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Review Into CYF Involvement With Tamati Pokaia

Media Release

Wednesday, December 17, 2003

Child, Youth And Family Releases Findings Of Chief Social Worker's Review Into Its Involvement With Tamati Pokaia

Child, Youth and Family has released the findings of its case review following the death of three-year-old Tamati Pokaia while in the Department's care in April 2002.

The release of the review follows the sentencing today of Tamati's foster father, Michael Waterhouse, to 10 years in prison for manslaughter.

CYF General Manager, Social Work and Community Services, Ken Rand said today that the Department was deeply saddened that Tamati had died while in its care.

The review found however, that based on the information available to the Department at the time, the placement decision was justified.

"Social workers exceeded official requirements during their assessment of the Waterhouses to be approved caregivers," Mr Rand said.

A thorough questionnaire was gone through with the applicants. The family GP provided a medical check, saying he saw no reason why the Waterhouses should not be approved as caregivers. A police check was done and references were taken from two referees. Letters were sent to other agencies asking whether the couple had been involved in caregiving for them and school reports were sought in respect of the couple's own children.

"Notably, police had no record of Waterhouse having any previous convictions or any history of violence," Mr Rand said.

The Department has subsequently learned that some family members had concerns about Waterhouse's mental health, and that the GP who was contacted during the assessment held information he had not disclosed that Waterhouse had been involved in alcohol related violence some years ago.

As a consequence, the Department will be initiating talks with relevant medical bodies about the importance of full disclosure during caregiver assessments, Mr Rand said.

Concerns were raised in the review that following Tamati's placement with the Waterhouses, the Department did not meet its standard of visiting children in care every two months.

"Arrangements were made for visits and there were telephone discussions but because of deferral or cancellation by the Waterhouses, a visit did not eventuate after one made on December 11," Mr Rand said.

"One of the things we have learnt from this review is that, particularly with newer caregivers we will follow up more quickly on appointments that are cancelled in the absence of a good reason. We expect arrangements for these follow-up appointments to be made as a priority and the Department is issuing a practice note to all social work staff to this effect."

The report discloses that Tamati was taken into care after he was admitted to Waikato Hospital in February 2000 with serious injuries.

"Child, Youth and Family social workers must act to protect children from abuse," Mr Rand said. "In doing so they do not act alone. Other agencies are involved. The Family Court oversees the actions of social workers in these circumstances and is informed of actions they have taken."

He said formal disciplinary action was not warranted in relation to the case because the report raised no significant individual practice issues.

Every day Child, Youth and Family has around 4,700 children in care.

Case Review

Review of involvement of the Department of Child, Youth and Family Services with Tamati Pokaia

Report from: The Office of the Chief Social Worker

Child, Youth and Family

December 2003

Circumstances of death

Tamati Pokaia was born on 30 June 1998 and died on 29 April 2002, while in the care of Child, Youth and Family approved caregivers, Michael and Maata Waterhouse. The autopsy report identified that Tamati died of internal injuries following an assault. Michael Waterhouse was subsequently charged with murder in relation to Tamati's death and convicted of manslaughter. At the time of his death, Tamati was in the custody of the Chief Executive of Child, Youth and Family, subject to s101 of the Children, Young Persons and Their Families Act 1989. He had been in the care of Mr and Mrs Waterhouse for five and a half months, placed there with his younger sibling.

Review methodology

Most of the social workers who worked with Tamati and his family have now left the Department. Therefore, the review has been done from an examination of the electronic and paper records, with those remaining staff provided with a draft copy for comment. A chronology of the Department's involvement was prepared, reviewed and discussed with managers for the Waikato East area and practice issues were identified.

This report is not the original review report because that report includes details relating to people who have the right to privacy (withheld under Official Information Act s9(2)(9)). This report, though, is drawn from the review report, contains all of the salient facts, as known to Child, Youth and Family, and provides the review findings and comment.

Background of involvement with Tamati

Child, Youth and Family became involved with Tamati at the age of 6 months, following a notification received from Waikato Hospital, on 15 December 1998, in respect of physical abuse of his older brother. At a whanau meeting, Dionne Pokaia, the children's mother, admitted to the abuse. No charges were laid by the Police in respect of this incident.

Throughout the first part of 1999, Child, Youth and Family continued to support Dionne and her whanau to care for her children. Attendance at various counselling and parenting programmes were facilitated and community support and monitoring arranged. The children were cared for by whanau. By June 1999, the whanau had returned both children to Dionne's full-time care with support continuing to be provided by a number of agencies.

A further notification was received in respect of the children being home alone. This was investigated and substantiated. In September 1999, Child, Youth and Family and Dionne agreed to a Family/Whanau Agreement. Dionne was to continue with personal counselling and attend a "Moving Beyond Violence' programme and the children were to be enrolled in Kohanga Reo. Monitoring over the period September 1999 to November 1999 by various agencies indicated that Dionne continued to make progress and the children were well cared for. Thomas Hone (Tamati's father) and Dionne were now living together and requested arrangements to be made for them both to complete a parenting programme together. In November 1999, the case was closed with all parties involved notified and asked to monitor the situation.

