Release of practice review into infant death

Child, Youth and Family was involved with an infant, referred to in the practice review as Infant B, and his family. Tragically this infant was found dead in his cot. Today, the Ministry for Vulnerable Children, Oranga Tamariki released findings from its practice review into the infant’s death.

The main objective of the review was to develop a deeper understanding of what happened and to identify actions that can be taken to better protect and support children. 

Ministry Chief Executive Gráinne Moss said, “When things go wrong and a child suffers we all look for answers.”

“Child, Youth and Family weren’t the only agency involved in this infant’s life. But it was the agency that had the sole mandate for the care and protection of children.”

“We need to acknowledge the failings identified in the review and implement what needs to be done to make improvements.”

There was considerable CYF involvement with the infant boy and his family in the last three months of his life. However the review revealed CYF social workers had not sufficiently looked into some patterns of parenting and some significant information had not been fully captured.

The review team found little evidence of collaboration with other agencies involved in the infant’s wellbeing. Neither was there robust safety planning in the decision for him to be discharged from hospital five days before he died.

Gráinne Moss said, “In response to these findings a plan is in place to strengthen practice and support decision making. At a local level, new systems have been put in place to address issues including management of staffing levels, allocation of work, and processes with local partner agencies.”

“A work programme is underway to apply review recommendations to our front line social work practice as a whole, including building the capability of staff to exercise professional judgement in areas of risk and ambiguity.” 

 “The complexity of what our social workers do every day should not be underestimated.”

“I have great respect for the unrelenting efforts of social workers, health professionals, police, and NGO providers to work with some of our most vulnerable families.”

“Our staff are involved in cases were children may be brought up in an environment of physical abuse, domestic violence, parents’ drug and alcohol abuse, chronic supervisory neglect, even sexual abuse. It is a tapestry that forms overtime and cannot be unpicked overnight.”

“To compound this, we work with families where children often face dealing with Foetal Alcohol Syndrome, Serious Conduct Disorder, ADHD, ADD and Oppositional Defiance Issues”

“When these factors are at play in families, they form a habituated pattern that requires skill, patience, and determination on the part of professionals and the community to reverse.”

“It’s also important to understand that for every action we can take to help, we need the family to engage, to be able to envisage a better future.”

“There are legal restrictions on some information. There are suppression orders currently in place. By releasing a plain English executive summary and our operational response, we have done our best to strike a balance between privacy and the public’s right to know.”