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CYF Report Into Handling Of Ron Burrows Phone Call

CYF Releases Findings Of Report Into Handling Of Ron Burrows Phone Call

Child, Youth and Family has today issued the findings of an inquiry by Ailsa Duffy QC into the handling of a phone call that Ron Burrows, father of Coral-Ellen, made to the Department on 21 January 2003.

The Department announced the urgent investigation on 17 October after the phone call, which was handled by the Department’s national call centre, was identified during a detailed check of Child, Youth and Family’s telephone records undertaken by the Department and TelstraClear.

Ailsa Duffy QC presented her report to the Department on Friday, 12 December.

In a response issued today, Acting Chief Executive Brenda Pilott welcomed the report.

Where possible, the Department would make immediate changes to its operations in response to the concerns raised, Ms Pilott said. Other issues would be considered as soon as possible, she said.

“The overarching objective we want to achieve is to improve the provision of professional support systems in the call centre to make sure that our social workers have the resources they need to do their work well,” Ms Pilott said.

Chief Executive’s Response to Duffy Report

I welcome the report from Ailsa Duffy Q.C. about Child, Youth and Family’s management of the telephone call made by Mr Ron Burrows to the Department’s Call Centre on 21 January 2003.

The report was requested by Child, Youth and Family in October 2003. The then Chief Executive was concerned to ensure that issues arising from that telephone call and about the operation of the Call Centre were subject to independent scrutiny. This reflects the importance of the Call Centre to the Department’s role in the protection of children from harm and abuse.

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The terms of reference set by the Department particularly asked Ms Duffy to consider and report on questions relating to:

Child Youth and Family’s standards and processes for receiving reports of child abuse and determining whether or not an investigation is required; and

What happened to Mr. Burrows’ call on 21 January 2003.

Ms Duffy’s report comes to a number of conclusions regarding both Mr Burrows’ call and the Department’s general management of child abuse reporting. The Department accepts Ms Duffy’s conclusions in the main. Some recommendations will be actioned immediately. Others require further consideration and planning before implementation can proceed.

The Report’s Conclusions

Below I have summarised the conclusions drawn by Ms Duffy and then set out the Department’s response.

Mr Burrows’ call was dealt with by the Call Centre on 21 January 2003. On the balance of probabilities, it was dealt with by an identifiable social worker. The call would have focussed on Coral-Ellen’s sibling but Mr Burrows is likely to have mentioned Coral-Ellen. It should have been treated as a notification of child abuse but was not.

The Department accepts Ms Duffy’s conclusions and has apologised to Mr Burrows for its response to his telephone call of 21 January 2003.

The Department’s policy requires revision in the area of how notifications should be identified and treated.

Ms Duffy has raised a significant issue about what constitutes a notification, which requires careful consideration. Her view is that the Department should develop consistent and objective criteria which will assist social workers and their supervisors in determining whether calls should be treated as notifications. I accept that this area of policy requires clarification. Work has already begun on this, as a result, in part, of the baseline review. It is due to be completed during 2004.

The Department’s orientation and induction of social workers into the Call Centre does not pay due regard to the particular environment in which Call Centre operations occur.

The Department has already taken steps to improve its induction and orientation processes at the Call Centre. A review of induction and training of Call Centre social workers is underway. We are assessing the level of support and coaching all Call Centre social workers are currently receiving, to ensure it fits with their level of experience at the Call Centre. The level of support and coaching for all new social workers who join the Call Centre in the future will be intensified.

Mandatory policies regarding clinical supervision are not adhered to in the Call Centre. Supervision does not occur in respect of decisions about whether a call should be treated as a notification.

There is to be immediate adherence to the Department’s supervision policy, which will see staff receiving more frequent supervision than is currently the case. Decisions about whether calls should be treated as notifications or ‘advice’ calls will be reviewed by supervisors on a weekly basis until final decisions are made about the Department’s recording standards and practices. In addition the Call Centre always has a duty supervisor available for social workers to discuss any call they are unsure about with respect to whether or not calls should be treated as notifications.

All calls received by intake social workers should be recorded in some way. The lack of audio-recording is of crucial importance and should be remedied promptly.

The Department is already reviewing its recording practices at the Call Centre. The audio-recording of all calls received by intake social workers at the call centre is one option being considered. Final decisions will be made in March 2004. All calls received by intake social workers are now logged and will be recorded in a manner which enables decisions to be subject to audit by supervisors.

Summary and Concluding Comments

The report recognises that quality assurance processes in the Call Centre are unreasonably compromised due to systems issues impacting on what is an extremely busy workplace. The report accepts that there are quality assurance systems in place but suggests that they require enhancement in order to be entirely effective. It particularly recognises that the Department’s current quality assurance processes do not cover decisions about whether a call should be accepted as a notification. I accept these criticisms of the management of the Call Centre.

Child, Youth and Family will take such steps as are immediately available to deal with the particular problems noted above. Some changes have already been made. Systemic problems will need to be considered in more depth, including consideration of resourcing implications. Some of the issues raised can be dealt with in the context of work already underway as a result of the baseline review report. We accept that the issues raised are of fundamental importance to a child protection agency and we are committed to making improvements in the areas of concern identified.

The Duffy Report has also confirmed some things about which the Department was already aware. Call Centre staff are competent, committed and conscientious workers who wish to do a good job. We now need to work on improving the professional support systems and ensuring that reasonable resources are available to support these social workers in the performance of their important tasks.

Brenda Pilott Acting Chief Executive 17 December 2003


It has always been the Department’s intention to release this report in its entirety. There is, though, a need to balance this against a child’s, and our workers’, rights to privacy. For that reason, particular details, especially those which describe Storm’s behaviour, have been altered or deleted. Throughout the report, italicised text in square brackets will indicate wherever information has been changed or removed. None of these changes affect Ms Duffy’s conclusions in any way.


Establishment of Review

The Chief-Executive of the Department of Child Youth and Family Services (hereafter Child Youth and Family) appointed me to conduct a review into the response of Child Youth and Family to a telephone call it received on 21 January 2003 from Mr Ron Burrows expressing concern about the well-being of his children Storm and Coral Burrows. The letter of appointment, which contains the review’s terms of reference, is attached to my report as appendix 1.

Terms of Reference

The terms of reference describe the object of the Review as being to establish the facts relating to Child Youth & Family’s management of the telephone call received from Mr Burrow’s home and to consider the systems used by Child Youth & Family to manage reports of child abuse. In particular to consider and report on the following questions:

1. What are Child Youth & Family’s standards and processes for: Receiving calls [and other communications] which intend to report concerns about children and young persons? Determining whether an investigation under s17 of the Act is necessary? Logging telephone calls [and other communications] - which lead to investigations? - which do not lead to investigations?

2. What happened to Mr Burrow’s call on 21 January 2003? What was its content? What record does Child Youth & Family have of the call? Was it handled in accordance with the Department’s standards and processes? If not, why not?

Are Child Youth & Family’s standards and processes for receiving information about children and young persons adequate – particularly in relation to: Determining whether the report requires investigation? Record keeping? For any other matters that the reviewer considers relevant to these questions.


Private interviews were carried out with persons able to provide helpful information. All interviews were audio recorded. Some of the persons I interviewed were accompanied by a support person and/or a solicitor.

I interviewed Mr Ron Burrows in his home at Te Puke. With me at the time were his partner Sarah Wastney and Joann Field of Child Youth & Family Tauranga. To obtain an appreciation of the work of social workers in general, and particularly that carried out by social workers employed at the National Call Centre of Child Youth & Family, I interviewed two persons with social work expertise. They were: Vaughan Milner of Presbyterian Support Otago and Michael Munnelly of Child Youth & Family. Mr Milner has a diploma in social work, a certificate qualification of social work and he is a member of the Aoteoroa New Zealand Association of Social Workers. He has been a social worker for 29½ years. Before working for Presbyterian Support Otago, he worked for the earlier equivalents of Child Youth & Family for just under 25 years. Mr Michael Munnelly is the current regional manager for Child Youth & Family. He has a masters degree in social work, certificate qualifications of social work, a post-graduate certificate in management and an undergraduate degree in social sciences. He worked as a qualified social worker in 1980 in the United Kingdom and since 1996 he has worked in New Zealand.

To obtain a general understanding of how call centres worked I observed both the Child Youth & Family National Call Centre and the New Zealand Police Call Centre in operation. I also interviewed the New Zealand Police regarding the management of their call centre. I interviewed Superintendent John Lyall, who is the manager of the Police Calls & Communications Centre at Auckland and Inspector Peter Sawyer, who has worked at Auckland Communication Centre for the last 10 years.