In February 2000, Tamati was admitted to Waikato Hospital with serious head injuries (an old fracture of the skull) as a result of abuse. Dionne was pregnant with her third child. It was established that domestic violence had occurred over the Christmas period. Further, Dionne and Thomas had been physically abusing the oldest child and had been neglectful in seeking medical treatment for both children. The children were dirty and neglected and the explanations offered regarding Tamati's injuries were inconsistent. The perpetrator of Tamati's injuries was not identified.

The children were uplifted on a s39 Place of Safety Warrant on 29 February 2000 and placed in the care of the maternal grandparents. On 3 March 2000, the Family Court made a s78 Interim Custody Order in favour of the Chief Executive. A further referral for family group conference was made in March 2000. As the maternal grandparents found it stressful caring for the two children, they placed the children with the paternal grandparents.

In April 2000, consideration was given to Dionne and the children going into a residential parenting programme. However, Dionne refused to go. On 28 April 2000, Dionne gave birth to a third son. Child, Youth and Family had asked for the midwife to inform them of the birth but the midwife believed she was not able to do that and was not prepared to do so. This matter was raised with Waikato Health Management. Child, Youth and Family discovered only from a neighbour on a home visit that Dionne had given birth. It became apparent to the Department that, prior to this baby's birth, the grandparents had returned the children to Dionne's care, without the Department's knowledge or consent. Following the birth, the grandparents had subsequently taken the children back from Dionne.

In May 2000, a family group conference was held with the outcome being an application for declaration. This was unopposed. The plan stated Dionne was to attend a residential parenting programme, the oldest child was to remain with maternal grandparents and Tamati was to be placed temporarily with his paternal grandparents. The youngest child was to remain in Dionne's care. Tamati moved to be with Dionne at the programme in mid-June. However, by the end of June, concerns were being expressed over Dionne's commitment to the programme and disruptive behaviour on her part. Her relationship with Thomas had resumed.

In July 2000, a meeting was held with Dionne and the residential programme coordinators and it was agreed there would be a further attempt made to complete the programme, with the oldest child to join his siblings at the residential programme. It was confirmed also that Thomas was to only have supervised access to the children. Over August/September, Dionne made little progress at the residential programme, resuming her relationship again with Thomas and finally leaving the programme on 8 September 2000. Both Tamati and the oldest child were placed together with an approved caregiver that day.

On 5 September 2000, an Interim Custody Order to the Chief Executive for the youngest child had been made, along with a further family group conference referral. The social worker began to look for non-kin carers for Tamati and his older brother, after concerns were raised by a number of parties, including Dionne and the whanau, over continued whanau placements. The paternal grandmother offered to take care of the youngest child. On 27 September 2000, a family group conference was held and Interim Custody Orders in respect of all three children were confirmed on 3 October 2000. In November 2000, the youngest child moved to be with his brothers at the same caregiver, at the paternal grandmother's request. Dionne and Thomas had again resumed living together and Dionne filed an application for custody in respect of the children.

In December 2000, Tamati accidentally fell into a swimming pool while visiting friends of his caregiver. There were conflicting accounts of the level of supervision and whether Tamati nearly drowned. Tamati was medically examined and found to be well. Social work staff subsequently established there was no negligence involved. For the six months to March 2001, it is noted that the children's behaviour had been difficult and challenging. Access with the parents had also become difficult and at times confrontational.

In April 2001, all three children were removed from the caregiver following disclosures of neglect and abuse by the caregiver. Tamati and the youngest child were placed with another approved caregiver on 17 May 2001. This caregiver cared for them until her move overseas necessitated a further placement.

Tamati and the youngest child moved to the care of Mr and Mrs Waterhouse on 17 November 2001. On 28 November 2001, a further Court hearing was held with the Custody Orders to continue for all three children.

On 5 December 2001, Child, Youth and Family was given information that Maata Waterhouse was smacking Tamati to discipline him and using inappropriate time out periods. It was also indicated that Michael Waterhouse had said he had a preference to only care for the youngest child. On 11 December 2001, a home visit was made to the Waterhouse home. Only Maata Waterhouse was at home. The social worker addressed alternative discipline methods, the couple's attitude to having both children, discussed the support available to them as caregivers, (this included discussion of respite care and support available from the Fostercare Federation) and explored Tamati's needs. Maata Waterhouse admitted to the smacking in response to an incident when Tamati had encouraged the youngest child to climb up the balcony. Maata indicated they wished to continue to care for both children.

In early 2002, possible whanau placement options continued to be explored and assessment checks instigated. In February 2002, Maata Waterhouse informed the Department that the youngest child had fallen off a bunk bed and bruised his face. A GP visit was arranged but no outcome is recorded. In March 2002, difficulties over access again arose between Dionne and Thomas. Mr and Mrs Waterhouse indicated that they were not prepared to have weekend access arrangements because of previous access difficulties and their own children's sporting commitments at weekends. On 4 March 2002, the social worker tried to make arrangements for a home visit to see Mr and Mrs Waterhouse that day but the time suggested was not suitable for the Waterhouses. Another home visit was proposed for 17 April 2002 but this was cancelled by Mr and Mrs Waterhouse. Tamati died at approximately 3:30 pm on 29 April 2002.

