Errors in child death revealed

A review of Child, Youth and Family has exposed a host of mistakes and oversights in its handling of the case of a toddler who was allegedly murdered in October 2015.

The 17-month-old Southland boy was found dead in his cot. An autopsy revealed bruises to the boy’s left eye and the right side of his forehead.

He had suffered a blow to the back of the head and spinal injuries.

Police charged the partner of the boy’s mother with murder three days later. He died at Otago Corrections Facility – a suspected suicide – on November 22.

The man had been arrested for dangerous driving, burglary, assault and car theft several months earlier.

He was initially refused bail, because his risk of offending was too high. However, it was eventually granted two weeks before the toddler died.

The judge in part cited a Child, Youth and Family (CYF) report that ‘‘speaks favourably of [the man] and the steps that he and his partner have taken in relation to their relationship and to her care – until recently – of the children’’.

‘‘It was a significant tragedy,’’ Ministry for Vulnerable Children chief executive Grainne Moss said.

‘‘There’s no doubt that there was a failing and we need to accept that, own it, and say that we’re going to make it better in the future.’’

The ministry review found CYF was aware of a long history of parenting, childcare and relationship issues in the toddler’s family, but the information was not properly considered in the weeks before his death.

The report CYF provided to the court on the bail application was outside its usual remit, the review said, and failed to account for the risks involved.

‘‘Consequently, the purpose and format of the report, and the process for approving the draft report requested of Child, Youth and Family, was ambiguous and unclear . . . In hindsight, the report request should have been queried with the Courts.’’

The review highlighted poor communication within CYF and with other agencies, particularly around the toddler’s hospital stay less than a week before he died and

"There's no doubt that there was a failing and we need to accept that." Grainne Moss, Ministry for Vulnerable Children chief executive

the risks in discharging him back home.

‘‘[The boy] had sustained a number of injuries including one of some severity and there remained a lack of clear explanation for these . . . there was a known history of concerns about the adults responsible for his care.

‘‘It was noted that whilst agencies and individuals considered in this review ‘shared’ concerns, there was less evidence of them sharing responsibility for considering what these concerns could mean and how best to manage a response.’’

The review listed six recommendations for changes at CYF, which was replaced by the Ministry for Vulnerable Children. The ministry released a plan to implement them by 2018. It received extra funding in the last two budgets and Moss was confident resourcing issues could be addressed.

‘‘The challenge will be getting the number of staff and also the quality of staff,’’ she said, particularly in their ability to exercise professional judgement ‘‘in areas of risk and ambiguity’’.

‘‘The very challenging environments that our social workers work in is often very chaotic and complex. They have to make fine judgments often in a very short timeframe.’’