I interviewed those Child Youth & Family National Call Centre social workers who were on duty on 21 January 2003 and who were currently available for interview. Some persons on duty that day were no longer available for interview. In view of the information I was able to obtain, I am satisfied that there was no need for me to interview them. I also interviewed the supervisor of the National Call Centre. Representatives of the Public Services Association met with me. During some of the interviews with the Call Centre intake social workers, a legal representative, (Ms Anna Fitzgibbon) who was instructed by the Public Service Association, was present. On occasion an officer of the Public Service Association was present as well at these interviews. Transcripts of the interviews will be provided to the persons with whom I have spoken.

The Public Service Association and some National Call Centre workers expressed concern regarding their possible identification in this review. For the purpose of completing my review I saw no need to identify the Call Centre workers I interviewed. Where necessary, I propose to refer to them by alphabetical letter only. The identity of the person I have concluded is likely to have taken Mr Burrows’ call is already known to Child Youth & Family and so it is unnecessary for me to identify this person in my report. In addition to the report, I have prepared appendices which include copies of the transcripts of interviews and a list of the persons I interviewed.

There was little direct evidence to enable me to reach my conclusions on the issues to be addressed under the terms of reference. Because of the electronic tracing of telephone calls received on 21 January 2003 there is no doubt that Mr Burrows telephoned Child Youth & Family at 9.13am on 21 January and that the telephone call was connected for a total of 21 minutes 42 seconds. Apart from those facts, there is nothing else which conclusively identifies the person to whom Mr Burrows spoke, or what was said. Nevertheless, if I approach the issues upon which I have to reach conclusions using an evidential test of the balance of probabilities there is sufficient circumstantial evidence to enable me to draw conclusions which answer the terms of reference.


The background to this report is most tragic. On 21 January 2003 Mr Burrows called Child Youth & Family to express concern about his children’s well-being. On 9 September 2003 his daughter Coral went missing, on 19 September her body was found. The circumstances of her disappearance and death attracted great publicity. She went missing after her step-father, Stephen Williams, drove her to school. A full scale search was commenced and her disappearance attracted much attention in the news media. A number of days later her body was found. Since then Mr Williams has been arrested and charged with her murder. He pleaded guilty to her murder at an appearance in the Masterton District Court on 10 December 2003.

After Coral’s death, Mr Burrows’ solicitor wrote to Child Youth & Family requesting a record of the telephone call and actions taken in response to Mr Burrows’ call of 21 January. The initial response of Child Youth & Family was to deny the call had been made. This was because Child Youth & Family had no official record of the call. However, as a result of the electronic tracing of phone records, Child Youth & Family was able to determine that at 9.13am on 21 January 2003 a call had been made from Mr Burrows’ number to the Child Youth & Family 0508 Family number. The call was recorded as lasting for 21 minutes 42 seconds. No notification of the call being made was entered on Child Youth & Family’s computer system with the result that Child Youth & Family took no action in response to Mr Burrows’ call.

Term of Reference 1: Child Youth & Family’s standards and processes:

Receiving calls (and other communications) which intend to report concerns about children and young persons

Since 28 October 1997 Child Youth & Family has used a National Call Centre to handle most telephone calls that are made to the service. In January 2003 the Call Centre operated during business hours only. After hours calls were handled differently. The Call Centre now takes calls 24 hours of the day. Only if callers specify a named person or have access to an employee’s direct dial number are they likely to speak with someone other than one of the Call Centre intake social workers at the National Call Centre. The standard process is for all incoming calls regarding children who have no history with Child Youth & Family to be directed to one of the intake social workers at the National Call Centre. Incoming calls are initially answered by a telephonist. It is the telephonist’s responsibility to ascertain if the call is reporting a concern about children, or of a different nature. If it comes within the first category it is transferred to a Call Centre intake social worker.

The Call Centre intake social workers I interviewed impressed me as being well qualified and experienced social workers who were conscientious and concerned to carry out their role properly. They clearly understood that as Call Centre intake social workers they were the first experience an outside caller had of Child Youth & Family. They were aware of the importance of carefully handling calls intended to report concerns about children and young persons. The Call Centre intake social workers I interviewed all recognised the unique nature of their task and its importance for ensuring the safety and protection of children and young persons. Unlike other social work a Call Centre intake social worker receives all information by telephone. This means that communication between the outside caller and the social worker and the impression each forms of the other are dependent simply on oral communication. The type of non-verbal information readily available to persons in a face to face interview is absent. The performance of social work in this circumstance requires a unique set of skills and I think they are not something that a site social worker can be expected to acquire and execute well immediately on assuming this role.

I also formed the view that the Call Centre intake workers are always busy. For the period from 1 July 2002 to 30 June 2003 the Call Centre answered 731,098 calls, and of these the telephonists referred 29,223 calls to the intake social workers. The social workers are under pressure to balance the number of calls they take each day against the time spent on each call. Most of the Call Centre intake social workers I spoke with emphasised the tension they felt between balancing quantity of calls taken against quality of processing each call.

Determining whether an investigation under s17 of the Act is necessary

The Call Centre intake social workers are qualified experienced social workers. Many of them have tertiary qualifications. The Call Centre has a handbook which sets out standard protocols for call processing. Included in that is a schedule (known as the RES) for determining the urgency of response. The RES sets out four categories of notification which require further action. They are critical (being a same day response); very urgent (being the day of notification plus one day); urgent (being a response within 7 days); low urgency (a response within 28 days). In addition to the categories of response requiring further action I learnt that there is a fifth category for notification which is known as a NFA ie no further action. The information for each notification, either a further action required notification or a no further action notification, is entered into Child Youth & Family’s computer system, known as CYRAS. There are a series of on-screen computer prompts which specify the information for input. Once a notification is entered in the system it is referred to a site office which carries responsibility for completing the investigation.

The impression I gained from my interviews with the Call Centre intake social workers is that how each worker handles calls is very dependent on the personal style of the social worker. As at January 2003 the system depended very much on the skill, judgment and experience of the call taker. I understand that now a practice manager has been appointed to supervise clinical decision-making. This step should ensure better consistency in approach. At some stage during the course of a call a decision is likely to be made as to whether it will be treated as a notification or as an advice call. Some social workers make extensive handwritten notes and then enter the information into the computer system. This is time consuming but it does give them the opportunity to review the information they have recorded and to assess how to categorise it. Others make entries almost directly into the computer.

The social workers are not required to record all incoming calls. Advice calls are not formally recorded. If handwritten notes are not made, and during a call the social worker decides not to treat it as a notification there is no opportunity to re-assess that decision. Such a call is lost. The clinical outcome of a call therefore depends on the skill and judgment of the call taker and how he or she determines the call’s criticality in terms of the RES. This is what initiates an investigation under s17 of the Act. Consequently an exercise of poor judgment on whether or not to treat a call as a notification will mean there is no investigation.

Logging telephone calls (and other communications which lead to investigations or do not lead to investigations)

Where a telephone call leads to an investigation the information obtained from the caller is entered into CYRAS as a “further action required” notification. If a telephone call is not going to lead to an investigation it can have two consequences. First, the information could still be treated as a notification which is entered into CYRAS but this will be as a “no further action” required notification. CYRAS provides an input prompt for this type of notification. The consequence of this is that Child Youth & Family has a formal record of the call being made. In addition, as all notifications are signed off by the team supervisor the call taker’s assessment of the criticality of the call will be checked by someone else. This presents an opportunity for reassessment of the notification’s criticality.

However, if the intake social worker decides to treat the call as an advice call there will be no entry in CYRAS whatsoever. This means there is no formal record of the call being received. There may be a handwritten note in the worker’s notebook but since social workers are not required to record advice calls that is a matter of personal style.

Each notification that is entered into CYRAS must be signed off by a supervisor. The Call Centre intake social workers work under a team system and each team has a team supervisor as well as there being a general supervisor for the Call Centre. The result of this requirement is that whenever a notification is entered into CYRAS the Call Centre intake social worker’s decision on the criticality of the notification is checked by a supervisor. This means the supervisor has input into the notification categorisation and it can result in the chosen “criticality” being increased or decreased.