Background on caregivers

Michael and Maata Waterhouse applied to become caregivers for Child, Youth and Family on 5 August 2001. At the time of their application, they had five children of their own, ranging in age from 17 years to 3 years, all living in their home. In the home assessment that was completed, they outlined that they were motivated to foster as a natural extension to their current family/home environment, where they always had extended family around to visit and stay. They said they would like to have more children around. They had provided a home for two international students each year for some years.

Significant factors outlined in the home assessment report include:

- Applicants outlined a good support network with large number of family members living in close proximity;

- Applicants identified long-term care as suiting their needs;

- Reference to Michael's health problems and implications of this (hip replacements);

- Applicants outlined no exposure to family violence, any previous violent relationships or current relationship as being violent;

- Both described each other as strong, capable and loving parents;

- Outlined use of smacking of the younger children when they think behaviour is unacceptable; (The Department's policy on smacking was discussed and reiterated. Both applicants stated they understood the position.)

- Stated they wished only to have pre-school children requiring long-term placements placed with them;

- Did not want to deal with children with behavioural issues;

- Assessor noted applicants as having no experience of dealing with challenging behaviours;

- Applicants noted they would not want to become involved with the family of any foster children but would support access.

The required medical form was completed by the applicants' GP. In this, the doctor said he had known the applicants for three years and there were no health or psychological issues and they were well adjusted and capable parents. The GP saw no reasons they would be unable or unsuitable to care for children.

Although referee check forms were posted, it seems they did not arrive at the intended recipients. Subsequently telephone calls were made to each of the referees.

Waikato East SDU then undertook two checks which are over and above those required by current policy on caregiver approvals. The first is that letters were sent to other agencies, who had foster caregivers providing care, to establish if Mr and Mrs Waterhouse had been caregivers for them. No information was received to indicate they had undertaken care giving for any other agency.

The second extra check was that school reports were sought in respect of Mr and Mrs Waterhouse's own children, asking for:

- The school's perception of the physical care of the children;

- Whether any behaviour problems were apparent;

- Parental cooperation with the school;

- Parental support given to the children.

Responses received indicated there were no issues of concern in respect of their application to be caregivers.

Approval was given for Mr and Mrs Waterhouse to be caregivers on 13 November 2001. A caregiver liaison social worker was appointed as the family's social worker. Tamati and the youngest child were placed with the couple on 17 November 2001. They were the first foster children placed with them. A review was required to be done within the first six months. This was completed by the caregiver liaison social worker on 11 December 2001 and identified the following:

1. Preparation training undertaken No

2. Letter of approval completed Yes

3. Caregivers handbook provided Yes

4. Aware of support from NZFFCF Yes

5. Aware of local support Yes

At the time, Child, Youth and Family was in negotiation with the Child Protection Studies Institute to provide foster care training. The contract had not been finalised and therefore a number of new caregivers were waiting for training to be available.

In the course of making enquiries into Tamati's death, it was found that there had been domestic violence in the Waterhouse's relationship. The Police state they had no information pertaining to domestic violence in regards to the Waterhouse's.

The Police also told Child, Youth and Family that members of the Waterhouse family also queried Michael Waterhouse being approved, because of historical psychiatric issues previously not disclosed.

The GP also provided information after Tamati's death that there had been historical incidents of alcohol-related violence in relation to Mr Waterhouse.

None of this information had been made available to the Department at the time the caregiver assessment was being undertaken.

Significant Practice Issues

1. Involvement of Whanau, Hapu and Iwi

The extent to which the whanau, hapu and iwi were engaged in this case varies over the period of the Department's involvement. Initially, whanau provided care for Tamati, and did at various stages until September 2000. However, at times, whanau informed social workers that this was becoming too stressful and the whanau would make arrangements for Tamati to be moved to other whanau or returned to his mother's care. On occasions, Child, Youth and Family staff were not informed of these changes in arrangements nor were Child, Youth & Family informed after they had occurred.

Frequently, caregivers were suggested by whanau, partial assessments made and then the proposed caregivers rejected. At various times, both sets of grandparents expressed concern and criticised each others ability to care for the children. Dionne herself raised issues of concern in respect of their care, as did the Counsel for Child. By September 2000, when the social worker made the decision to look for non-kin carers to be found for the children, this was because issues had arisen over the grandparents being able to be adequate protectors for the children. No caregiver assessments appear to have been completed for the grandparents.

Care and protection issues for children must be continually discussed with whanau and wider family. Had this occurred, this would have helped the family understand the difficulties Child, Youth and Family were facing in finding a placement for the children. Family placement options that were identified after Tamati's death may have become apparent earlier. The principles of the Children, Young Persons and Their Families Act 1989 are very clear. They include enabling and supporting the involvement of the child's family, whanau, hapu and iwi in their care and protection.

