Reviews in relation to Malachi Subecz and whānau and our response

After the murder of Malachi Subecz in November 2021, we have participated in, or held, the following reviews to examine and improve safety nets to prevent child harm:

In 2022, Dame Karen Poutasi completed an independent review of the children’s system response to abuse. It identified 5 critical gaps that can result in a child at risk becoming invisible to the system.

On 9 October 2025, Child Poverty Reduction Minister Louise Upston announced that the Government has agreed to accept all 14 recommendations made in the Review.

Children’s system changes following the review

Changes to implement the 14 recommendations will be complete in stages across multiple public agencies. We are 1 of 8 agencies that will action and support them.

The changes will strengthen the children’s system. They will improve the safeguards that will protect against child harm and ensure better responses. 

As chair of the Child and Youth Ministerial Group, Minister Upston is the lead Minister on this important mahi. 

Find out more on the work to implement the recommendations on the Ministery of Social Development's website.

Commissioning agencies

The Chief Executives of 6 public agencies commissioned this review to identify if the system could have done more to prevent harm being done to Malachi.

Each agency completed their own reports into their interactions – direct and indirect – with Malachi, his mother, his wider whānau, and Michaela Barriball.

The 6 agencies that commissioned the review are:

• Department of Corrections | Ara Poutama Aotearoa
• New Zealand Police | Ngā Pirihimana o Aotearoa
• Oranga Tamariki Ministry for Children
• Ministry of Education | Te Tāhuhu o te Mātauranga
• Ministry of Health | Manatū Hauora
• Ministry of Social Development | Te Manatū Whakahiato Ora

Progress reports 

Read reports provided to the Minister for Children and to Cabinet of Dame Karen Poutasi's findings and on our progress implementing her 14 recommendations.

Our Chief Social Worker completed a review of our practice in relation to Malachi Subecz and his whānau. Their role is to provide independent advice on our practice to our Chief Executive.

Their investigation found we did not meet our obligations and our response was inadequate.

As a result, we accepted full responsibility for the failings identified and apologised to Malachi’s whānau for them.

Detailed findings of the review

The Practice Review found that:

• We did not meet our obligations to Malachi or his whānau, and our response to their concerns was inadequate.
  
  
• We should have undertaken a comprehensive assessment of the care Malachi was receiving after concerns were reported to us.
  
  
• We did not engage with Malachi’s whānau as fully as we should have, and the paternal whānau did not have their voices heard.
  
  
• The environment for social work staff within the Te Āhuru Mōwai site contributed directly to decisions made about Malachi.
  
  
• There are gaps within practice guidance, professional development, and processes for social workers working with partner agencies regarding responding to Reports of Concern.
  
  
• There should have been a more collaborative response to the reports of concern from Oranga Tamariki, the community, and other agencies.

Changes following the review

We made changes to our practice as a matter of urgency, including:

• Ensuring core practice aims can always be met. This will be enabled by internal promotion of support to aid quality practice and implement responses when they are not met.
  
  
• Addressing the issues identified at the Te Āhuru Mōwai site.
  
  
• Ensuring all sites offer an environment where social work staff have the support needed to undertake quality practice.
  
  
• Making sure social workers have reasonably sized and well managed caseloads.
  
  
• Consider the need to undertake professional, reflective and responsive practice.
  
  
• Undertaking a review of the legal position and policy underpinning our initial assessment, which currently prevents engagement with tamariki and whānau.
  
  
• Developing a complaint process fit for tamariki and whānau, which needs greater independence and accessibility, considering the experiences of Malachi’s whānau.
  
  
• A fundamental shift to how we assess and respond to Reports of Concern with our partner agencies to ensure collaborative decision-making and support.