However, because no records are kept of all incoming calls if the intake social worker decides that an incoming call will not be treated as a notification there is no means of checking this decision. Nor is the decision able to be reviewed during supervision of the social worker. The decision whether or not to treat a call as a notification hinges solely on the intake social worker. This means that the initial threshold for whether or not a call is treated as a notification which will result in an investigation being carried out under s17 is unsupervised in any formal sense. I was told by the social workers and by their supervisor that because they sit grouped together calls are overheard and in this way informal supervision can occur. However I cannot see how the ability to overhear one side of a discussion in a room where many such discussions are taking place can constitute any form of supervision.

If an intake social worker is setting the threshold too high for treating a call as warranting notification that may go unrecognised by the worker’s supervisor. Of all the intake social workers I interviewed, (and this was only those who were present on 21 January and available for interview when my interviews were carried out), I learnt that during their formal supervision their supervisor did not look at their handwritten notebooks. The notifications they made and cases they handled might be discussed but there was no examination of their handwritten records in their notebooks and no discussion about how they exercised their initial decision to treat a call as a notification or not.

While something that falls within the first two categories of the urgency of response schedule is likely to be obvious to anyone, I learnt that assessing whether a call comes within the two lower RES categories, particularly the lowest category of 28 days, or whether it should be a “no further action” notification is often difficult. I can understand this as these categories are more applicable to emotional and behaviour problems displayed by children and the assessments of these is likely to be more complex, especially when made from a Call Centre. The social workers do extensive telephone checking of relevant sources of information (eg schools) but it must be more difficult to make these assessments without having anything other than telephone communication. The social workers I interviewed all said that the decision as to whether to treat a call as a 28 day notification or a “no further action” notification was a difficult one. The processing of this type of call is often more time consuming than the critical and very urgent calls. This is because more extensive background checking is required.

Term of Reference 2: What happened in relation to Mr Burrow’s call on 21 January 2003?

My interview with Mr Burrows took place on 31 October 2003. It was a long interview and the transcript runs to 15 pages. Mr Burrows told me that he had telephoned Child Youth and Family on 21 January 2003. He spoke with two persons. The first was a receptionist who answered the call and then he was transferred to someone else. He was clear that he only spoke with two persons. He did not know whether he had contacted the Children Youth and Family’s National Call Centre or a site office. This is not surprising as the 0508 Family number listed in the telephone directory is a national number for Child Youth and Family and calls to this number from anywhere in New Zealand are routed to the National Call Centre. When outside callers ring the 0508 Family number in their local telephone directory listing for their local Child Youth & Family office the calls go directly to the National Call Centre. I expect that many persons who ring Child Youth & Family for the first time have no idea they are speaking with a National Call Centre worker located in Auckland.

I have already identified the standard processes for receiving calls to report concerns about children and young persons. I have no reason to believe that Mr Burrows’ call would have been handled differently from the standard process. A (a supervisor of one of the teams of telephonists at the National Call Centre) confirmed for me that, when calls are answered during business hours (which was the case with Mr Burrow’s call), if there is no known history of the child or young person being reported, the call will be transferred to one of the Call Centre intake social workers at the National Call Centre. I was advised that in A’s experience all first instance calls would automatically be transferred to a Call Centre intake social worker. It is only when a family has a known history and/or the caller specifically asks to be put forward to a named social worker at a particular site that the telephone call will be directed to a site office.

Neither of Mr Burrow’s children had a recorded history with Child Youth & Family. The call Mr Burrows made on 21 January was the first and only call he made to Child Youth & Family. It would be contrary to all standard procedures for a call of this type to be transferred to a site office by the telephonist who took the call. There is no chance a Call Centre intake social worker, on receiving the call from the telephonist, decided to transfer it to someone at a site office (the technology permits this) as Mr Burrows only spoke with two persons. I am satisfied that the call would have been dealt with in accordance with standard processes for calls of that nature and put through to a Call Centre intake social worker.

After Child Youth & Family realised Mr Burrows had called the National Call Centre on 21 January an investigation was carried out to see if there was any record whatsoever of the call being received. The Call Centre intake social workers on duty that day were interviewed. In addition to the official records, the handwritten notebooks which each Call Centre intake social worker uses were examined. In respect of one Call Centre intake social worker whom I will refer to as “B” a notation was found in this person’s notebook recording the words “Storm” and “5 yrs”. I understand that B started work at 8am on that day. Mr Burrows’ call is logged as being received at 9.13am. The notation “Storm” is the 3rd notation in the handbook. If B started work at 8am, this fits with B receiving the third call of the day by 9.13am. No other social worker’s notebook makes any reference to Storm or Coral.

There is no record anywhere at the National Call Centre which would link any other Call Centre intake social worker to being the recipient of Mr Burrows’ call. Child Youth & Family has made enquiries of site offices and there are no records at site offices of a call being received from Mr Burrows. Clearly someone took the call. At a time when B was present at the National Call Centre and Mr Burrows would have been telephoning Child Youth & Family, B has recorded in the notebook a reference to “Storm” and to “5 yrs”. Burrows is likely to have been directed to a Call Centre intake social worker. While all of this is not conclusive evidence it is sufficient to satisfy me on a balance of probabilities that B took the call. When I interviewed B he/she accepted that “it’s quite likely that was me.”

What was its content?

Mr Burrows advised me that the triggering event for making a call to Child Youth & Family were issues in respect of Storm’s behaviour the previous afternoon. These issues had so unsettled Mr Burrows that by the following morning he had decided to contact Child Youth & Family. Mr Burrows struck me as the sort of person who would attempt to resolve a problem for himself before resorting to help from a government agency. I make this comment, which is not to be construed as being in any way critical of Mr Burrows, because this view of him helped me to determine what he is likely to have said to the person he spoke with at Child Youth & Family. I think Storm’s behaviour must have been very unsettling for Mr Burrows if it prompted him to make the call to Child Youth & Family. I think it follows that he would have described the behaviour to the intake social worker he spoke with.

Mr Burrows told me that when he started his conversation with the call taker he was virtually in tears. He was that upset by the issue. He said that when he was talking to the call taker his main worry at the time was both Storm and Coral. He said he was scared for the safety of both his children because they were acting “totally abnormal”. Mr Burrows said he told the call taker that the children’s school had brought in counsellors because of their conduct.

“I said the school’s been so concerned that they have called in a counsellor over it, for both of them.”

The way he described the call was as follows:

“I phoned up and I started off the call - – You will have to excuse me this is hard for me, understand this is my children I am talking about. And then I went on and said I have concerns for the safety of my children because of their erratic behaviour as shown by my son, and my daughter soiling herself all the time. I told him/her about [Storm’s behaviour] and I told him/her about that and that my daughter was soiling herself. But, however after a little short time of being up here it would stop and then she would go home and then she would come back and she was soiling herself again up to six times a day and that I believed my concerns were valid and that the school had even bought in counsellors etc due to Coral soiling herself and Storm’s [behaviour]….. .”

Mr Burrows continued by telling me:

“My belief is that why he [Storm] […], but what the bottom line was is that yeah these are very hard to prove. You cannot lead the children into saying stuff or whatever or therefore ask them directly because if you do that’s bad and I think he/she said 9 times out of 10 these cases turn out to be unproved and then the father loses all access and then you can’t help them at all. At least this way you are getting to see them on the holidays which is some way of monitoring what’s going on. And that was pretty much the end of the call and I thought at least they might contact the school. I believed that every call was recorded not just random ones but I believed that that was part of the department’s thing that’s why they had the computers that were on the phone lines. So I believed that someone will see it and follow it up.”

Although Mr Burrows said he believed Child Youth & Family would follow up his complaint, later he told me he was left with the impression that Child Youth & Family could not help him:

“I couldn’t believe it when I got off the phone with that advice. That there was nothing I could do, and if I try I’ll lose visitation.”

Mr Burrows said he had advised B that the children began behaving abnormally after Stephen Williams’ arrival:

“Question: When did she [Coral] first have that problem [soiling herself]? Answer : Shortly after Steve Williams was put in the house. Now that man is not allowed near his own children and I have told the [call taker] that on the phone. He is not allowed near his sister’s children. He has court orders stopping him because of the violence. . .when I asked the children I said to Stormie […] and I said you know there must be some reason you’re like this son and he goes yeah we miss Mummy and then both of them said yeah we miss Mum. And I said what do you mean you miss Mum and they said well Mum’s never home. She’s working or going out and we have to be babysitted. Now the babysitter was Steve. He was doing a home detention in the house. Now while this is going on he’s smashing up their house as well, punching holes in the wall, smashing the windows out of the house etc.”