Response: see comments and finding below

2. Referral for family group conferences

On 17 December 1998, the Care and Protection Resource Panel supported a referral for a family group conference. On 18 June 1999, a social worker told the parents there would be a family group conference. Neither of these referrals were followed through and records do not provide reasoning as to why these did not happen. The conference process is one of the cornerstones of the Children, Young Persons and Their Families Act. At a conference, whanau/family agree on a plan about how the whanau and agencies will work towards wellbeing outcomes for the children. Conference plans address all the relevant risk factors and contain contingency plans. If the family group conferences in 1998 and 1999 had taken place, this would have enabled the care and protection issues for the children to be put to the whanau and a plan put in place.

Two family group conferences were held, the first on 16 May 2000 and the second on 27 September 2000. The plan made on 27 September 2000 was for Dionne and the children to move to live with whanau. However, it became apparent less than a month later that this plan was not viable. The conference was not reconvened.

Comments: This comment is in response to issues 1 and 2 listed above. It is acknowledged that placement within family is not always easy, especially when conflicting information is being provided about the suitability of family members. The family group conference is the primary and most appropriate forum for sharing information with wider family and enlisting their support in making safe decisions for children.

The primary role in caring for and protecting children or young people lies with the child or young person's family, whanau, hapu, iwi and family group.

Finding: The wider family networks were not fully accessed consistently throughout Child, Youth and Family's involvement with Tamati. Social workers are required to involve family/whanau in supporting, assisting and protecting children. The principles of the CYPF Act provide unequivocal guidelines on the requirement to involve a child's family.

3. Inter-agency protocols

Inter-agency agreements between Child, Youth and Family and Waikato Health were not kept. The Department requested to be notified of the birth of the youngest child and this did not occur. The midwife refused and the baby was a week old before the Department was informed of his birth by a neighbour. A comprehensive multi-agency approach is required to increase the safety of the children.

Comments: The introduction of the Privacy Act may have led to some misunderstanding about information-sharing between agencies. In recent years, the Department has developed inter-agency protocols with a range of agencies, in an effort to enhance inter-agency cooperation. The care and protection of children is paramount and sharing information is essential.

Finding: Social workers, other agencies in the welfare sector and health professionals did not share critical information. An examination and an analysis of the effectiveness of the existing policies and protocols is required in order to ensure the policies and procedures support the responsiveness to care and protection issues for children. There must be an unambiguous understanding of the Privacy Legislation in order to avoid misunderstandings of this nature.

4. Information gathering and assessment

Assessments are made on the basis of extensive and full information gathering. They are subject to change and social workers constantly need to review their assessment and subsequent intervention strategy in light of new information, changes in circumstances and identified significant gaps.

Over the Department's period of involvement, referrals were made for assessments with no outcomes subsequently recorded. For example, on 22 December 1998 and again on 1 March 2000, referrals were made for Dionne's psychological assessment. A psychological assessment for Dionne was received in September 2000. Dionne attended parenting programmes, counselling, budgeting assistance, and "Moving Beyond Violence' programmes. Conflicting information at times was provided regarding Dionne's motivation, participation and commitment to these programmes.

The Family/Whanau Agreement of 7 September 1999 required Dionne, again, to complete a parenting programme and the "Moving Beyond Violence' programme, even though she had already completed it twice in the preceding six months.

CYF policy requires the Risk Estimation System (RES) tool to be completed in the following situations:

- Abuse and/or neglect has been substantiated

- Abuse and/or neglect has not been substantiated but there is a need to assess the elements of risk.

- Decisions are to be made which require a reassessment of risk

There are two records of RES being completed, on 18 June 1999 and again on 28 February 2000. RES could have been applied at other points in the case to help inform direction. The outcome of both applications of the tool was "high'. Despite this, the children remained in the care of Dionne and Thomas. Interim Custody Orders in favour of the Chief Executive was obtained on 3 March 2000.

Response: see comments and finding below

5. Placement breakdowns and drift

Case direction becomes unclear in 2000. A coherent, explicit and documented case management strategy is not evident. The level of intervention in this case over the period would have benefited greatly from the application of a clear and frequently reviewed case management strategy.

Since 2000, there were seven documented and known placements for Tamati, culminating in the eighth placement with Mr and Mrs Waterhouse on 19 November 2001. Some of these placements were with whanau, in the first half of 2000. At one point when the children were in the Custody of the Chief Executive, their whereabouts were unknown, as they had been moved within the whanau without the Department being informed.

If Child, Youth and Family did not intend to return the children to Dionne and Thomas, social workers needed to put a permanent alternative plan in place.

Comments: This comment is in response to issues 4 and 5 listed above. Social work involvement in this case was active. Information was gathered, assessments made and interventions put in place. Time and again, the plan was for Dionne Pokaia to go through a programme, even when she had just completed that programme.

