An internal Oranga Tamariki review has identified significant shortcomings in the agency's handling of an infant who was later killed by his father. The findings highlight failures in risk assessment, case oversight and ongoing monitoring despite earlier concerns about the child's safety.
Report by eLocal: Based on reporting by Sam Sherwood for RNZ. Original article HERE.
An internal review has found Oranga Tamariki failed to adequately assess and monitor the safety of nine-and-a-half-month-old Mustafa Ali before he was killed by his father in June 2024.
The review, obtained by RNZ under the Official Information Act, examined the agency's handling of the case after Mustafa had earlier been hospitalised with serious injuries.
His father, Mukzameel Ali, was sentenced to six years' imprisonment in May after pleading guilty to manslaughter.
Early warning signs
According to the review, concerns were first raised in October 2023 after a health professional reported unexplained injuries suffered by Mustafa.
Ali told authorities the injuries occurred when he fell while carrying the baby down stairs. Mustafa suffered a fractured collarbone, fractured ribs and bleeding to the head.
Oranga Tamariki initially responded by placing Mustafa in the care of his grandparents following his discharge from Waikato Hospital while safety planning took place.
A Family Group Conference later developed a staged plan for Mustafa to return to his parents' care. By early March 2024 he was living back with them full-time.
A second Family Group Conference was held in May before Oranga Tamariki staff visited the family home in early June.
Mustafa died on 8 June.
Review identifies failings
While the review found the agency's immediate response following Mustafa's first hospital admission was appropriate, it concluded several critical shortcomings emerged as the case progressed.
The report found there was only minimal analysis of the risks facing Mustafa and little documented assessment of the medical evidence that questioned the family's explanation for his injuries.
It also found no documented analysis explaining why the decision was made to continue transitioning Mustafa back into his parents' care after receiving the full medical assessment.
The review said Family Group Conference plans lacked clear objectives and specific timeframes for addressing ongoing safety concerns.
Monitoring arrangements were also criticised, with social worker visits described as insufficiently robust given the seriousness of Mustafa's injuries and wider parenting concerns.
Oversight failures
The assessment also identified several breakdowns in case management and organisational oversight.
Investigators found updated assessment reports were missing at three critical decision-making stages, including approval for intervention, referral to a Family Group Conference and planning before the conference.
Safety plans were not regularly reviewed to reflect changing circumstances, and there was no clear evidence demonstrating how officials measured whether risks had actually reduced once Mustafa returned home.
The review also found inadequate documentation of supervision and case decision-making, with important records missing from Oranga Tamariki's internal systems.
In addition, Mustafa had not been placed on the Vulnerable Unborn/Newborn Register, despite guidance recommending additional monitoring for infants considered at heightened risk.
Staff capability questioned
The review also raised concerns about staff capability and supervision.
It recorded reports from staff describing gaps in basic social work knowledge and understanding of relevant legislation among some workers and supervisors.
Reviewers also found no evidence that intervention plans adequately reflected recognised child protection practice or a clear understanding of abuse dynamics and future risk.
Staff reported that formal supervision did not consistently occur during critical decision-making stages.
Agency response
Oranga Tamariki Deputy Chief Executive Thomas Ronan described Mustafa's death as devastating.
He acknowledged that while a safety plan had been established, more should have been done to ensure it remained effective.
Ronan said the social worker responsible for the case was no longer employed by the agency.
He said Oranga Tamariki has since strengthened staff training, increased professional supervision, introduced improved assessment tools and expanded collaboration with Police, Health and community agencies.
Calls for lasting reform
Chief Victims Advisor Ruth Money said she was "absolutely devastated" after reading the review.
She noted that many of the same failures identified in Mustafa's case had previously been highlighted following the death of Malachi Subecz.
Money said weak supervision and professional practice below expected standards continued to appear in reviews involving preventable child deaths and urged Oranga Tamariki to implement meaningful and lasting improvements.
Source
Original Article: RNZ
Author: Sam Sherwood
Independent reporting. Original context. Credited sources.