B was given a copy of the transcript to read prior to our interview. When I interviewed B he/she had read the transcript of my interview with Mr Burrows. The transcript was discussed. B told me that she/he had highlighted the parts of the transcript which would have caused him/her to enter a notification. The parts of the transcript that I quote were highlighted by B. One of the highlighted parts was Mr Burrow’s description to me of Storm’s issues. B’s response to this was that:

“I think that if he’d (Mr Burrows) said a third of these things (in the transcript), any of these things that I’ve marked, if he’d said any of those to me I would have made notes and I would have discussed at least with my supervisor. There is no way. I can’t believe unless I had a blackout or something I can’t believe that I would not have followed up on this information that he’s given.”

I then went through passages of the transcript with her/him. In relation to Storm’s behaviour the interview went as follows:

“Question: . . .he said what in fact prompted him to make the call was concern about his son Storm’s [issues]… Answer: I definitely say we’d have to follow that up.[….]”

When questioned about Coral and Mr Burrows’ description of her soiling herself B ‘s response was:

“Question: There was Coral soiling her pants. What would you have made of that?” Answer: When I read this what did he say she was soiling up to 6 times a day. Now if someone had told me that I’d say take your child immediately to a GP to be checked out because she would be dehydrated if nothing else, you know what I mean, that again needs immediate follow-up.”

B’s response to these incidents was no different from that of other social workers. I had the impression that among the Call Centre intake social workers there was a feeling of disbelief that Mr Burrows actually said this to the call taker; their view being that if he had said such things, a notification would have followed.

B’s team supervisor described B as a “competent social worker with years of experience. B had worked for Child Youth and Family and its earlier equivalents at a busy site office in the Auckland region since 1988. During B’s time with the service he/she had participated in extensive training courses. I was told that B consults well with the team supervisor on criticality assessments and whether or not to treat a call as an intake. Given B’s background it seemed surprising that B could have made comments along the lines described by Mr Burrows.

However, I was also provided with information on the average number of notifications B generates. B’s average is within the standard range now. The centre average of notifications per day generated by Call Centre intake social workers is 3.8. B’s daily average is 3.5. This is within the expected range. But I also learnt that for the first three months at the Call Centre B generated an average of 2.8 notifications per day.

B commenced work at the Call Centre on 16 December 2002. During this time B did not take any telephone calls as he/she spent time becoming familiar with the Call Centre processes. Between 24 December and 10 January B was on holiday. B started taking telephone calls on his/her return to work in January 2003. Mr Burrows’ call was taken on 21 January. This was within the first month of B commencing work on the telephones.

Taking calls was something B would have done earlier (before the National Call centre became operative) at the site office where B worked. Despite this experience, the work of a Call Centre intake social worker is different from performing this duty at a site office. The Call Centre operates nationally. The social workers cannot rely on any local knowledge as regards the families they are dealing with, or the alternative agencies available to provide help. The type of information and the networks a local site office social worker builds are not available to a national Call Centre intake social worker.

Although B is seen by those supervising her/him as being an experienced social worker, my view is that no social worker from a local site office can be expected to step into the role of a call centre intake social worker and function effectively from the outset. Superintendent Lyall of the New Zealand Police advised me that the Police consider it takes on average 6 months before the call takers at their national communications centre have settled into the job and can be relied upon to perform effectively. In B’s case, because of B’s experience with Child Youth and Family someone sat with B at the telephone system for a day or two, and listened to how B handled calls. Then B was left to get on with the job. From that time on B was treated no differently from the other call takers.

The absence of any formal monitoring or auditing of B’s work during this period makes it difficult to assess now how B was performing during this time. All that can be done is to look at the information available to see if a conclusion on his/her likely performance at that time can be reached. B’s average rate for generating notifications was lower than the centre average. When I asked B’s supervisor what changes if any was he/she likely to make to B’s criticality assessments, the supervisor’s response was that, if a change was made, it was likely to be to increase the criticality assigned to a particular notification. B informed me she/he did more intakes since working at the Call Centre than at the site office where B formerly worked and that the criticality assessments assigned to intakes were higher at the Call Centre. B’s reasons for this were that the local knowledge of site social workers permitted them to take a less interventionist approach.

Mr Burrows call was taken by B within the first fortnight of B commencing work as a call taker. B’s average notification rate during this period was below the centre average. It may well be that B was struggling to adapt to the Call Centre environment and during this period applied a higher threshold to making notifications than was wise. B should have received formal training on being a Call Centre intake social worker. But no such training was given to him/her. B should have been under observation for a longer period of time. That did not happen. B’s work for the first three months should have been carefully monitored. It was not. All this suggests to me that when B first started work at the Call Centre B may have been setting too high a threshold for when to treat a call as a notification. However, because of the lack of effective quality assurance processes at the Call Centre I have not been able to obtain a clear picture of B’s work performance and so I can not go further than this.

When I look at what Mr Burrows told me and when I take account of his actions in telephoning Child Youth and Family there are some factors which are clear to me. First, I see no reason to doubt Mr Burrows’ description of Storm’s behavioural issues.… The day after this incident Mr Burrows was still so affected by Storm’s behaviour that he thought it necessary to ring Child Youth & Family. I cannot see why he would tell me this if it were not true. Given these circumstances I think it is likely that Mr Burrows said something similar, if not exactly the same to B. If Storm’s behaviour caused Mr Burrows to ring Child Youth & Family I would expect it to be upper most in his mind when he spoke with B. Therefore, I would have expected Mr Burrows to describe the behaviour in the much the same terms as he described it to me. In this circumstance I think he would have said a lot about Storm’s behaviour and what he thought was prompting Storm to behave as he had. The notation made in social worker B’s notebook for 21 January 2003 records the name “Storm”. This notation suggests to me that the emphasis of Mr Burrows’ call was on Storm. I cannot imagine he would have described Storm’s conduct as less serious than when he described Storm’s conduct to me. I also think he would have outlined his concerns about why Storm was behaving so….

The next question is whether or not he mentioned Coral at that time. He tells me he did. I have no reason to doubt him. B has recorded 5 years and that was the age of Coral at the time. Coral’s name is not recorded.

Given the tragic events which have occurred since the time of the call his focus on Coral, when relating his discussion with the intake social worker to me, may put more emphasis on her now than at the time of the call. B says that if he/she had received that information he/she would have referred Mr Burrows to a general practitioner.

I am in no position to resolve this factual dispute. I think it likely that B would have asked some questions about the family circumstances and this would have elicited information about Coral. For these reason I am satisfied that Coral was mentioned and that the problem with soiling herself was probably mentioned because that was the concern Mr Burrows had in regard to Coral. Other information available to me has confirmed that she did have soiling problems.

Because it was Storm’s behaviour which caused Mr Burrows to make the call, I believe that in January Storm’s behaviour would have been foremost in his mind when relating his concerns for his children to the intake social worker. I cannot say now whether everything that Mr Burrows has related to me was said to B. B’s response is that if told of a third of what Mr Burrows told me he/she would have followed up on the call. A notification would have been made. Despite what B says, I am satisfied that at the very least the incident with Storm would have been well described for the reasons earlier outlined. I also think it is likely that reference was made to Coral and her soiling problem.

My conclusion that Mr Burrows would have told B about Storm’s behaviour has consequences. All of the social workers I interviewed, both Call Centre intake social workers and Mr Milner and Mr Munnelly considered that this information alone should have led to a notification being made. They differed on whether it should have been a “no further action” or a 28 or 7 day notification. But they all were agreed that a description of Storm’s behaviour alone would justify a notification requiring further action. The degree of criticality to place on the notification varied, but everyone I spoke with thought that a further action notification of some type was required. This would have resulted in an investigation by the Child Youth & Family site office nearest to where the children lived. From then on the matter would have been in the hands of the site office social workers.

Because there is no record of Mr Burrows’ discussion with B, other than the brief handwritten notes I have already described, I cannot be sure that everything else Mr Burrows has said to me was in fact said to B. This is no reflection on Mr Burrows. I am aware that memory can play tricks on people. It can be difficult to recall exactly conversations of a couple of months ago let alone something of the duration of 9 months. However, I do not think it necessary for me to form a view on whether or not the entire content of my interview with Mr Burrows was communicated to B. I am satisfied enough was said to warrant a notification. It is not necessary for me to go any further than this.

Mr Burrows advised me that B listened to his concerns but he had the impression that she was treating him more as an overly-concerned father than someone expressing serious concerns about his children. He told me that he was advised that proving physical abuse was difficult and that if he complained too much he might run the risk of not seeing his children at all.