Finding: In this case social workers did not sufficiently re-evaluate case direction within a reasonable timeframe. Social workers must make decisions to move to a new direction if the current plan is not effecting the required change and desired outcomes for the children.

Clear case management direction and oversight must be provided by the supervisor.

6. Access arrangements

The frequency, duration and supervision arrangements of access varied during the period the children were in care. It is recorded that access became confrontational and caused difficulties to caregivers, parents and whanau at various times. At times, no explicit access arrangements were in place. This resulted in conflict and confusion.

Mr and Mrs Waterhouse had indicated, in the home assessment, that whilst they would support any access, they did not want to become involved with the family of any foster children and would prefer not to have personal contact. In March 2002, weekend access arrangements for Tamati with his siblings and parents became a problem for Mr and Mrs Waterhouse. Attempts were made to arrange a home visit to the Waterhouses to discuss these issues but the Waterhouses cancelled these visits.

Comments: Access arrangements are always difficult when they occur against a background of conflict. In this case, the social worker made significant attempts to ensure that access arrangements were made for the children to spend time with their family. Consideration must be given to whose interests were being met by having access, the children or the adults.

Finding: Given the confrontational nature of the adults, access arrangements were carried out well. However, ongoing access arrangements need to be reviewed to ensure they are always in the children's best interests.

7. Caregivers -Michael and Maata Waterhouse

A comprehensive assessment of Mr and Mrs Waterhouse was completed. Checks were made in excess of those required by policy. No information was obtained or offered in respect of domestic and alcohol related violence or historical mental health issues. Support was available to them through the Community Liaison Social Worker. It was expected that training would be available in early 2002.

Finding: The assessment process exceeded the requirement of the Department's policy. No concerns were raised in this process by the professionals or whanau. Receiving concerning information AFTER Tamati's death was neither helpful nor beneficial to Child, Youth and Family nor to Tamati.

Finding: The Department currently has arrangements with Police, to receive information regarding any criminal convictions of people applying to be caregivers. These arrangements need to be reviewed to ensure the Department is made aware of any domestic violence related information.

Finding: The Department currently has arrangements with medical practitioners, to receive information regarding the medical history of people applying to be caregivers. These arrangements need to be reviewed to ensure that all relevant information as to the suitability of applicants as caregivers is provided.

Finding: When the Department becomes aware that prospective caregivers have cared for international students, the coordinating agency, responsible for those students, should be contacted for comment on suitability as caregivers.

8. Monitoring of children in placements

Tamati and the youngest child were placed with Mr and Mrs Waterhouse on 17 November 2001. A home visit was made on 11 December 2001 and the children were sighted. It was noted, at this visit, that the Waterhouses were to be away on holiday during January 2002. There were phone conversations with Maata Waterhouse in February 2002. A home visit was planned for 4 March 2002, subsequently cancelled by Mrs Waterhouse, as the time was not suitable. Two more phone calls were made in March and a home visit proposed for 17 April 2002. Again, this was cancelled by Mrs Waterhouse.

Comments: The Department's policy for visiting children in care requires that they are visited and spoken to at least every two months, at a minimum.

Finding: The Department's policy was not followed in this case. The Department's policy on the minimum requirements for social workers maintaining contact and support of children in care is explicit. In this case it was not adhered to. Reiteration and compliance of this policy is required.

Supplementary report

Tamati Pokaia died on 29 April 2002. Mr Michael Waterhouse was charged with his murder and the first criminal trial ended in a hung jury. At a second trial the jury found Mr Waterhouse guilty of manslaughter. Criticism has been levelled at the Department's involvement in the case and the Department has been unable to comment in any detailed way, while criminal proceedings were underway. Now that sentencing is complete, criticisms made and questions raised in media reports can be answered as follows.

There was insufficient reason for the Department to remove Tamati and his brother from their mother's care.

Child, Youth and Family applied to take Tamati into care in February 2000. He had a serious head injury. Tamati had a fractured skull as a result of abuse. Two years before, his brother, then aged three years, had suffered a broken leg through non-accidental injury. The mother admitted to hitting and kicking the children and to asking her partner to kick them on her behalf. There was an extensive history of domestic violence in this family.

Child, Youth and Family social workers must act to protect children from abuse of this nature. In doing so, it is noted that they do not act alone. Other agencies were involved. The Family Court oversees the actions of social workers in these circumstances and is informed of actions they have taken.

Family were not provided with an opportunity to care for Tamati and his brother.

Family members provided care for Tamati and his brother at various stages. The children's' maternal grandfather has certainly cared for them for a time. Paternal grandparents cared for Tamati as well. When the Place of Safety Warrant was taken, in February 2000, the children were placed with their maternal grandparents who later gave them to the paternal grandparents, who gave them back to their mother. Social workers would describe Dionne's relationship, at this point, with her whanau as strained. In November 2000, when two of the children were already with a non-family caregiver, Dionne's whanau asked for the third to be placed with non-family as well.

Tamati and his brother were placed in several different foster homes. Tamati suffered abuse in one of the foster homes.

