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

Thursday, 1 December 2022

Malachi Subecz was murdered by his caregiver last year.

Critical gaps in the system rendered Malachi Subecz an “invisible child” who was failed by multiple agencies and his community, a sweeping review into the child’s murder has found.

An investigation into how government departments could have intervened to prevent Malachi Subecz’s murder at the hands of his caregiver, Michaela Barriball, identified “ongoing holes in our safety nets and gaps” in a weak care and protection system.

“My terms of reference ask that I assess whether agencies within the system interact effectively. My response is that they do not,” Dame Karen Poutasi’s report said. “The system needs to be reinforced so that child protection is every agency’s responsibility, not just that of Oranga Tamariki.”

Poutasi, who led The Review of Children’s Sector Response to Abuse, has recommended mandatory reporting of child abuse across healthcare, welfare, education, children’s services, residential services and law enforcement.

* Pics of abuse suffered by Malachi Subecz didn't reach police until after his murder

* Children's Minister Kelvin Davis wants answers from Oranga Tamariki over murdered 5-year-old

* Details of horrific abuse inflicted on 5-year-old murder victim revealed

“How much longer must families and children wait for a system to understand and effectively use its own policies and procedures? We must create the certainty and compulsion to act now,” she said.

Mandatory reporting was one of 14 recommendations made to close five “critical gaps” that failed Malachi. Others included ensuring carers for children of sole parents being jailed were vetted by Oranga Tamariki, linking and strengthening information sharing, adding health services to the Child Protection Protocol and better monitoring child protection in early childhood education.

Minister for Children Kelvin Davis said the Government had accepted nine recommendations and was committing to look carefully at the other five, including mandatory reporting and vetting of caregivers, to ensure there were no unintended consequences.

“It’s essential the system changes. Mistakes were made and the Government is committed to fixing them so they are not repeated.”

He had been assured senior Oranga Tamariki staff involved in Malachi’s case “no longer work for the organisation”. Government agencies have said they will make changes as a result of the review.

Poutasi said Malachi became an “invisible child” because some tried to act but were not listened to, some were uncertain and did not act, and some knew and chose not to act.

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

“At no time was the system able to penetrate and defeat Ms Barriball’s consistent efforts to hide the repeated harm she was causing to Malachi that culminated in his murder.

“There was an urgent need to consolidate a whole picture of the risks for Malachi. Each agency had part of Malachi’s reality but did not register the red flags to bring it to each other in one view.”

Malachi was four years old when he was led from court by his killer on June 22, 2021. His mother, who was imprisoned, had entrusted Barriball with his care.

He died in Starship Hospital from blunt force injuries inflicted by Barriball, 27, on November 12, after days, weeks and months of horrific torture, including being slammed into walls, burned, starved, made to stand for hours, hit, deprived of medical attention, and physically and psychologically abused.

Six government agencies including Oranga Tamariki, police, Corrections, the ministries of social development, education and health contributed reviews to Poutasi’s report, with input from Malachi’s family and experts, and a review of 33 previous reports into child abuse.

Oranga Tamariki’s chief social worker carried out a separate review, finding the department had failed Malachi and his family in multiple ways. It included an apology from OT to the family.

Evidence of multiple failings

In her report, Poutasi said Malachi was a gentle, kind and thoughtful child, who was also adventurous and charming. He was his mother’s “whole world”, she said.

Poutasi walked through the points of contact with adults where Malachi had been failed.

Malachi was seen by multiple organisations, particularly in the first month he was in Barriball’s care – in just the nine days from June 21-30, 2021, there were 14 interactions with six agencies. But his voice wasn’t prioritised, Poutasi said.

Malachi’s family and stepfather made multiple reports of concern to Oranga Tamariki which were not acted upon.

A Department of Corrections probation officer also contacted Oranga Tamariki with concerns about Malachi’s care, fearing Malachi could be used as leverage to influence the court process.