“Mr Burrows: I think the advice she offered me was based on prior cases that she had dealt with where the father had come forward and tried to help his children and as a result was barred was seeing them. Question: Did she tell you that or did you just assume that? Answer: That’s what I got from her. Question: Did you have the impression then that when she was telling you that she was trying to be helpful to you? Answer: Yeah I think she was trying to say I realise you are a concerned father but you’ve got to look at this side of it too. How can you help your children if you can’t see them at all. At least this way you’re still getting to see them and monitor them and she also told me that you can’t come out directly and ask the children who’s assaulting them or whatever because it’s misconstrued as leading the children or whatever it is. She told me that as well you can’t go and directly ask them. I said so what am I to do then. She said well you’ve just got to hope that they come up and tell you that somebody is hurting them or whatever.”

The general response from the Call Centre intake social workers was that they would not say anything like this to a caller. B’s response to me was:

“Question: What would you have said in a situation like that? Answer: Sometimes it depends what the people are saying to you and very often they say I think someone might be molesting my child and I say well you do have to be very sure that there is molestation happening. You can report that to the Police then they deal with that we deal with the victim side of the child so you have to be sure. You do say that to parents you know and if you’re not sure…things to do but there’s no way you’d say that to them because that’s silly. You don’t say if you do that. Parents often say stuff you and I’ve been told that if you do this and somebody else had this and their child was taken off them and you can’t do this and you can’t do that my response to that is there is no way I would’ve said that and its not general advice that you’d give.”

While I can accept that if the information was communicated to Mr Burrows in this fashion, that would be unusual and not good practice, I do not see this as being a reason for not accepting what he says. I find it difficult to see why Mr Burrows would invent these comments and I cannot see why he would attribute these comments to B, if in fact he heard them elsewhere. In our interview he was not critical of B in so far as he did not suggest that B was dismissive of, or disinterested in his complaint. His complaint was that B’s advice had caused him to think that Child Youth & Family could not help him and so he did not consider approaching the service again. It may be that B did not intend to give Mr Burrows the impression he appears to have gained. His account of the discussion with B is his interpretation of what B said. There is a greater potential for miscommunication during telephone conversations than in face to face discussions. This may explain the disparity between Mr Burrow’s account of his call and the response of B together with the general rejection by the Call Centre social workers of the likelihood of any social worker giving this type of advice. I cannot resolve this conflict, nor do I need to. I have already concluded that Mr Burrows would have told B about Storm’s behaviour. That information was enough to warrant a notification. No notification was made.

What record does CYF have of the call?

Child Youth and Family has no formal record of receiving Mr Burrows’ call. The telephone system has provided an automated record of the call and its duration but that occurred by default. B has a very brief hand-written note which I have concluded, in view of the other available information, can be linked to Mr Burrows. Without the telephone tracing record of the call coming on 21 January 2003 the hand-written note would have been insufficient to link the name Storm with Mr Burrows. The name appears in Child Youth and Family records of other families. Child Youth and Family has nothing else to record Mr Burrows’ call expressing his concern about his children’s need for care and protection.

Was it handled in accordance with the Department’s standards and processes?

No it was not. Mr Burrows is recorded as being on the telephone for 21 minutes and 42 seconds. While some off this time would have been taken up with waiting for the call to be transferred to an intake social worker I think it reasonable to assume that he would have been online to B for at least 15 minutes. The average overall duration of most calls to the Call Centre is 12 minutes.

I was told by the intake social workers I interviewed that they are always busy and that there is constant pressure on them to answer incoming calls. They all sit in an open room. They would be well aware of the pressure on other workers to take incoming calls. In this circumstance I do not believe that a social worker would spend more time on an individual call than was strictly necessary. In view of this, I have concluded that B must have considered it was worthwhile devoting some time on Mr Burrows’ call. Despite this B did not enter the call as a notification, nor did she/he make full notes about the call’s content in the notebook.

Mr Munnelly and Mr Milner thought there should have been a notification. Mr Milner also thought the hand-written notes were inadequate.

“Question: if he [Mr Burrows} wasn’t saying anything reasonably meaningful I can’t imagine why the person at the Call Centre would have allowed the conversation to continue. Answer: No not for that length of time.”

And later in the interview:

“Question: Would it be a reasonable inference for me to draw then that if the Call Centre worker talked to Mr Burrows for, by your calculation 14 to 15 minutes, then he was saying something which [the call taker] thought worth listening to? Answer: Or he was distressed enough and the [call taker] was concerned enough about the nature of that distress that long [she/he] felt that sort of time was necessary. But again you would assume in that case there would have been some record of it. Question: And if it was just more of a general distress, like he presented himself as a man who was distressed, how much time would you expect a Call centre worker to spend on that? Answer: You would expect them to refer him to some other service. …You wouldn’t expect them to be spending their time on that. They would be looking to get that person pointing in the right direction.”

Mr Munnelly was critical of the hand-written notes that were taken. His view was that at the very least more should have been recorded in the notebook:

“Question: In this case, working on the basis that the call took from 14 to 15 [minutes] this is what has been recorded. It says name Storm which is the name of Mr Burrow’s son. Five years is. . .Coral was 5 years at the time and Mr Burrows had been apart from his partner for 5 years. So whether that 5 years refers to Coral’s age with the length of separation from the mother I don’t know. That is all that was recorded of the 14 to 15 minute call. Now what do you have to say about that? Answer: Well that’s not adequate is what I’d say. At the very least you’d expect something like, because of the way they do record you may get like “Storm 5 years” details. You’d expect concern, you’d almost have a summary of what you thought it was about. Concern re custody issues, advice, contact solicitor. Ring back. That kind of . . .so you get a sense of what the outcome was at the very least. But I would have expected there to have been some key words jotted down as the call is being taken on the basis of age, about the separation, it would be issues around [the behaviour], the soiling 5 times a day, referral to a school councillor, those kind of key features. Question: Of course the call taker here decided not to treat this as a notification so of course if it had been a notification you’d expect to have had information going into the computer. If the decision is made not to treat it as a notification would you still expect to have some record made, perhaps so there was a reason as to why it’s not a notification? Answer: Yes absolutely. There are many reasons for doing that. One is a kind of macro thing where it is important the Call Centre knows the type of information that’s coming into it. How successful it might be in terms of diverting work. It’s really good for that. The other is building patterns and relationships of kids.”

One of the Public Service Association’s representatives with whom I met said the call would have been treated as a 7 day notification if she/he had taken the call. The Call Centre supervisor thought that information regarding Storm’s violence would warrant a 28 day notification. That would have been the supervisor’s starting point because the violence was between children and pointed to an emotional or behavioural problem on the part of Storm. There was no-one who thought it appropriate to treat the call (as I have defined it) as an advice call.

The general consensus of everyone I interviewed was that the information about Storm’s behaviour alone would have justified a notification. This included B. The criticality to be assigned to the notification varied according to whom I spoke with. Despite this general agreement as to how the call should have been treated, one of the few certainties in this case is that the call was not entered as a notification of any type nor was any handwritten note made of the call which would reveal something of its content.

Term of Reference 3: The adequacy of Child Youth & Family’s standards and processes for receiving information about children and young persons

In the course of carrying out what has been a discrete review into how one telephone call was handled I gained some insight into the general working of the National Call Centre. It seemed to me that at times the practical implementation of the standards and processes departed from the theoretical expectation. More importantly I think that the failure to ensure that the content of all incoming telephone calls is audio recorded is a key factor both in terms of this review and in respect of the general management of the Call Centre. I deal with this in greater detail below.

Determining whether the report requires investigation?

The Children Young Persons and Their Families Act 1989 sets out the statutory obligations of Child Youth and Family for the care and protection of children and young persons. Under s.15 of the Act:

“Any person who believes that any child or young person has been or is likely to be harmed (whether physically, emotionally, or sexually) ill-treated abused neglected or deprived may report the matter to a social worker or a member of the Police.”

Under s.17(1) where a social worker receives a report under s.15 relating to a child or young person that social worker is obliged to undertake or arrange for the undertaking of any necessary investigation. Under s.17(3) where a s.15 report is received then as soon as practicable there should be an investigation, or a decision made to not investigate. Unless it is impracticable or undesirable to do so, the person who made the s.15 report is to be advised if the report is being investigated and if so what further action has been taken.