It is true that the children moved from one set of relatives to another. Tamati and his two brothers were then placed with a non-kin, approved caregiver in September 2000. In April 2001, all three children were removed from that caregiver following disclosures they made about neglect and abuse. They went into the care of another approved caregiver who cared for them until she moved overseas in November 2001, when they went to Mr and Mrs Waterhouse's home.

There is no record whatsoever of any family member alleging Tamati was unsafe while with Mr and Mrs Waterhouse.

Tamati nearly drowned in an accident in a swimming pool.

In December 2000, Tamati was with his caregiver, visiting friends. Other adults and children were sitting around outside the home when Tamati accidentally fell into the swimming pool. Social work staff investigated the accident and established that no negligence was involved.

Mr and Mrs Waterhouse's suitability to be approved as caregivers.

Mr and Mrs Waterhouse applied to be caregivers for Child, Youth and Family on 5 August 2001. They had five children of their own, whose ages, at that time, ranged from 3 years to 17 years. Tamati and his brother were the first children placed by the Department with Mr and Mrs Waterhouse.

There has been a suggestion that the home was too small and the fostered children would be required to sleep in a caravan. This is incorrect. The family did have a caravan which they were preparing for the eldest child to move into. Although foster children would be required to share a bedroom, there were sufficient beds for each child to be accommodated.

The couple spoke of having many other relatives' children to stay. They were not strangers to caring for children.

The caregiver assessment process they went through was entirely in line with the Department's policies and procedures relating to the assessment of caregivers. A thorough questionnaire was gone through with the applicants. The family GP provided a medical check, saying he saw no reason why this couple should not be approved as caregivers. A Police check was done. References were taken from two referees. Letters were sent to other agencies, asking whether the couple had been involved in caregiving for them. School reports were sought in respect of each of the couple's own children.

New information

After Tamati died, the family GP, Police and members of the Waterhouse extended family provided information to Child, Youth and Family which, had it been known during the assessment process, may well have resulted in a different outcome.

The GP reported that there had been incidents in the past when Mr Waterhouse had become violent in alcohol-related incidents. This was not disclosed at the time the caregiver assessments were undertaken.

Extended family members reported that Mr Waterhouse had suffered from psychiatric issues in the past. This was not disclosed at the time the caregiver assessments were undertaken.

Contact after Tamati's death

Senior members of the Department, along with the Counsel for Child, met with the whanau. Whanau had decided not to allow Dionne or Thomas to be present. At that time, the whanau put forward a family member to be caregiver to the remaining two children. This placement has gone well. Sincere regrets and condolences were given to the whanau that day.

Child, Youth and Family's response to the Chief Social Worker's report into the Department's involvement with Tamati Pokaia

The Chief Social Worker has made comments and findings in respect of eight areas of practice. Each is listed below and the Department's response follows. Some responses are applicable to the Department nationally while others are relevant to the Hamilton East Service Delivery Unit. In many cases, progress has been made in the time since this case was being actively managed.

1. Involvement of Whanau, Hapu and Iwi

2. Referral for family group conferences

Chief Social Worker comment and findings:

Comments: It is acknowledged that placement within family is not always easy, especially when conflicting information is being provided about the suitability of family members. The family group conference is the primary and most appropriate forum for sharing information with wider family and enlisting their support in making safe decisions for children. Wherever possible, a child's whanau/family should participate in decisions affecting a child or young person.

Finding: It would have been useful if wider family networks had been accessed in this case.

Response - national

The Department has a clear statutory responsibility to access and involve family/whanau members in ensuring the safety and wellbeing of children and young people. This responsibility is clearly reflected in Departmental policy and practice frameworks and both social work practitioners and Care and Protection coordinators have clearly defined roles in this regard. Both this review and the recent Baseline Review have shown that the department does not always meet its own expectations in this regard.

The Baseline Review identified that this was for two main reasons:

- trading off the demands of managing high workload volumes against the quality and depth of the social work response and engagement; and

- ongoing retention issues that have resulted in a significant erosion of the Department's social work experience base.

The Baseline Review recommended changes to the way the department convenes Family/whanau hui and Family Group conferences, and how it implements plans that are formulated in such forums. Planning is underway in respect to these recommendations and will have a specific goal of increasing the usage of both informal and formal processes for consulting and planning with family/whanau members. An additional $2.72million (GST incl.) this year and $6.53 million (GST incl.) per annum for the next two years is being provided to the department to implement these improvements.

Family/whanau engagement can be extremely challenging and at times confrontational and it is essential that practitioners have the experience, skills and confidence to effectively manage these processes. The department provides intensive Induction training for new staff and has a national training curriculum which includes courses focused on both the legal responsibilities and practice skills required to manage such relationships in a statutory context.

Response - Hamilton

The Hamilton East site made several attempts over a period of years to engage whanau in the lives of this sibling group and to identify a possible family placement. A range of whanau options were actively explored and the children were placed with whanau members for periods of time. Regrettably, these early whanau placements were not able to be sustained and so the department moved to non-kin care placements.

