot and I messed up. People who had a relationship with me understood my context and knew the difference. Someone reporting me would’ve destroyed my confidence as a young parent.)

And even when ‘red flags’ are present, protective factors can be too, like the good parenting my friends were doing. A worker who has a relationship with a whānau can often see both ‘red flags’ and protective factors - so might be able to make more balanced judgements about the actual level of risk a whānau is facing.

Relationships matter in other ways too. Mandatory reporting can damage trust between whānau and services, which can blow back on kids. For example, what if the parent who’s abusing her child starts to fear the services that help her child are going to get her in trouble? Does she decide to stay away from the GP, so her kid doesn’t get his vaccinations? Does she avoid the dentist, so he doesn’t get treatment for his tooth pain? Does she take him out of ECE, where he’d been doing pretty well: making friends, getting a nutritious lunch and staying warm to help manage his asthma?

What if the abuse starts taking place behind closed doors, where it worsens - and instead of bringing help, mandatory reporting takes away the only lifeline a child had?

After I made the call to CYF I waited. On the phone, I’d chosen my language as carefully and respectfully as I could - explaining that I could see the good stuff my friends were doing, but laying out why I was worried. I never thought to ask what would happen next.

It was an anxious wait. How would I know what CYF had done, or when they’d done it? Would I only find out because my friends wanted nothing to do with me anymore - because I’d thrown away our relationship?

I kept waiting. Nothing happened. Perhaps there was a reason: processes take time, I told myself. But nothing ever happened. Life went on. So did the violence. Only one thing changed: the whānau also became a caregiver to another child from their extended family. I couldn’t believe it, and yet I could believe it. CYF always struggled to find carers for children, and perhaps that’s unsurprising. Caregivers often feel unsupported and aren’t always paid.11 Some give care in incredibly challenging situations, including taking in distressed children at short notice in the middle of the night.12 It’s the kind of mahi that takes special people.

Individuals like me aren’t the only ones who find reporting difficult: at the coalface, services also have issues. To tease out these issues, we need to look at how the child protection system actually works. Back to Emily Keddell. In 2024, Keddell and her academic colleagues published research on NGOs that work with children and families, and are a key source of reports to Oranga Tamariki. These NGOs employed social workers and other types of workers. Were the NGOs reporting when they should? If they weren’t, why not? Keddell found problems - but they might not be the problems you think. A bit of context can help explain.

We can think about the job of Oranga Tamariki in two main parts: intervening when the abuse of a child reaches a statutory threshold (a point where the law says authorities can step in), and doing preventive work to stop whānau getting to that statutory threshold. But the reality is that Oranga Tamariki has limited people and money, so they have to focus mostly on children who’ve reached the statutory threshold and are in the worst situations. In other words, Oranga Tamariki are so busy being the ambulance at the bottom of the cliff, it’s hard for them to build a fence at the top.

It’s NGOs who tend to act as the fence, but that’s a job involving a lot of tricky judgements, including when to pick up the phone to Oranga Tamariki. Keddell heard how NGO workers took different approaches to these judgements. We’ll look at a few and generalise a little.

Keddell discovered that NGO workers treated some types of harm as ‘categorical’ and reported them automatically: sexual abuse, immediate danger to a child, and (usually) hitting or threatening to hit a child. But she also found these categorical situations weren’t common, partly because workers found it hard to figure out the statutory threshold at which Oranga Tamariki is more likely to act.

Mostly, NGO workers would seek to understand a family in a more holistic way, including the family’s protective factors, and they’d try to support the family through a problem before involving Oranga Tamariki. They’d look out for ‘tipping points’ in risk that might signal a report should be made - maybe the family’s contact with their service dropping off; an increase in violence, mental health issues or drug use; or a new and potentially unsafe person in the home. However, they wouldn’t go ahead with a report if Oranga Tamariki had received and closed a report on the family recently, or if Oranga Tamariki had already indicated they wouldn’t receive the report.

And NGO workers thought pretty carefully about their own possible bias before they reported - especially bias against Māori and Pacific whānau, low-income whānau, whānau who’d already been in contact with Oranga Tamariki, and mums with learning disabilities (who are sometimes assumed unfairly to be unable to parent). Some NGO workers distinguished between physical hitting and discipline - so if, for example, a mum smacked a kid on the hand, but she was regretful about it and getting support to change, that might not be reported. And workers had stopped reporting parents for smoking weed - something no longer seen as a big risk. Workers were aware Oranga Tamariki has moved towards keeping kids in their families where possible, and they supported this approach.