The probation officer then contacted the prison intelligence team with the same concerns. The intelligence team discussed internally that the probation officer should notify their concern to the police, but the probation officer was not advised of this.

Procedural issues in the Family Court meant a hearing for custody to put Malachi in the care of his extended family didn’t take place. Malachi was murdered before it could be rescheduled.

Barriball received a benefit for looking after Malachi, and approached the Ministry of Social Development for housing assistance at the Te Puna property where they lived.

Abbey’s Place Childcare Centre took photographs of the abuse suffered by Malachi Subecz before his murder but did not alert any authorities to his extensive injuries.

Barriball took Malachi to the doctor on October 28 to get a letter to say he did not have autism. At the time there was an extensive burn on Malachi’s abdomen. “Ms Barriball did not mention the serious burn on Malachi’s abdomen, and no physical examination was deemed required, nor was undertaken.”

He was airlifted to Starship Hospital with blunt force trauma injuries four days later.

Poutasi also mentioned a function attended by Barriball and her whānau where at least one of Malachi’s injuries – a burn on his forehead – was obvious to some attending. When raised with Barriball, she falsely said he had already seen a doctor.

Barriball also sent text messages to her partner stating that, among other things, she hated Malachi and feared she would kill him, and to her sister and father saying she was too scared to take him to hospital or get medical attention in case she got into trouble.

What needs to change

Mandatory reporting would need to be enshrined in law, with clear guidelines and training required for all frontline workers and for employment in government agencies, Poutasi said.

Concerns about mandatory reporting included swamping the system with reports or dissuading parents from interacting with professionals. But these risks were already in play to some degree and could be mitigated by introducing categories of risk, she said.

A parent being jailed was a “red flag for risk” and Oranga Tamariki should be involved with every case where a sole parent was facing imprisonment, Poutasi said. Children should also be given legal representation.

More information sharing, including medical records, was needed and health agencies needed to be party to the Child Protection Protocol, which makes reporting suspected abuse to police mandatory.

Monitoring of Early Childhood Education Centres’ (ECEs) management of potential child abuse should be more active, and regular review of the implementation of their Child Protection Policies should be required.

“Young children, especially non-verbal children, are particularly vulnerable and ECEs must be particularly alert,” Poutasi said. “There should be regular checks that Child Protection Policies are offering effective protection, not just that they are in place.”

The Ministry of Social Development should have a system to notify Oranga Tamariki when a caregiver who has not been reviewed by Oranga Tamariki or authorised through the Family Court requests a sole parent benefit or emergency housing.

There needed to be more interaction between iwi, whānau and non-governmental organisations on the ground.

And there needed to be a public awareness campaign, she said. “Aotearoa simply cannot afford to look away. As a society, we cannot continue to allow a cycle of abuse, review, outrage and distress – and then retreat from the difficult challenges. There must be sustained, determined and bold change.”

The recommendations should be reviewed in one year’s time by the Independent Children’s Monitor.

Malachi’s daycare, Abbey’s Place Childcare Centre, was closed down by the Ministry of Education in October.

A separate investigation by the Ombudsman in October found a 'litany of failures' in Oranga Tamariki's handling of the case in the months leading up to Malachi's murder.

In sentencing Barriball to life with a non-parole period of 17 years in June, Justice Paul Davison admonished those who could have acted to try and prevent the child’s abuse. “Adults could have taken steps to intervene … this is the clear lesson,” he said.

Five critical gaps in the child protection system identified by Dame Karen Poutasi:

In identifying the needs of a dependent child when charging and prosecuting sole parents through the court system.
In the process for assessing the risk of harm to a child, which is too narrow and one-dimensional.
In agencies and their services not proactively sharing information, despite enabling provisions.
In a lack of reporting of risk of abuse by some professionals and services.
In allowing a child to be invisible. The system’s settings enabled Malachi to be unseen at key moments when he needed to be visible