Family/whanau engagement to support the care and wellbeing of children can be extremely challenging. Families can often be fragmented and have conflicting views of a child's best interests or can be unwilling or unable to acknowledge the safety and wellbeing issues that need to resolved. Doing this work well is very time intensive.

3. Inter-agency protocols

Chief Social Worker comment and finding:

Comments: The introduction of the Privacy Act may have led to some misunderstanding about information-sharing between agencies. In recent years, the Department has developed inter-agency protocols with a range of agencies, in an effort to enhance inter-agency cooperation. The care and protection of children is paramount and not sharing information is no longer acceptable.

Finding: Social workers, other agencies in the welfare sector and health professionals must work more closely together to examine whether existing policies and protocols are working and to examine the need for any new arrangements to be made. There must be an unambiguous understanding of the Privacy legislation in order to avoid misunderstandings of this nature.

Response - national

The Department continues to work actively at developing its inter-sectoral response and is an active participant in a range of inter-sectoral forums at both a national and local level. The departments employs a network of Community Liaison Social workers in addition to its operational managers and staff who attend a range of regular forums such as Strengthening Families Management and case forums.

The Department provides national training on the Privacy and Official Information Acts and staff are well supported with any issues by the department's Legal Services. The department believes that uncertainty and misunderstanding of the Privacy legislation has reduced and departments, community agencies and other professionals generally have a good understanding of their responsibilities where the safety of a child is an issue.

Response - Hamilton

The Hamilton East site has noted that there are now limited issues in relation to the flow of necessary information regarding the safety and wellbeing of children. As noted other departments, professionals and community agencies are generally supportive of the Department's need to seek information in relation to the safety of a child and Departmental staff are clear about the use of legal provisions should there be any issue.

Occasionally information can be withheld from the Department as a result of professionals having a role with parents and other family members. In this circumstance the motivation to support and provide advocacy for an adult such as a parent can be in direct conflict with the needs and wellbeing of the children.

Such potential interface issues are actively addressed locally through a range of regular forums and meetings with other providers in the sector and other Government departments.

4. Information-gathering and assessment

5. Placement breakdowns and drift

Chief Social Worker comment and finding:

Comments: Social work involvement in this case was active. Information was gathered, assessments made and interventions put in place. Time and again, the plan was for [Tamati Pokaia's mother] to go through a programme, even when she had just completed that programme.

Finding: Social workers must re-evaluate case direction within a reasonable timeframe. They must make decisions to move to a new direction if the current plan is not effecting the required change and desired outcomes for the children.

Response - national

The Children Young Persons and their Families Act charges social workers with a complex set of statutory responsibilities and they are required to carry these out within a framework of principles that require a focus on both the safety and wellbeing of a child and the need for the active engagement of the child's family/whanau. Inevitably this dual focus creates a level of tension that needs to be managed through the planning and assessment processes.

In managing this tension and creating an appropriate and safe balance, staff are able to draw on a range of professional tools and practice frameworks and are able to access relevant training from the national training curriculum. In addition to this staff are encouraged to fully utilise professional support structures such as supervision to ensure that planning process are appropriately focused on the outcomes sought and can be reflected on and reviewed over time.

Response - Hamilton

The Pokaia case was a complex and challenging one where the significant individual needs of a sibling group needed to be balanced in a context of strongly held and at times divergent views from whanau as to how the children's interests could be best meet.

Staff worked very proactively to manage this tension and planning and re-evaluation of the children's needs and best interests received a high level of oversight and support from senior practice staff. The dilemma of balancing the children's needs and the interests of the adults was at times significant and very careful consideration was given, on an ongoing basis, to the provision of "adequate opportunities for change" acknowledging that course commitment and completion was erratic.

The Hamilton East site continues to place a strong focus on the adequacy of planning for children in care and accesses specialist input and additional training for staff at a local and regional level to ensure this area of practice continues to be advanced.

6. Access arrangements

Chief Social Worker comment and finding:

Comments: Access arrangements are always difficult when they occur against a background of conflict. In this case, the social worker made significant attempts to ensure that access arrangements were made for the boys to spend time with their family.

Finding: Given the confrontational nature of the adults, access arrangements were carried out well. However, ongoing access arrangements need to be reviewed to ensure they are always in the children's best interests.

Response - national

As has been noted the Department seeks to actively manage its responsibilities both to the children and young people in its care and the family/whanau of these children. In providing access, the Department works closely with the Family Court and a child's Legal Counsel to determine what form and frequency of access would be appropriate. Access may be facilitated by Departmental staff, by family/whanau members depending on the circumstances or by a range of community/Iwi providers.

Response - Hamilton

Significant efforts were made to accommodate and support access in an environment that was at times confrontational. Significantly reducing the level of access may well have appeared to be in the children's best interests but the site was straongly committed to seeking a solution which would enable both parents and whanau to have an ongoing presence in the children's lives.

The Hamilton East site made significant efforts to explore a range of alternative access arrangements at different venues and with alternative supervisors in an effort to reach a solution which both met the children's needs and the adults' interests.