At this point, a reminder: NGOs are only one kind of service that works with families and kids. Keddell’s research doesn’t cover all services who might need to decide whether to report child abuse - but for what it’s worth, I felt reassured by her findings. It sounded to me like NGO workers were doing a good job. So what was going wrong for them?

Well, Oranga Tamariki had told some workers they wouldn’t get involved if a whānau was receiving NGO help, so workers thought there was no point asking. Some workers felt Oranga Tamariki had raised the bar for accepting reports too high, and weren’t taking NGO’s professional concerns seriously enough. Reporting itself was seen as difficult, sometimes involving hours on the phone. And some NGO workers felt the same worry I did: a report might have no effect, damaging their relationship with a whānau for no gain, or even making life for the whānau worse.

Now we know a bit about how our child protection system works, including some weaknesses. What would happen if mandatory reporting was layered over top of this system? This is where Keddell gets worried.

You’ve probably guessed some of the downsides of mandatory reporting - but you might be thinking, maybe it’s worth it. Cast the net wide, and it’ll catch a few families who shouldn’t be there, but it’ll also catch more families who should be there.

Again, Keddell thinks it’s more complex than that. Mandatory reporting is likely to make child workers risk averse because they’re now worried about getting in trouble with the law. Instead of using their professional judgment - weighing red flags against protective factors, using relationships to try and help a family first - workers will probably go straight to Oranga Tamariki. Oranga Tamariki could find itself swamped with a flood of reports, many of them lower-risk. All those reports will suck their already limited people and resources away from any preventive work, meaning even less help to stop families falling off the cliff.

But it gets worse. A flood of reports to Oranga Tamariki could create a needle-in-a-haystack situation, making it even harder to see the children in most desperate need of help.

For all the good intentions behind mandatory reporting, kids like Malachi could become more invisible, and more in danger, than ever.

After my phone call to CYF there was anxiety, but another feeling mixed in: relief.

I’d been tying myself in knots. Was I overreacting to my friends’ situation? Was I just a meddler? Who was I to judge someone else’s parenting anyway? But the advice from my friend with her long career in social work leadership had lifted a weight. It was as if she’d drawn a clear line between what was OK and what wasn’t, shown me what side of the line things were on, and set out what I needed to do about it. As she did, I understood I’d been trying to carry a complex situation, involving many people and causes, by myself. No wonder it was taking its toll.

We’ve used Emily Keddell’s work to look at potential problems with mandatory reporting. But is it possible to overcome these problems? We’re now going to circle back to the Poutasi review - the report into Malachi’s death - and see how Dame Karen thinks mandatory reporting could be made to work. We’ll see that just as clarity and certainty mattered for me, they also matter for services who work with children.

Now, Dame Karen didn’t set out a detailed design for mandatory reporting, because that wasn’t her job. (Reviews like hers will often recommend a high-level direction, then it’s up to the Government to figure out if and how it will respond.) But she sketched out the main features. She said a mandatory reporting law should cover people in these workforces: health, welfare, education, children’s services, residential services and law enforcement. Workers in these services should be given a guide setting out ‘red flags’ for child abuse, each with a clear definition. And workers should be required to do training on recognising ‘red flags’ and meeting their reporting responsibilities. The wider child protection system should be gripped up to support mandatory reporting, including with more resourcing.

Dame Karen acknowledged some of the problems with mandatory reporting we’ve talked about, especially families being put off accessing services and services being flooded with reports. But she thought these problems could be addressed. As part of her review, she talked to child protection authorities in New South Wales. New South Wales has had mandatory reporting since 1977 - and they were flooded with reports at first. In response, they adjusted their approach, trying to draw a much clearer line so mandatory reporting only applied to child abuse causing significant harm. They created a ‘decision tree’ tool that sets out specific abuse situations a child could face and what workers should do about them.13 Dame Karen reported that this adjustment reduced the flood of reports child protection authorities were receiving.

But does that mean the New South Wales approach to mandatory reporting is a success? I had a look for evaluations, and the most recent I found was carried out by the Audit Office of New South Wales in June 2024 - to be fair, almost two years after the Poutasi review. What I found I can only describe as deeply disturbing. New South Wales is a child protection system in disarray.14

The Audit Office found that despite a number of reviews, New South Wales remains ‘crisis driven’ instead of focusing on early intervention. Most families in the system don’t get services to help them address their risk of child abuse. About a third of children who manage to get case worker support are re-reported within a year, suggesting the support isn’t helping them enough. Children taken from their families and placed in other settings aren’t monitored, so nobody knows if they’re safe or not. The proportion of kids placed in care who are returned to their families once it’s safe has been declining. This proportion is worse for Aboriginal children than non-Aboriginal children.