On my reading of these provisions every call to the Call Centre which expresses concern about a young person’s well being should be entered in the system as a notification, whether or not this is followed by a decision to investigate the report. In other words it should be registered as either a notification requiring further action or one requiring “no further action”. A notification of some type must be entered. The response to Mr Burrows’ call failed to meet this statutory obligation.

The Call Centre handbook sets out flow charts which show how a call should be processed. I do not consider that the Handbook emphasises with sufficient clarity the statutory obligation to treat every call expressing concern about a child or young person’s well-being as a notification. The emphasis is on the application of the RES (risk estimate system). However, the RES focuses mainly on the risk of physical or sexual harm to children. It places less emphasis on emotional harm. This was accepted by the intake social workers I spoke with. The practical reliance on the RES when processing calls runs the risk of the statutory obligation to treat all reports raising care and protection issues regarding a child or young person being overlooked.

There are work pressures on the Call Centre. The entry of notifications of “no further action required” calls or “low risk further action required” calls can be delayed for days at a time. Given these pressures, the statutory obligation to treat every report on a care and protection issue as a notification is at risk of being overlooked.

This risk is real because as I have identified earlier in this review the existing standards and processes fail to address properly the initial decision made by a call taker regarding whether to treat a call as a notification or not. The existing process requires all notifications to be signed off by a supervisor. Thus once a call has cleared the barrier of being recognised as warranting notification the criticality attached to the notification will be checked by a team supervisor. However, the decision which determines whether or not a call clears this barrier is not subject to any formal check. Any call that is not treated as a notification can pass through Child Youth and Family without being recorded.

When I questioned the Call Centre workers about the formal supervision they received it became clear to me that their work is not audited in a way which would enable the team supervisors to identify someone whose criticality assessments differed from those made by other social workers. There was a belief that a team supervisor, by simply signing off notifications each day, would form a general impression of how call takers assessed criticality and whether there was consistency within the team.

It was made clear to me that the workers at the Call Centre always feel busy and under pressure. From everything I have seen of the Call Centre I have no reason to doubt that. It follows however that I find it difficult to imagine how a team supervisor in a busy work environment who is being required on a daily basis to sign off the notifications made by his or her team members can at the same time stand back from this process and form a more general view on how each member fits within the team when it comes to consistency of criticality assessments. I am sure that someone whose decisions were completely outside the norm would stand out. But I can also imagine that someone could be consistently under-assessing criticality in a less dramatic way and go unnoticed. This could mean that an intake social worker was regularly under-assessing criticality without even being aware that he or she was doing so.

The Call Centre intake social workers also agreed with me that there was likely to be inconsistency among teams. Given the lack of formal auditing of the criticality assessments being made within teams and between each team I can well see how inconsistency could occur.

I therefore think that the current standards and processes are deficient because they do not provide a means to ensure adherence to them. Without formal monitoring and auditing, inconsistency of approach when making criticality assessments will develop; this is unavoidable. I understand that there has now been a practice manager appointed who will be responsible solely for clinical practices. This is a good development as this person can take responsibility for ensuring consistency of practice among the intake social workers at the Call Centre. However, until something is done to ensure that all incoming calls are recorded the possibility of a social worker setting too high a threshold for a notification cannot be eliminated.

A pivotal decision, namely the decision whether to treat a call as a notification or not, is incapable of being monitored or audited at present. This is because not every call is recorded. It is possible for calls to come in and be treated as advice calls by one call taker when they should in fact be treated as notifications. If this is happening there is no way it can be deleted. Obviously if someone’s rate of notification was very low he or she would stand out simply by reason of the lack of notifications made. However it could be possible for someone to be below an acceptable threshold but not far enough that in a busy work environment without monitoring and auditing he or she would stand out. Furthermore I have learnt that because of work pressure in the case of the 28 day notifications and “no further action” notifications these can take between 2 and 4 hours to complete. Some of the call taker social workers that I interviewed advised me that in respect of these types of notifications they may have detailed written notes in their handbook, but it could take days before they entered them in the computer system. It is not therefore possible to know how many notifications flow from the calls taken in any one day. I note that in the case of B, one consequence of my review was that another call was identified as being taken by B on 21 January 2003 where hand-written notes of the call were taken but no record was entered on CYRUS when it should have been. The call concerned a family with a history at Child Youth & Family. The case was closed at the time of the call, however I understand that the call takers are required to check all calls on CYRUS to see if they involve children with a history at Child Youth and Family. If that requirement had been complied with, the history of the subject family would have been revealed and B would then have been required to make a notification, even if it were a “no further action” notification. The failure to carry out this step was only revealed as a result of my review. This is another example of how the system in place at present would not have detected a call taker’s failure to enter calls which should have been entered as notifications into CYRUS. No-one had checked B’s hand-written notes to see if every call noted there had been appropriately dealt with. Because this particular call could have been linked through CYRUS with a family history, this was one incident which was capable of being monitored. However, that did not occur.

Record keeping

I have in part addressed this matter above. As regards notifications the system is completely computerised. It appeared to me to work well. No-one suggested that the computer system was in any way deficient. However, I have learnt that because of work pressure in the case of the 28 day notifications and “no further action” notifications these can take between 2 and 4 hours to complete. Some of the intake social workers that I interviewed advised me that in respect of these types of notifications it could take days before they were fully entered in the computer system.

I am concerned that the present system does not require every telephone call received by the Call centre intake social workers to be recorded in some way. I am even more concerned that all telephone calls are not audio-recorded, given that the technology to do so exists. From my discussions with the New Zealand Police I learnt that their Call Centre audio-records every call received. In addition the call takers are required to make some computer record of every call received. This provides an important record of whether or not a call has been made and the content of the call. Another benefit of the Police system is that it is designed in such a way that it permits a call taker on the conclusion of a call to immediately replay the call back. This means that the call taker can be focus on information-gathering during the course of the call rather than detailed record taking. In addition the call taker is not placed in the position of having to make a decision about how to assess the call at the time it is in progress. Those calls that are borderline in the case of Child Youth & Family for example in respect of whether or not they should be notifications (and if so “no further actions” or 28 day notifications) could be with the Police technology replayed immediately. This would allow the call taker to make a second assessment. It would also allow the call taker to have the team supervisor listen to the call. It would have very good quality assurance benefits as during regular monitoring and auditing of performance the records of the calls could be randomly selected and assessed.

I was told that there are some ethical concerns about audio-recording of telephone calls at the National Call Centre. While I can see that people might have privacy concerns it seems to me that at present records are being kept of calls that result in notifications, and even with advice calls some of the call takers make extensive handwritten notes. Since the information is stored either in handwritten or electronic form, to introduce audio recording of calls would simply be to implement another mechanism for recording the calls. It would have the advantage that, unlike present practice which relies on the subjective assessment of the call taker, an audio-recording could ultimately speak for itself if questions were ever raised about how a call was handled. In the present case if Mr Burrows’ call on 21 January 2003 had been audio-recorded there would have been no need for this review. Assessment of how the call was dealt with and by whom could have been made quite easily by a senior officer within Child Youth & Family. I think that the lack of audio-recording of calls is of crucial importance and is something that should be remedied promptly.

Any other matters regarding Child Youth and Family’s standards and processes for receiving information about children and young persons that the reviewer considers relevant

Other relevant matters that the review has identified are: non-compliance with the Child Youth and Family supervision policy for social workers; lack of formal training for carrying out the role of a Call Centre intake social worker and the absence of quality assurance systems.

Non-Compliance with Supervision Policy

The Chief Social Worker Shannon Pakura provided me with a copy of Child Youth and Family’s supervision policy for social workers. Under this policy social workers (including social worker supervisors/managers) must have “regular and formal supervision guided by a negotiated and written contract.’ For the first 18 months of social work practice they must participate in at least 1.5 hours of formal professional supervision each week. After 18 months practice formal supervision must occur for at least one hour per week regardless of competence, experience or length of service.

B received monthly supervision. Most of the intake social workers I interviewed received monthly supervision. In the case of one intake social worker she/he advised me that formal supervision had not occurred for two or three months.

“Question: What level of supervision do you get? Answers: It varies, I mean, I’m always able to speak to a supervisor about a call if I need to but in terms of regular supervision going and sitting down. Question: That’s what I’m talking about. Answer: Yes that varies. I mean I think I’ve gone 2 or 3 months without having any. . But my supervisor would have the dates. Question: When you do have a supervision meeting how long does it take? Answer: About an hour. Question: And does your supervisor look at your notebook? Answer: No. Question: Is there any discussion with your supervisor during these times about clinical practice issues and decisions you might have made in terms of whether to treat something as a notification or not? Answer: Not really, because usually if I’ve got any questions about a call we do that at the time. I might be thinking it’s a 7 day and she’ll say no it’s a 28 day so we’ll discuss that at the time.”