The Midlands region has developed a practice framework to support staff managing the ongoing dilemmas of access arrangements for children in the Department's care. This framework clearly establishes the range of options for access processes and provides some additional parameters for practitioners to assist in aligning access arrangements with the overall outcomes sought for a child or young person.

7. Caregiver assessment

Chief Social Worker comment and findings:

Finding: The assessment process exceeded the requirement of the Department's policy. No concerns were raised in this process by the professionals or whanau. Receiving concerning information after Tamati's death was neither helpful nor beneficial to Child, Youth and Family nor to Tamati.

Finding: The Department currently has arrangements with Police, to receive information regarding any criminal convictions of people applying to be caregivers. These arrangements need to be reviewed to ensure the Department is made aware of any domestic violence related information.

Finding: The Department currently has arrangements with medical practitioners, to receive information regarding the medical history of people applying to be caregivers. These arrangements need to be reviewed to ensure that all relevant information as to the suitability of applicants as caregivers is provided.

Finding: When the Department becomes aware that prospective caregivers have cared for international students, the coordinating agency, responsible for those students, should be contacted for comment on suitability as caregivers.

Response - national

The Department has a clear policy and practice framework for the assessment of potential caregivers. Potential caregivers must consent to a Police check, a medical check with the family GP and two additional general references. Nationally standardised templates mean the department collects consistent information on all potential caregivers. In addition to this the assessing social worker completes an extensive home assessment which includes a comprehensive overview of the potential caregiver's individual, relationship and parenting history.

This review process has identified an issue in relation to the provision of information from Police records. While all criminal conviction information is obtained through the processes outlined above, incidents of domestic violence are not necessarily identified..In some locations there are processes in place for the sharing of POL 400s (the Police record of attendance at domestic incidents) but this is not nationally consistent. As a result of domestic violence issues arising out of the reports into the Department's involvement with Saliel Aplin and Olympia Jetson, work is underway between Child, Youth and Family, Police and Women's Refuge to set up referral processes between the three agencies. The issue of more robust information sharing about family violence incidents will also be addressed as part of this work.

In respect to the existing interface with General Practitioners, personal and medical information has been considered sufficient up until now. Given the issue raised in this review, the Department will be initiating discussion with the Royal NZ College of General Practitioners to facilitate the further development and effectiveness of this process.

Response - Hamilton

As has been noted in the course of the review the Hamilton East and West sites have developed caregiver assessment processes which exceed the national standard and provide additional sources of feedback as to potential caregivers' suitability.

In addition to the application of the national assessment framework the Hamilton office requires a potential caregiver to consent to a social worker contacting the schools attended by their own children with a view to obtaining feedback on their parenting history and style. Potential caregivers are also asked to indicate if they have any history as a caregiver or potential caregiver with any other agency and if so agree to the Department seeking feedback from this source.

The Hamilton office has recently introduced a further addition to the assessment process: potential caregivers are requested to attend an interview conducted by a number of senior practice staff, including a departmental psychologist and supervisor or practice manager.

The National assessment processes were fully and appropriately applied in respect to the Waterhouse caregiver assessment and, in addition, the supplementary local processes with the exception of the Assessment Panel were also utilised.

The outcome of all these investigations was that the Department reached a conclusion that the Waterhouses were capable and caring parents who were successfully raising their own children and would have much to offer a foster child.

8. Monitoring of children in placements

Chief Social Worker comments and finding:

Comments: The Department's policy for visiting children in care requires that they are visited and spoken to at least every two months, at a minimum.

Finding: The Department's policy was not followed in this case. Social workers need to be reminded that children in care must be seen at least every two months and they are required to make every effort to do so.

Response - national

The Department's responsibilities in relation to children in care are clearly established in Departmental policy and practice frameworks. Compliance with the minimum requirement is consistently measured and monitored through the Department's professional quality assurance systems.

Notwithstanding the requirement for compliance with this standard, the recent Baseline Review of the Department identified that the social work resource able to be applied to such care management is significantly compromised by the need to manage high levels of new notifications where children or young people are potentially at immediate risk. The development of demand and workload management systems will ensure that practitioners are able to have the time necessary to meet the required standards. Work is already underway in this area through the Baseline Review implementation but it will take some time.

Response - Hamilton

At a local level the need for compliance with minimum visiting standards for children in care is totally supported and social work staff make significant efforts to meet this wherever possible. Local processes have been put in place by supervisors to monitor this requirement and the site has had plans in place for improving this area of practice.

While improvement has been made, in the context of significant increases in notifications requiring follow-up and a high percentage of them requiring an immediacy of response, these efforts can be compromised.

That is not the situation in this case. Two appointments and a number of phone contacts were made with the Waterhouse family, but the two appointments were cancelled by the Waterhouses. Given the presence of the positive caregiver assessment and the absence of concerns, nothing sinister was attributed to the cancellations. In future the department will follow-up cancelled appointments more quickly.

ENDS

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