Oranga Tamariki has admitted a litany of mistakes in the lead up to its controversial attempted uplift of a Hastings new born in May.
Children's Commissioner, Andrew Becroft, says the lessons from this case prove a need to bring about wholesale change:
"I think it's fair to say that many have said it's likely to be an isolated incident and there are deeper structural issues that emanate from this case that will need to be addressed," he told Newshub.
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Other reviews into Oranga Tamariki are underway.
The controversial attempted uplift is being seen as a lesson in what not do to.
Oranga Tamariki has apologised to the whānau after admitting serious mistakes.
Becroft says it seems every step was handled poorly:
"The final steps played out for the whole country to see on the video, it seems to me that all the just about all the concerns that played out on behalf of the family had been vindicated, sadly and tragically."
Oranga Tamariki has apologised and is making immediate changes to ensure greater scrutiny on how children are taken into care.
"I know we have hurt this whānau - and I am truly sorry," chief executive Grainne Moss said.