Apart from the reference to being without formal supervision for 2 or 3 months, the experience described by this social worker was not that much different from the others. Generally supervision occurred monthly. No Call Centre intake social worker that I interviewed was subject to weekly formal supervision.

I understand it is suggested that the professional supervision policy is more suited to site social workers and not to Call Centre intake social workers. Certainly, there is a marked difference in the type of work a site social worker carries out in comparison with that of a Call Centre intake social worker. However, I do not think that this difference is a justification for reducing formal professional supervision. In my view, which is based only my interviews with the expert social workers and the call takers I interviewed, the work of a Call Centre intake social worker is unique and specialised. I think this requires recognition. I think to do the job well requires a special set of social work skills. I do not think that long service at a site office can necessarily equip a social worker with the type of skills needed to work effectively at a National Call Centre.

To sit for a full working day receiving phone calls and making decisions on the appropriate social work response to them on the basis of information initially obtained over the telephone is a difficult job to carry out effectively. I think that the persons who carry out this role would benefit from supervision on a more regular basis than at present.

Mr Munelly told me that:

“There is a whole lot of literature around professional dangerousness among social workers around child protection. And certainly one of the features is either being completely risk averse and responding to everything and equally the opposite of taking extreme risks on the basis of previous experience that says that didn’t really happen. ”

I think that Call Centre intake social workers may be just as much at risk of “professional dangerousness” as social workers at site offices. The peculiar character of their task in comparison with site social workers may demand a different type of supervision, but I cannot see why it should mean that less supervision was needed. Many of the intake social workers at the Call Centre with whom I spoke emphasised the specialised task they carried out. For example, one intake social worker at the Call Centre who attended B’s interview as a Public Service Association representative has post –graduate university qualifications in social work as well as considerable practical experience. This person, to whom I will refer as G, struck me as being a highly motivated, skilful and effective social worker. G, when speaking about the difficulties of performing a social worker’s role over the telephone said to me:

“Going back to your point about the phone I was out of Child Youth and Family and I came back in [as a Call Centre intake social worker] and I found two things. I found unique skills are involved and I’m personally very comfortable with the phone … I found coming to the Call centre and picking this up not an easy task and I came here as an experienced social worker.

Question: When you say picking this up you’re pointing to the urgency of response [RES] so you’re saying you found that hard?

Answer: I found that quite hard and there was a tendency to see many things as very critical. I’m probably conservative in social work a bit. I found that it took me some time before I had confidence about my basic work.

All the social workers I interviewed at the Call Centre thought that being able to sit down with their team supervisor for the specific purpose of discussing clinical practice issues arising from incoming calls would be beneficial. I received the impression that every one of them would welcome such supervision. However, their view was that the Centre was so busy and so under-resourced that there simply was not the time to schedule weekly sessions of this nature.

Apart from the lack of formal weekly supervision for intake social workers in general there appears to be no formal supervision of the supervisors. I only spoke with one team supervisor, and that was the supervisor responsible for B. This supervisor informed me that he/she had not had any formal supervision in this role:

Question: Do you have any formal supervision as supervisors?

Answer: I haven’t had any.

Question: How long have you been here?

Answer: I’ve been here about a year and a half.

Question: …So you, from the organisation, have had no feedback in a formal sense of what it thinks of you as a supervisor?

Answer: Informally, but not formally.

I think it essential for the Call Centre intake social workers and their supervisors to receive proper professional support, and I include here formal supervision in accordance with the Child Youth and Family professional supervision policy. I do not see how they can operate effectively if they are not receiving the formal professional supervision that Child Youth & Family expects all its social workers to receive. The type of supervision needed may differ from that of site workers but that is not a reason to reduce the frequency of the supervision.

I received the impression, from the intake social workers and the team supervisor I interviewed, that the importance of formal supervision was not unrecognised at the Call Centre. It was just that there were insufficient resources to enable it to be carried out properly. B’s supervisor told me:

“It’s actually really, really difficult because of the pressure of time. It’s not something that hasn’t been discussed. I’m very much aware and all of us are aware as supervisors of the importance of supervision in things, but its also about support. We’re not getting it here. Its not going to happen so I and X [another team supervisor] do a lot of informal peer reviewing.”

If pressure of work is preventing compliance with the professional supervision policy, the Call Centre needs to be given sufficient human resources to ensure that each social worker is receiving proper professional support.

A practice manager with responsibility for clinical issues has recently been appointed. This is a good step. However, it is no replacement for adherence to the professional supervision policy. Until such time as those responsible for senior management at Child Youth and Family determine that the call centre can safely depart from the existing supervision policy it should be followed.

Absence of Formal Training as a Call Centre Intake Social Worker

The unique role carried out by Call Centre intake social workers has not been fully recognised. I cannot see how site social workers can move to the Call Centre and commence working as intake social workers without any further formal training. During the course of the review I learnt that persons who are new to Child Youth and Family go through a special induction course which familiarises them with the operation of the service. This includes no more than a couple of days spent on Call Centre work. Others, who are already working for Child Youth and Family (like B) can arrive at the Call Centre and receive no specialised training as an intake social worker. The time B spent off the telephones (from 16 December to 24 December) was spent learning the computer system’s operation. There appears to have been no time spent on training in clinical practice as a Call Centre intake social worker.

Question: between 16 December and 24 December can you tell me what you were doing please?

Answer: The intake process like when you’re in the office at site you use a different part of the CRYAS system. At the Call Centre you use the intake. What you do for intake is slightly different and when you’re on site you very rarely have to do intake. I was on the CYRUS system which is our computer system so it was just taking me through that. I had used the system before when CRYAS first came in we had training on it. But that was a few years ago so it was just refreshing on the actual intake.

Question: And did you sit in and listen to any calls or anything like that during that time?

Answer: No, during that time no.

Question: And when you came back from holiday?

Answer: It was I think about the 10th January. I had the Christmas break.

Question: When did you start on the phones?

Answer: When I cam back on 10 January and there might have been one or two days … [Z ] listened while I did calls but as …[he/she] said that was all I needed because I had lots of phone work on site.

Question: Was the approach then that [Child Youth and Family] took that because of your wealth of experience as a social worker and the work you’d done on phones at the [local] site that you were perhaps brought in differently from say someone new?

Answer: I can’t really comment on that because I don’t know. Because when we’re at site you still do, everyone has to take turns to do duty, so you’re actually still doing intake work there, but not to the same extent. You don’t do the recording part of it. But you do, anybody walks in, you deal with that person you say to them do they want to make a notification. You can ring the Call Centre or we can take it and say do you still… I wouldn’t say it would be specifically, probably the fact that I had as much experience as I did would mean that I had knowledge of CYRAS and the processes but I don’t think it would be specific to that training was specific to anybody else you ever did.

Question: You did bypass some training. Other people have had a 6-8 week induction and in the context of that course they’ve done some work progressing on call centres. You bypassed that?

Answer: Because we’d already been in the field, and it was quite funny because we used to say in the field the new ones need an induction and that induction was brought in because those were thrown in the deep end and a few months later they had the induction.

PSA Rep’s comment: Within the Call Centre, new folk have CYRAS our in-house programme training. And they can have other people who come from outside and when you work for [Child Youth and Family]…you either trained to the general level of familiarity with [Child Youth and Family’s] processes. Some people have greater experience in coming to the Call Centre, some people come to Call Centre who’ve never worked in [Child Youth and Family] ever before and then they have learn about [Child Youth and Family] and about our computer programme and they start behind the

Question: So the focus of what training you did have was on familiarity with the computer in terms of the intake process.

Answer from B: That’s it

B’s team supervisor was asked about the training the intake social workers received when they commenced work at the Call Centre:

Question: … some of the call centre workers I have interviewed they go through an induction process and some of them said they’ve had something like a couple of days. How much time is devoted to training people specifically as call centre workers Answer: I think it’s very much individually based.

.I can see no reason why there should be such disparity between the training of Call Centre intake social workers. Unless all intake social workers at the Call Centre receive clear training on the clinical practice standards expected of them, I cannot see how consistency can be achieved. If all calls taken at the Call Centre are to be handled consistently the intake social workers require careful training to ensure they are fully aware of the Call Centre’s standards and perform in accordance with these. Without this the chance of disparate practices occurring among the individual intake social workers is real. When this is coupled with a failure to ensure that ongoing supervision complies with the professional supervision policy there is every risk that the outcome of each call taken hinges solely on the capability of the social worker taking the call.