And how is mandatory reporting working in New South Wales?

Well, in recent years, report numbers have grown - driven by people being more aware of their mandatory reporting responsibilities, and by a new online reporting option. When a report comes in, it’s like a first gate: the authorities go through a ‘desktop’ exercise to see if the significant harm threshold might be met. A full 40% of reports don’t meet the threshold, but they still use up staff time and resources. The reports that make it through this first gate involve children who are now presumed to be at risk of significant harm, so there’s a second gate: an in-person assessment by case workers.

But by this stage of the process, there’s much less staff time and resources to go around. Only 25% of children presumed at risk of significant harm actually get a case worker assessment. The other 75% simply have their cases closed, without anyone ever seeing them. And what happens to this 75%? Again, nobody knows. Without enough staff time or resources, the child protection authorities don’t track these kids. I read those statistics over and over, convinced I must have misunderstood them.

Now, not all of the problems with the New South Wales are to do with mandatory reporting - systems and politics are always more complex than that. But we need to ask ourselves if theirs is an approach we want to emulate.

Malachi, if he lived in New South Wales today, would likely be even more invisible than he was in Aotearoa.

Back in Naenae, I loved those kids. When I’d visit my friends’ house, the older ones would give me a Hey, Anna! The youngest would chatter happily to me, the way little children do - when you can’t quite figure out what they’re saying, but you’re delighted to be the one they share it with.

Our families lost touch. We moved up the road to Upper Hutt, and they moved down the motu to Christchurch. I always wondered what happened to them.

Now that the Government has accepted all the recommendations of the Poutasi review, including the recommendation for mandatory reporting, a design phase will follow.15 We don’t know exactly what this design phase will involve, or who will be consulted, but we know that a lot hangs in the balance. I started this piece committed to being open to the evidence. I’ve tried to write about it avoiding emotive language. But here’s what I’ve concluded. Get this design phase wrong and children could die.

What can you do?

For a start, don’t be put off because mandatory reporting is about rules and processes. What might seem dry and technical is something we all have a stake in - especially workers who might end up with mandatory reporting responsibilities. If that’s you, your expertise matters so much right now. Maybe you could talk to your colleagues about it. Ask your union to take an interest. Look out for opportunities to give feedback. Make sure that whatever happens next, it works for kids like Malachi.

It was only by chance that I found out years later how my friends were doing, through someone who happened to know them. I’d thought about them a lot, hoping for the best but fearing the worst. The reality lay somewhere in between.

Their whānau continued to face some tough stuff, but they’d held it together. A local church group wrapped around them, with one of their members - a retired lady - driving the kids to and from school each day. Their nan and koro had the kids to stay when mum and dad were finding it hard. Mum and dad accepted the help, because education mattered to them, and they wanted their children to have a better shot than they’d been given. And those loved, resilient and all-round great kids? Well, they were doing OK.

I describe this to you like it’s simple, but it’s not. To get an outcome like this, with or without mandatory reporting, a lot of things have to go right.

In this kind of scenario, the kids’ driver needs time to do her job, a reliable car and money for gas. The kids’ nan and koro need extra help to heat their house and buy more groceries, instead of trying to eke the costs of mokos out of their superannuation. The kids’ school needs the resourcing to give the right support, including serving good quality hot lunches. At the end of the school day, the kids need to go home to a secure house - not one they’ll be forced out of the next time rent goes up. Their parents need an adequate income, access to help for drug problems and violence; and eventually, if all goes well, access to employment. If risks escalate for the whānau, Oranga Tamariki needs the right staff and resources and processes so they can pick up the phone straight away, offering a careful, proportionate, Tiriti-based response. If the kids put a foot wrong, because that’s what kids sometimes do, they need understanding - not angry public howls for bootcamps.

And right across a scenario like this, in every interaction, relationships matter. People aren’t just objects of rules and processes. They need to know the services they trust have their backs - and while they might not care what policies exist behind the scenes to make sure trust happens, they deserve the assurance those policies are in place.

You get what I’m saying.

The Poutasi report ends with this whakataukī: Mā o mokopuna koe e mōhiotia. It translates as, You will be known on the welfare and achievements of your descendants.

My friends knew the meaning of that whakataukī, putting it into practice the best they could every day they got those kids dressed, fed and to school. It’s work that should been seen and valued - and perhaps above all, work a whānau shouldn’t have to do alone.

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