I also think there needs to be training of team supervisors. B’s team supervisor had no training for this role:

Question: Did you get any training in terms of how to be a Call Centre supervisor or did you seem to pick that up as you went?

Answer: No, I didn’t get any training about being a Call Centre supervisor but I don’t know if that was because of my experience in [overseas] or not.

Question: Do you know if other Call Centre supervisors here have had training?

Answer: The only thing I can kind of speak of fairly clearly is …[W] who is one of my supervisor colleagues. He started off in the month before me in 1990, but he didn’t.

Question: Would you think that given the sort of job you’re having to do, it would be helpful if you had training as a supervisor for a team of Call Centre workers?

Answer: Yes, because I think the areas that you’re identifying are different to what you’re looking at site. I think site supervision is very much about cases, managing cases. Here, we don’t have cases. . And also I think very much about consistency across the supervisors have to start with …

Absence of Quality Assurance Systems

The absence of quality assurance systems is related to shortcomings in professional supervision. Compliance with the professional supervision policy is one means of achieving competent performance. Another is by implementing quality assurance practices.

Sound quality assurance practices would have identified that the professional supervision policy was not being adhered to. There is little point in having published standards and practices when there is no system in place to see that they are being followed. The following exchange occurred during one interview:

Question: So does that mean that although there might be systems mentioned in documents, that the reality is that they’re not actually followed through in practice?

Answer: Yeah. I mean I find things very murky in this department. I think there needs to be a lot more clarity to get that consistency, what we were saying before.

And earlier in the interview this exchange occurred:

Question: And do you think it would be helpful as a supervisor to have systems in place so you could just check to make sure that everyone was approaching things in much the same way?

Answer: Yes, I do.

There is nothing to suggest there has been an intentional failure to develop quality assurance systems at the Call Centre. Rather I think what has happened is that the Call Centre has become a victim of its own success. Originally it dealt with the Auckland region. As a regional Call Centre it could operate effectively with a small group of call takers who, because of their small number, were able to perform effectively without the need for formal quality assurance. However, the success of the Call Centre has seen it grow incrementally to the point where, it is now the national Call Centre. As it has grown it has responded to the demands placed upon it by focussing on the need to take and process incoming calls. However, I do not think it has been sufficiently resourced. This has meant that the energy and resources available have all focussed on managing incoming calls and less time has been devoted to management issues such as quality assurance. The lack of quality assurance may have had less impact while the Call Centre was regional and in its initial stages of growth, but since the Call Centre has become national there are simply too many persons working there, too many incoming calls and too many issues to be dealt with for the Centre to operate without management practices which include quality assurance.

At the Call Centre there is too great a reliance on the qualifications and expertise of the individual call takers. This is not good. While the social workers may be competent they have reached their level of competency in different ways. Some of the call takers are young social workers with tertiary degrees. They represent a new breed of social worker that sees social work as a profession. This is consistent with the requirement (about to be introduced) of social worker certification. Others are social workers of long standing who have a combination of extensive practical experience and tertiary education and qualifications in social work theory. There are others who have no tertiary qualifications and no qualifications in social work. B is an example of this. B has no social work qualification. B has been exempted from requiring a social work qualification because I understand that on the implementation of registration he/she intends to leave social work.

While the call takers are all experienced social workers, they have reached their levels of competency in different ways. It follows that each of them responds to incoming calls in an individualised way. I think the approach taken by a recent graduate with social work/tertiary qualifications is going to be different from someone who has built up extensive practical knowledge in the field over many years. This was confirmed for me by the Call Centre’s supervisor when I asked her about the possibility of someone setting the threshold for making a notification too high without realising he/she was doing so:

Question: The concern I have is that if you’ve got someone or someone who might be experienced who is confident in his or her judgement, that person might actually have a higher threshold for treating something as a notification than someone else, and so if that person doesn’t recognise, “This is an issue I should see someone about because I think this is acceptable as an advice call – I’m not going to treat it as a notification”, it would be difficult to pick that up.

Answer: Yes, I suppose that’s true to an extent. Certainly … the Call Centre in general, as I said to you, probably creates too many 28 day notifications and many of them … well a higher proportion of them would be created by the people who are newer, younger and less confident, have less knowledge, less life experience, less field social work experience in terms of giving people advice so that could be so.

Like many professions, social work does not stand still. New trends and ideas about social work are constant. It follows that the disparate mix of social workers at the Call Centre need formal monitoring and auditing if their work is to be consistent.

The social workers I interviewed all said that there was informal supervision which arose simply from them all working in the same room, and therefore being aware of each worker’s experiences and his or her reactions to these. There was also the regular contact with supervisors over the criticality chosen for each notification. However, I have already said I do not think that the involvement of the supervisors in this task can constitute any formal, effective monitoring and auditing of the type which would achieve consistency of approach among all social workers. The Call Centre is a busy open plan work environment. While on the one hand the social workers may be aware of what is happening to other workers, on the other I would think it necessary, in order to be able to work effectively in that environment, to develop powers of concentration which to some extent block out what other social workers were doing.

Apart from the pressure of work and lack of resources, another reason why effective formal monitoring and auditing has not occurred to date is because the necessary information is not gathered. No-one I interviewed thought it unnecessary. Every one I interviewed accepted there were risks that went with simply relying on a social worker’s professionalism to ensure he or she did the job properly. This is one of the reasons why I recommend audio recording of calls. Listening to these recordings would provide an effective means of assessing the quality of the call taker’s performance. At present the call takers are assessed randomly by team supervisors sitting in and listening to calls. This is something that has only been instituted in the last few months. It was not in operation in January of this year. While it is helpful to carry out this exercise, and all the social workers I interviewed had found it helpful, I do not think it would be as effective as listening to audio-recorded calls in the context of a formal supervision session. The call takers I interviewed supported audio-recording of incoming calls. The representatives of the Public Service Association did so as well. It seems there would be no resistance to this move from either the social workers or the Public Service Association.


The systems currently in place would allow the type of event responsible for this review to happen again. Until the Call Centre supervisor has a better idea of the consistency of each call taker’s work performance (which can only be achieved if effective quality assurance systems are put in place) and until all incoming telephone calls are audio-recorded there is nothing to stop this event occurring again. It could happen tomorrow.

The Children Young Persons & Their Families Act was passed by Parliament to achieve the following purposes:

“(a) To advance the well-being of families and the well-being of children and young persons as members of families, whanau, hapu, iwi or family group; (b) To make provision for families, whanau, hapu, iwi or family group to receive assistance in caring for their children and young persons; (c) To make provision for matters relating to children and young persons who are in need of care or protection or who have offended against the law to be resolved, wherever possible by their own family, whanau, hapu, iwi or family group;”

There has been comment in the media in recent times about care and protection of children and where the responsibility for this lies. The extent to which that responsibility falls on parents or other primary caregivers is a philosophical question not relevant to this review. What is relevant is that Parliament has chosen to enact the Children Young Persons and Their Families Act. It has recognised the reality of the need to protect children and young persons when their circumstances mean protection is not available from anyone else.

Parliament has placed a statutory obligation on Child Youth & Family to assist children and young persons in need of care and protection who are not receiving care and protection from anyone else. Children and young persons in this position are not responsible for their predicament. They can do nothing to remove themselves from it. They are vulnerable and helpless. If no-one else is caring for and protecting these children the choice for us as a society is either to leave them without protection or for services such as Child Youth & Family to step in. The latter course is what Parliament has chosen.

It is essential, therefore, that these children receive the benefit of the protection which Parliament has chosen to give them. For this to occur Child Youth & Family must receive sufficient resources to be able to carry out its statutory role. If it cannot, children who are vulnerable, unprotected, in need of care in our community will go unprotected. To avoid this it is essential that Child Youth & Family discharge its statutory functions effectively. If a National Call Centre is one of the means by which Child Youth & Family chooses to discharge its statutory obligations the Centre must work effectively. To accomplish this, the Centre must have sufficient resources. This includes resources to enable the Centre to implement measures that will assist it to perform effectively. The audio-recording of incoming calls and the implementation of quality assurance is essential to achieving this outcome. Without either of these, the chance remains of another event like that of Mr Burrows’ call passing without notice.

Ailsa Duffy QC

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